ML20212M745
| ML20212M745 | |
| Person / Time | |
|---|---|
| Issue date: | 02/28/1987 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| References | |
| NUREG-0940, NUREG-0940-V05-N04, NUREG-940, NUREG-940-V5-N4, NUDOCS 8703120167 | |
| Download: ML20212M745 (579) | |
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NUREG-0940 Vol. 5, No. '4 C Enforcement Actions: Significant Actions Resolved Quarterly' Progress Report October - December 1986 U.S. Nuclear; Regulatory-Commission Office of Inspection and Enforcement lE Enforcement Staff pR MGu gw&u V.r O.... i L .
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1 - I Availability of Reference Materials Cited in NRC Publications - 4 m , a :. ~
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fn i Most documents cited in NRC publications'will be'availabli from'one of the fEllowing sources: ,
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, S CAlthough the listing that follows represents'the majority of documents. cited in NRC publications,; .
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--Referenced documents av' a ilable' for inspection and copying for a fee from' the NRC Public Docu- .J
' ment Roorn include NRC correspondence and internal NRC memorandai NRC Office of Inspection - ~
f" and Enforcement l bulletinstcirculars, information notices,' inspection and l'nvestigation' notices;-
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j Licensee Event Reports vendor reports and correspondenceiCommission' papers;and apsticant arid ' l licensee documents and correspondence. - ' e
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~ ' 1The followingl documents in the. NUREG series are availabid for purchase fromTthe GPO. Sales
'. Program: formal NRC staff andiconsactor reports, NRC-sponsored conference proceedings, and-
* - NRC booklets and brochures. Also available are Regulatory Guides NRC regulations in the Code of . ,
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r -4 Documents available from[the -NationalTechnica'l 'Information Service include NUREG series - ~ A freports and technical reports' prepared by other federal agencies and reports prepared by the Atomic L
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< , Documents available~ from public and special technical libraries include all open literature items, ~
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- l such as books, journal and periodical articles, and transactions. Federal Register notices, federal and -
- 1 s' tate legislation, and congressional reports can usually be obtained from these libraries.
,' f Documents such as theses,- dissertations, foreign reports and translations, and non-NRC conference
$ fproceedings are available for purchase from the organization sponsoring the publication cited.
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,7 7, Single copies of NRC draft . reports are available free, to the extent of supply, upon written request d' ' to the Division of Technical information and Document Control, U.S. Nuclear Regulatory Com- % i mission, Washington, DC 20555. p Copies of industry codes and standards used in a substantive manner in the NRC regulatory process Lare maintained at the NRC Library, 7920 Norfolk Avenue, Bethesda, Maryland, and are available there for reference use by the public. Codes and standards are usually copyrighted and may be
; purchased from the originating organization or, if they are American National Standards, from the F American National Standards Institute,1430 Broadway, New York, NY 10018.
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NUREG-0940 Vol. 5, No. 4 Enforcement Actions: Significant Actions Resolved Qutrterly Progress Report October - December 1986 Minuscript Completed: December 1986 D:ta Published: February 1987 IE Enforcement Staff Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Wmhington, D.C. 20666 f s,, i 4,'%...../ i l l
l ABSTRACT This compilation summarizes significant enforcement actions that have been resolved during ~one quarterly period (October - December 1986) and includes copies of letters, Notices, and Orders sent by the Nuclear Regulatory Commission to licensees with respect to these enforcement actions and the : licensees' responses. It is anticipated that the information in this l publication will be widely disseminated to managers and employees engaged in activities licensed by the NRC, in the interest of promoting public health and safety as well as common defense and security. NUREG-0940 111
s; a 4 CONTENTS P_agg A85 TRACT............................................................... iii INTR 000CTION........................................................... 1 SUMMARIES.............................................................. 3 I. REACTOR LICENSEES A. Civil Penalties and Orders American Electric Power Service Corporation i Indiana and Michigan Electric Company, Columbus, Ohio (Donald C. Cook Nuclear Plant, Units 1 and 2) 7 EA 86-150....................................................I.A-1 Arizona Nuclear Power Project, Phoenix, Arizona (Palo Verde Nuclear Generating Station, Units 1 and 2) EA 86-65....................................................I.A-18 Commonwealth Edison Company, Chicago, Illinois ,. (Zion Generating Station, Unit 1) EA 86-49....................................................I.A-27 l Duke Power Company, Charlotte, North Carolina (McGuire Nuclear Station, Units 1 and 2) EA 86-52....................................................I.A-44 Florida Power and Light Company, Juno Beach, Florida (Turkey Point Nuclear Plant, Units 3 and 4) EA 86-20....................................................I.A-62 Florida Power and Light Company, Juno Beach, Florida (Turkey Point Nuclear Plant, Units 3 and 4) EA 86-38...................................................I.A-115 Florida Power Corporation, St. Petersburg, Florida , (Crystal River, Unit 3) i EA 86 - 3 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A- 15 3 i General Public Utilities Nuclear Corporation, Parsippany, New Jersey (Three Mile Island, Unit 2)
; EA 86 - 146 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A- 174 Nebraska Public Power District, Columbus, Nebraska (Cooper Nuclear Station)
- EA 86-44...................................................I.A-184 1
NUREG-0940 v l \
e P_ age REACTOR LICENSEES (CONTINUED) Philadelphia Electric Company, Philadelphia, Pennsylvania (Peach Bottom, Unit 3) EA 86-59...................................................I.A-193 Portland General Electric Company, Portland, Oregon (Trojan Nuclear Power Plant) EA 86-113..................................................I.A-219 Sacramento Municipal Utility District, Sacramento, California (Rancho Seco Nuclear Generating Station) EA 86-94...................................................I.A-223 South Carolina Electric and Gas Company, Columbia, South Carolina (V. C. Summer) EA 86-45...................................................I.A-255 South Carolina Electric and Gas Company, Columbia, South Carolina (V. C. Summer) E A 86 - 12 6 . . . . . . . . . . . . . . . . . . . . . . . . .~ . . . . . . . . . . . . . . . . . . . . . . . . . I . A- 2 8 3 Southern California Edison Company, Rosemead, California (San Onofre Nuclear Generating Station, Unit 1) EA 86-97...................................................I.A-295 Tennessee Valley Authority, Chattanooga, Tennessee (Browns Ferry Nuclear Plant, Units 1, 2, and 3) EA 86-56...................................................I.A-309 Union Electric Company, St. Louis, Missouri (Callaway Station, Unit 1) E A 8 6 - 119 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A- 3 4 7 B. Severity Level III Violations, No Civil Penalty Carolina ?ower and Light Company, Raleigh, North Carolina (Shearco Harris, Unit 1) EA 8 6 - 171. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . 8 - 1 Gulf States Utilities, St. Francisville, Louisiana (River Bend Station) EA 86-183....................................................I.B-3 Niagara Mohawk Power Corporation, Syracuse, New York (Nine Mile Point, Unit 2) EA 86-135....................................................I.B-7 NUREG-0940 vi
Page REACTOR LICENSEES (CONTINUED) Northern States-Power Company, Minneapolis, Minnesota (Monticello Nuclear Generating Station) EA 86-165...................................................I.8-10 University of Kansas, Lawrence, Kansas EA 86-186...................................................I.B-15 II. MATERIALS LICENSEES A. Civil Penalties and Orders Astrotech, Incorporated, Harrisburg, Pennsylvania EA 85-86....................................................II.A-1 Combustion Engineering, Inc., Windsor, Connecticut EA 86-51...................................................II.A-22 Eastern Virginia Medical Authority, Norfolk, Virginia EA 86-172..................................................II.A-37 Mercy Hospital, Wilkes Barre, Pennsylvania EA 86-40...................................................II.A-47 NOW Logging, Perforating, Inc. , Enid, Oklahoma EA 86-138.................................................II.A-101 Progressive Engineering Consultants of Grand Rapids, Inc. Grand Rapids, Michigan EA 86-79..................................................II.A-111 Valley Radiology Associates, Inc., Kingston, Pennsylvania EA 86-41..................................................II.A-135 B. Severity Level III Violatfor.s, No Civil Penalty ! Amersham Corporation, Burlington, Massachusetts E A 8 6 - 18 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . B - 1 National Steel Corporation, Encorse, Michigan EA 86-178...................................................II.B-4 PTL Inspectorate, Inc., Pittsburgh, Pennsylvania EA 86-123...................................................II.B-8 St. Francis Hospital, Evanston, Illinois EA 8 6 - 16 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . B - 15 l NUREG-0940 vii
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fage MATERIALS LICENSEES (CONTINUED) Veterans Administration, Harry S. Truman Memorial Veterans Hospi tal , Col umbia , Mi ssouri EA 86-177. . . . . . . . . . . . . . . . . . . . . II. B-18 Washington University School of Medicine, St. Louis, Missouri EA 86-125..................................................II.B-21 Y 1-3 4 i l 4 t l NUREG-0940 vili
I ENFORCEMENT ACTIONS: SIGNIFICANT ACTIONS RESOLVED October - December 1986 INTRODUCTION This issue of NUREG-0940 is being published to inform NRC licensees about significant enforcement actions and their resolution for the fourth quarter of 1986. Primarily emphasized are those actions invc1ving civil penalties and Orders that have been issued by the Director of the Office of Inspection and Enforcement and the Regional Administrators. An objective of the NRC Enforcement Program is to encourage improvement of licensee performance and, by example, the performance of the licensed industry. Therefore, it is anticipated that the information in this publication will be widely disseminated to managers and employees engaged in activities licensed by NRC, so all can learn from the errors of others, thus improving performance in the nuclear industry and promoting the public health and safety as well as common defense and security. A brief summary of each significant enforcement action that has been resolved in the fourth quarter of 1986 can be found in the section of this report entitled, " Summaries." Each summary provides the enforcement action number (EA) to identify the case for reference purposes. The supplement number refers to the activity area in which the violations are classified according to guidance furnished in the U.S. Nuclear Regulatory Commission's " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986). Violations are categorized in terms of five levels of severity to show their relative importance within each of the following activity areas: Supplement I - Reactor Operations Supplement II - Facility Construction Supplement III - Safeguards Supplement IV - Health Physics Supplement V - Transportation Supplement VI - Fuel Cycle and Materials Operations Supplement VII - Miscellaneous Matters Supplement VIII - Emergency Preparedness Part I.A of this report is comprised of copies of completed civil penalty or order actions involving reactor licensees, arranged alphabetically. Part I.B includas copies of Notices of Violations that have been issued to reactor licensees for Severity Level III violations but for which no civil penalty was assessed. Part II.A contains civil penalty or order actions involving materials licensees. Part II.B includes copies of Notices of Violations that have been issued to materials licensees for Severity Level III violations but for which no civil penalty was assessed. The licensees' responses also are included in Parts I.A and II.A. ! Actions still pending on December 31, 1986 will be included in future issues of this publication when they have been resolved. NUREG-0940 1
SUP94 ARIES , I. REACTOR LICENSEES A. Civil Penalties and Orders American Electric Power Service Corporation Indiana and Michigan Electric Company, Columbus, Ohio (Donald C. Cook Nuclear Plant, Units 1 and 2) EA 86-150, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued Novecber 18, 1986 based on the failure of licensee personnel to follow procedures in the removal and reinstallation of wires and in the initiation of a nonconformance report to resolve a wiring problem. The base civil penalty was reduced by 50 percent because of the licensee's unusually prompt and extensive corrective actions that included (1) procedure enhancements, (2) documented independent verification on all lifting / landing of leads, (3) establishment of turnaround time limits for Condition Report processing and feedback to the originator, and (4) deletion of information tags from the list of approved tags. .The licensee responded and paid the civil penalty Deceraber 18, 1986. Arizona Nuclear Power Project, Phoenix, Arizona (Palo Verde Nuclear Generating Station, Units 1 and 2) EA 86-65, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $100,000 was issued May 5,1986 based on multiple security violations, including access control, degraded vital area barriers, and failure to report. The base civil penalty was increased by 100 percent because of prior notice of similar problems and because several of the violations involved multiple examples. The licensee responded on June 4, 1986. After careful consideration of the licensee's l response, an Order Imposing Civil Monetary Penalties in the amount of l $100,000 was issued October 10, 1986. The licensee paid the civil penalties on November 7, 1986. l Commonwealth Edison Company, Chicago, Illinois ! (Zion Generating Station, Unit 1) EA 86-49, Supplement I l A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued April 15, 1986 based on the discovery in January 1986 that, as a result of testing and maintenance activities, service water to the bearing oil cooler on the 1B auxiliary feedwater pump was isolated, rendering the pump inoperable for 22 days. The base civil penalty was reduced by 50 percent because the licensee l identified and reported the violation and because of the licensee's l past good performance in the area of concern. The licensee responded on May 14, 1986. After careful consideration of the licensee's response, j NUREG-0940 3 1 :
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the staff concluded that a sufficient basis existed for the severity level to be changed from Severity Level III to Severity Level IV and the proposed civil penalty be withdrawn. A letter withdrawing the l civil-penalty was issued December.19, 1986. j Duke Power Company, Charlotte, North Carolina (McGuire Nuclear Station, Units 1 and 2) EA 86-52, Supplement I 4 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued June 2, 1986 based on the failure
.to meet the Unit 1 technical specification requirements.in that a limiting condition was exceeded and appropriate measures were not taken. Specifically, two valves required to isolate the volume control tank on a safety injection signal were left disabled in the open rather than closed position when the plant entered operational Modes 2 and 3 on November 2, 1985. The licensee responded on July 2, 1986. After careful consideration of the licensee's response, an Order Imposing Civil Monetary Penalty was issued on September 19, 1986. The licensee paid the penalty on October 3, 1986.
Florida Power and Light Company, Juno Beach, Florida (Turkey Point Nuclear Plant, Units 3 and 4) EA 86-20, Supplement I i A Confirmatory Order and Notice of Violation and Proposed Imposition i of Civil Penalties in the amount of $300,000 was issued August 12, 1986 based on violations involving the auxiliary feedwater (AFW) syrtem_in which failure to satisfy technical specification and 10 CFR 50.59 requirements were identified. The Order was issued to confirm commitments for a comprehensive reassessment and examination of other plant systems to determine whether problems exist similar i to those identified in the AFW system. The licensee responded and paid the civil penalties on October 1, 1986. . Florida Power and Light Company, Juno Beach, Florida (Turkey Point Nuclear Plant, Units 3 and 4) EA 36-38, Supplement IV A Notice of Violation and Proposed Imposition of Civil Penalty in j the amount of $50,000 was issued April 28, 1986 based on a violation involving an unauthorized entry of a plant worker into a locked high-radiation area. During the entry, numerous procedural violations occurred, including (1) failure to notify health physics personnel prior to operation of the incore detectors, (2) performing work outside the scope of the plant work order, (3) failure to have two 1- persons present during the entry, and (4) failure to keep the worker's exposure within the limits established by the radiation work permit for the job. The licensee responded on May 28, 1986. After careful consideration of the licensee's response, the proposed penalty was mitigated by 50 percent based on the licensee's extensive corrective action. An Order Imposing Civil Monetary Penalty in the amount of
$25,000 was issued October 14, 1986. The licensee paid the civil
- penalty on November 13, 1986.
NUREG-0940 4
o Florida Power Corporation, St. Petersburg, Florida (Crystal River, Unit 3) EA 86-37, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $80,000 was issued October 23, 1986 based on deficiencies in the management of the training of licensed operators. Several 4 violations regarding the administration of licensed operator training l and requalification training and the documentation of the training were identified. The licensee responded and paid the civil penalty on November 21, 1986. General-Public Utilities Nuclear Corporation, Parsippany, New Jersey I (Three Mile Island, Unit 2) EA 86-146, Supplement;I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $40,000 was issued September 29, 1986 based on a modf*ication made to the reactor building polar crane without proper engineering review and documentation. The modification involved the addition of a hand release mechanism which directly affected the ability of the main hoist brakes to properly function. The licensee i responded and paid the civil penalty on October 29,- 1986. l
- Nebraska Public Power District, Columbus, Nebraska (Cooper Nuclear Station) EA 86-44, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalties in i the amount of $50,000 was issued April 28, 1986 based on violations involving a degraded vital area barrier and unescorted access to a temporary employee. The licensee responded on May 28, 1986. After careful consideration of the licensee's response, one of the violations
- involving unescorted access by a temporary employee was withdrawn.
. An Order Imposing Civil Monetary Penalty in the amount of $25,000 was issued October 10, 1986. The licensee paid the civil penalty on October 27, 1986. Philadelphia Electric Company, Philadelphia, Pennsylvania (Peach Bottom, Unit 3) EA 86-59, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $200,000 was issued June 9, 1986 based on the errors by several licensed personnel in (1) the withdrawal of a wrong control ! rod from the core, (2) the inadequate verification of adherence to the rod withdrawal' program, (3) the improper bypassing of the rod sequence control system (RSCS) for a control rod, and (4) the inadequate veriff-cation of the rod position before bypassing the RSCS during a reactor j startup on March 18, 1986. The ifcensee responded on July 23, 1986. After careful consideration of the licensee's response, it was , concluded that sufficient basis for mitigation was not provided in the response. An Order Imposing Civil Monetary Penalties in the amount of $200,000 was issued December 12, 1986. The licensee paid the civil penalties on December 24, 1986. j. NUREG-0940 5
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' Portland General Electric Company, Portland, Oregon (Trojan Nuclear Power P1 ant) EA 86-113,-Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued October 15, 1986 based on. violations
-involving the. failure to maintain operable flow paths for the residual heat removal system for cold leg injection and incomplete inspection by a contract quality control inspector-for the. installation of a pressurizer safety valve. The licensee responded and: paid the civil penalty on November 14, 1986.
Sacramento Municipal Utility District, Sacramento, California (Rancho Seco Nuclear Generating Station) EA 86-94, Supplement I and VIII A Notice of Violation and Proposed Imposition of Civil-Penalties in the amount of $375,000 was issued October 22, 1986 based on violations identified as a result of the event where loss of de power to the integrated control system occurred on December 26, 1985. The violations' involve the failure to (1) maintain the plant within technical specification cooldown limits, (2) correct known deficiencies, (3) establish appropriate procedures, and (4) adequately-follow existing-procedures. The base civil penalty for one violation was increased by 100 percent and and for three violations the base civil penalty was increased by 50 percent. -The licensee responded and paid the civil penalties on November 20, 1986. South Carolina Electric and Gas Company, Columbia, South Carolina (V. C. Summer) EA 86-45, Supplement I-A Notice of Violation and. Proposed Imposition of Civil Penalty in-the amount of $50,000 was issued April 15, 1986 based on the licensee's failure to comply with plant Technical Specifications in that one of two independent component cooling water and service water loops were inoperable in excess of 72 hours. The licensee responded on May 15 and 23, 1986. After careful consideration of the licensee's re;ponses, an Order Imposing Civil Monetary Penalty was issued September 17, 1986. The licensee paid the civil penalty on October 17, 1986. South Carolina Electric and Gas Company,-Columbia, South Carolina (V. C. Summer) EA 86-126, Supplement I A Notice of Violation and Proposed. Imposition of Civil Penalty in the amount of $50,000 was issued September 22, 1986 based on violations of technical specification requirements related to the charging pumps. One violation involved the circumstances in which none of the three charging pumps would have automatically started for approximately 13 hours under the conditions of a loss of off-site power followed by a safety injection signal. The second violation involved rendering inoperable two charging pumps for approximately 110 hours because of the position of a control switch for one pump and electrical interlocks for the second pump under certain conditions. The licensee responded and paid the civil penalty on October 17, 1986. NUREG-0940 6 l 1
1 Southern California Edison Company, Rosemead, California (San Onofre Nuclear Generating Station, Unit 1) EA 86-97, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $180,000 was issued September 17, 1986 based on violations associated with the loss of power and water hammer event which occurred on November 21, 1985. The violations involved (1) rendering inoperable the auxiliary feedwater flow path to the steam generators because five check valves failed to close, (2) the failure of the licensee's check valve testing program to assure continued operability of the five check valves, and (3) the failure to take adequate corrective actions to analyze, evaluate, and identify the source of noise in the area of one of the five check valves during plant operations in June 1985. The licensee responded and paid the civil penalties on October 16, 1986. Tennessee Valley Authority, Chattanooga, Tennessee (Browns Ferry Nuclear Plant, Units 1, 2, and 3) EA 86-56, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $150,000 was issued September 8, 1986 based on three violations irwolving (1) certain cable tray supports that were not adequately designed to withstand a design-basis earthquake, (2) five examples of failures of the licensee to take adequate corrective actions, and (3) four examples of failures to ensure that activities were accomplished in accordance with appropriate drawings and procedures. The licensee responded and paid the civil penalties on October 8, 1986. Union Electric Company, St. Louis, Missouri (Callaway Station, Unit 1) EA 86-119, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $25,000 was issued September 9,1986 based on two violations identified by the licensee. The first violation involved the inoperability of both trains of the intermediate head safety injection system for 6 hours and 8 minutes while the unit was in hot standby. The system became inoperable when a safety injection cold leg isolation valve was improperly closed during a surveillance test. The second violation occurred when the plant operated for 11 hours in mode 2 without the automatic start capability of the auxiliary feedwater pumps after the trip of all main feedwater pumps. The base civil penalty was mitigated by 50 percent because of licensee identification. The licensee responded and paid the civil penalties on October 9, 1986. B. Severity Level III Violations, No Civil Penalty Carolina Power and Light Company, Raleigh, North Carolina (Shearon Harris, Unit 1) EA 86-171, Supplement II A Notice of Violation was issued November 21 1986 based on two violations involving failure to conduct adra ote inspections of l NUREG-0940 7
electric ~ installations for physical separation of electrical cables for safety-related circuits and failure to take adequate corrective actions based on a previous NRC inspection which identified deficiencies in this area. A civil penalty was not proposed because of the licensee's. l' prior good performance in correcting conditions adverse.to quality in other function-areas and the licensee's unusually prompt and extensive actions to correct the problems once they were identified. Gulf States Utilities, St. Francisville, Louisiana (River Bend Station) EA 86-183,-Supplement I A. Notice of Violation was issued December 29, 1986 based on a violation involving failure to perform an adequate evaluation of a temporary modification to the control building ventilation system. A civil i penalty was not proposed because of the unusually prompt and extensive corrective actions taken to correct the problem and prevent recurrence and the licensee's prior good performance in the general area of concern. Niagara Mohawk Power Corporation, Syracuse, New York (Nine Mile Point, Unit 2) EA 86-135, Supplement VII ! A Notice of Violation was issued De' cember 23, 1986 based on an incident 'l
'of discrimination in violation of 10 CFR 50.7 against two quality assurance (QA) auditors. A civil penalty was not proposed because (1) the individual responsible for the discrimination was replaced, (2)-lead auditor status was restored to the two auditors with no loss of compensation or other privileges through self-initiated action on
! the part of new QA management, (3) significant QA management changes and program improvements were made, and (4) the alleged discrimination appeared to be an additional example of the underlying deficiency in l effective management control of the QA program identified during a l CAT inspection in 1983 which resulted in issuance of a civil penalty. i Northern States Power Company, Minneapolis, Minnesota (Monticello Nuclear Generating Station) EA 86-165, Supplement I
~A Notice of Violation was issued December 11, 1986 based on violations involving the inoperability of both trains of the standby liquid I control system during November 1984 - June 1986. A civil penalty was not proposed because the problem appeared to be an isolated case and the licensee had shown prior good performance in this general area of concern.
, University of Kansas, Lawrence, Kansas l EA 86-186, Supplement I A Notice of Violation was issued December 23, 1986 based on violations involving the failure to receive NRC authorization for dismantlement and disposal of the research reactor prior to initiating such operations. A civil penalty was not proposed because of the licensee's prior good performance in the area of reactor operations. I I NUREG-0940 8 l l
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II. MATERIALS LICENSEES A. Civil Penalties and Orders Astrotech, Incorporated, Harrisburg, Pennsylvania EA 85-86, Supplements IV, V, and VI A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $5,000 was issued August 20, 1985 based on numerous violations. Two of these violations involved the use of two indi-viduals as a radiographer and a radiographer's assistant who had not been certified to perform the duties of those positions. The licensee responded on September 10 and 16, 1985. After careful consideration of the licensee's responses, an Order Imposing a Civil Monetary Penalty in the amount of $5,000 was issued on November 26, 1985. The licensee requested installment payment and the last payment was received in December 1986. Combustion Engineering, Inc., Windsor, Connecticut EA 86-51, Supplement VI A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $15,000 was issued June 30, 1986 based on violations involving the unauthorized transfer of licensed material and use of licensed material at an unauthorized location. The civil penalty was increased because of the significant potential for adverse effects in the public health and safety. The licensee responded on July 22, 1986. After careful consideration of the licensee's response, an Order Imposing Civil Monetary Penalties in the amount of $15,000 was issued on October 10, 1986. The licensee paid the civil penalties on November 10, 1986. Eastern Virginia Medical Authority, Norfolk, Virginia EA 86-172, Supplement VI A Notice of Violation and Proposed Imposition of Civis Penalties in the amount of $2,500 was issued December 11, 1986 based violations involving the failure to ensure that the Radiation Safety Officer and Radiation Safety Committee fulfill their responsibilities, that adequate instrumentation was maintained, that required leak tests were performed, and that ash residues were analyzed prior to disposal. The licensee responded and paid the civil penalties on December 17, 1986. Mercy Hospital, Wilkes Barre, Pennsylvania EA 86-40, Supplements VI and VII A Order to Show Cause Why The License Should Not be Modified and a Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $5,000 was issued June 17, 1986 based on a misadministration which was not reported to the NRC or the referring physician and a material false statement made willfully by the Nuclear Medical Technician when questioned about the alleged misadministration. The licensee responded on July 14 and 15, 1986. On October 17, 1986 the licensee made a supplemental response and paid the civil penalty. NUREG-0940 9
NOW Logging,' Perforating, Inc. , Enid, Oklahoma
-EA 86-138, Supplements IV, V and VI A ' Notice of Violation and: Proposed Imposition of Civil Penalties in the amount of $800 was. issued-September'26, 1986 based on violations involving-(1)_ failure to properly store licensed material, (2). failure-to provide survey instruments, (3) failure to provide personnel dosimetry, and (4) failure to conduct leak tests. The licensee
-responded.and paid the civil penalties on October 22, 1986.
Progressive Engineering Consultants of Grand Rapids, Inc., Grand Rapids, Michigan, EA 86-79, Supplements IV, V, and VI A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $500 was issued May 30, 1986 based on violations. involving
. (1) failure to supervise the use of licensed material, (2) unauthorized trar:sfer of licensed materials, (3) failure to perform surveys, and (4)' failure to adhere to transportation requirements. The licensee responded on June 24 and July 1, 1986. After careful consideration of the licensee's responses, an Order Imposing Civil Monetary Penalties in the amount of $500 was issued November 5, 1986. The licensee paid the civil _ penalties on November 17, 1986.
Valley Radiology Associates, Inc., Kingston, Pennsylvania
.EA 86-41
~
~
.An 0rder'to Show-Cause Why'the License Should Not be Modified was issued June 17,;1986 based on a: violation of an NRC requirement in not reporting a misadministration to the NRC and to the-referring physician.
.The licensee respo'nded on July 24 and October 3, 1986. A letter closing the action was issued December 24, 1986.
B. Severity Level III Violations, No Civil Penalty Amersham Corporation, Burlington, Massachusetts EA,86-182, Supplement V A Notice of-Violation was issued December 8, 1986 based on violations involving the-transportation of a package containing-licensed material with a radiation level on a portion of the surface of the package in
. excess of the regulatory limit. .A civil penalty was not proposed because of the licensee's unusually prompt and extensive corrective actions and prior' good enforcement history.
National Steel Corporation, Encorse, Michigan EA 86-178, Supplements IV and VI A Notice'of Violation was issued December 30, 1986 based on violations
. involving the possible exposure of an individual while handling a radioactive. moisture / density gauge. A civil penalty was not proposed because of the. licensee's prior good performance in the area of concern and unusually prompt and extensive corrective actions. These actions included (1) prompt investigation involving senior management into the causes of the event, (2) retraining plant personnel as to the NUREG-0940 10 ,7
,;r J
limits of the license, (3) issuance of a company safety bulletin, (4) reissuance of the relevant safety procedures, and (5) prompt assignment of an authorized ~ acting Radiation Protection Officer until theLnew Radiation Protection Officer receives authorization. l PTL Inspectorate, Inc., Pittsburgh, Pennsylvania EA 86-123, Supplements IV and VI 4 A Notice of Violation was issued October 7, 1986 based on violations involving (1) the use of an uncertified radiographer, (2) failure to maintain direct surveillance of a high-radiation area, and (3) failure by.radiographers to follow emergency procedures and notify supervision
'when source disconnects were identified. A civil penalty was not proposed for two reasons. First, the majority of the violations were identified during inspections prior to the issuance of the civil penalty by the NRC on April 7, 1986. Second, the licensee's corrective actions were extensive and involved the creation of the position of a Corporate Liaison Manager whose~ sole purpose is to ensure radiation safety.
St. Francis Hospital, Evanston, Illinois EA~86-169, Supplement IV A Notice of Violation was issued November 24, 1986 based on violations involving the failure to perform a survey to assure'that all implants had been removed prior to a patient's release and failure to. perform a survey to assure that no sources remained in the room before another patient was admitted to that room. The failure to perform these surveys led to the loss of one iridium-192 ribbon containing ten ! sources. A civil penalty was not proposed because of the licensee's prior good performance in the area of concern and prompt and extensive corrective actions which involved numerous surveys at the hospital , and at the patient's home to locate the lost sources.
; Veterans Administration, Harry.S. Truman Memorial Veterans Hospital, l Columbia, Missouri, EA 86-177, Supplement VI l
A Notice of Violation was issued December 11, 1986 based on a violation involving a diagnostic misadministration reported to the NRC by the ' licensee. A civil penalty was not proposed because of the licensee's good prior performance and corrective actions to prevent recurrence. , Washington University School of Medicine, St. Louis, Missouri EA 86-125, Supplement VII A Notice of Violation was issued October 1, 1986 based on violations relating to deliberate falsification of survey records by a researcher. A civil penalty was not proposed because of the licensee's prior good performance and because the licensee identified and reported the falsification. The licensee also took extensive corrective actions that included increased supervision of graduate student's activities, prohibiting the student from conducting any licensee support activities ! such as surveys, and writing a letter of reprimand to the researcher in charge. NUREG-0940. 11
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'l I.A. REACTOR LICENSEES, CIVIL PENALTIES AND ORDERS S
18 4 NUREG-0S40
. - -. ~ ... .. . .. . _. . .. -
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- *.... NOV to m Docket Nos. 50-315 and 30-316 Licenses Nos. DPR-58 and 74 EA 86-150 American Electric Power Service Corporation Indiana and Michigan Electric Company ATTN: Mr. John E. Dolan Vice President 1 Riverside Plaza
- Columbus, OH 43216 l'
l Gentlemen: l SU8 JECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NO. 50-315/86029 and 50-316/86029) i This refers to the special safety inspection conducted during the period July 14
.through August 11,' 1986, at the Donald C. Cook Nuclear Plant of activities authorized by NRC License Nos. OPR-58 and 74. This inspection reviewed the circumstances associated with the inoperability of two of four power range
- excore nuclear instruments during a Unit 2 reactor startup. This discrepancy l- was identified by your staff and reported to the NRC on July 14, 1986. The results of the inspection were discussed on July 29, 1986, during an enforcement conference held in the Region III office between you and others of your staff and Mr. A. B. Davis and the NRC staff. A copy of the inspection report was sent to you by letter dated September 4,1986.
Violations I.A.1 and I.A.2.in the enclosed Notice of Violation and Proposed Imposition of Civil-Penalty (Notice) involved personnel failing to follow procedures when attempting to establish a correct wiring and drawing configu-ration for power range nuclear _ instrument channels-NI-41 and NI-42. After you determined on May 31, 1986 that both power range nuclear instrument channels
- appeared to be incorrectly drawn and/or wired, personnel failed to follow l procedures and initiate a Condition Report to resolve the problem. The Condition Eeport would have caused you to analyze the discrepancies and may have averted
- the inoperability of these nuclear instrumentation channels when their operabil-4 ity was required. In addition, conflicting statements on information tags and lifted lead tags for power range nuclear instrument channel NI-42 contributed 4
-to a personnel error that resulted in channel inoperability.
Violation I.B in the enclosed Notice involved your failure to realize that channels NI-41 and NI-42 were inoperable because of the wiring errors that resulted in non-conservative neutron flux trip setpoints. The Unit 2 reactor was operated up to 9 percent power for over four days with two of the four power range nuclear instruments inoperable in violation 'of your Technical i Specification requirements. l NUREG-0940 I.A-1 e
American Electric Power 2 NOV :o 935 Service Corporation a Theviolationsdescribedabovecollectivelyrepresentasignificantbreakdod in systems designed to control and prevent such occurrences. The initial wiring errors were compounded by the failure to properly implement procedures designed to control drawings, tagging, lifting wires, post maintenance testing verifications and issuance of Condition Reports. These multiple errors are indicative of a
. lack of attention to detail regarding procedures used for maintenance of safety systems.
To emphasize the importance of maintaining safety-related equipment operable and of having disciplined control of activities through proper use of work and design control documentation and deficiency reporting systems, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twenty-Five Thousand Dollars ($25,000) for Violation I described in the enclosed Notice. In accordance with the " General Statement of Polic Appendix C (1986) y and Procedure for NRC Enforcement Actions," 10 CFR Part 2,(Enfor aggregate as a Severity Level III problem. The base civil penalty for a Severity Level III problem is $50,000. However, the NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil penalty is reduced by 50 percent because of your unusually prompt and extensive corrective actions that included: (1)' procedure enhance-ments, (2) documented independent verification on all lifting / landing of leads, (3) establishment of turnaround time limits for Condition Report processing and feedback to the originator, and (4) deletion of information tags from the list of approved tags. Further mitigation was not given for your reporting of this event because of the time it took you to detect and correct the violation. Violation II in the enclosed Notice occurred when personnel failed to follow procedures and make a timely notification to your shift supervisor after discovering that the two power range nuclear instrument channels were inoperable. This violation has been characterized as a Severity Level IV violation. You are required to respond to this letter and should follow the instruction specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your rasponse to this Notice, including your proposed corrective actions, the NRC will determined whether further enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this' letter and its enclosures will be placed in the NRC Public Document Room. NUREG-0940 I.A-?
American Electric Power , NOV t e 19o5 Service Corporation The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, 6[JamesG.Kepp
~ % g IeY&_
Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Inspection Reports No. 50-315/86029 No. 50-316/86029 cc w/ enclosures:
W. G. Smith, Jr. , Plant Manager DCS/RSB (RIDS) Licensing Fee Management Branch Resident Inspector, RIII Ronald Callen, Michigan Public Service Commission EIS Coordinator, USEPA Region 5 Office Nuclear Facilities and Environmental Monitoring Section flVREG-0940 I.A-3
NOTICE OF VIO*JTICM AND PROPOSED IMPOSITION OF CIVIL PENALTY
~
American Electric Power Service Docket No. 50-316 _ Corporation License No. OPR-74 Indiana and Michigan Electric Company EA 86-150 D. C. Cook Nuclear Plant, Unit 2 An NRC inspection conducted during the period July 14 through August 11, 1986 identified violations of NRC requirements. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 97-295, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: I. Violations Assessed a Civil Penalty
-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 covering procedural adherence. Administrative Procedure PMI-2010, 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, Lifted 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 were noted. The discrepancies had the potential to render the equipment inoperable or degraded. NUREG-0940 I.A-4
Notice of Violation 2 NOV ie ace: 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 inust be placed in the tripped condition within one hour and the minimum channels OPERABLE requirement of three channels must be met. 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 app 1y. 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. Collectively, these violations have been evaluated as a Severity Level III problem (Supplement I). Cumulative Civil Penalty - $25,000 assessed equally between the violations. II. Violation Not Assessed a Civil Penalty Unit 2 Technical Specification 6.8.1 requires written proceduces be implemented covering applicable procedures reccmmended in Appendix A of Regulatory Guide No. 1.33, November 1972, which includes administrative procedures covering procedural adherence. Administrative Procedure PMI-2010, Plant Manager and Department Head Instructions, Procedures and Indexes, requires that instructions and procedures shall be adhered to by all plant personnel. NUPEG-0940 I.A-F
Notice of Violation 3 NOV '" 135 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. This is a Severity Level IV violation (Supplement I). Pursuant to the provisions of 10 CFR 2.201, Indiana and Michigan Electric Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation, if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrtctive steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Indiana and Michigan Electric Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the amount of Twenty-five Thousand Dollars ($25,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Indiana and Michigan Electric Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Indiana and Michigan Electric Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances. (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the NUREG-0940 f.A-6
Notice of Violation 4 NOV ir H 5 statement cr explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Indiana and Michigan Electric Company's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMISSION e ~ gy - A .-
# James 'G. Ke'p;Mfr Regional Administrator Dated at Glen Ellyn, Illinois this i d ay of November 1986 NilREG-0940 f.A-7
INDIANA & MICHIGAN ELECTRIC COMPANY P.O. 80X 16631 COLUMBUS. 0HIO 432t6 I ( 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 l CIVIL PENALTY Mr. James M. Taylor, Director i l office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 l
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 Regior. 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 $25,000 in full payment of the imposed civil penalty. Very tru1y yours, fnP.Alexich\h
~
y . VicePresident,hikhb g Attachment cc: John E. Dolan W. C. Smith, Jr. - Bridgman R. C. Callen C. Bruchmann C. Charnoff NRC Resident Inspector Bridgman J. G. Keppler Region III NUREG-0940 T.A-8
, .. . . , ,3 James M. Taylor AEP:NRC:1009 STATE OF OHIO COUNTY OF FRANKLIN M. P. Alexich, being duly sworn, deposes and says that he is the Vice President of Licensee Ind'ana i & Michigan Electric Company; that he has read the foregoing response to NRC Inspection Report 50-315/86029, 50-316/86029 and knows the contents thereof; and that said contents are true to the best of his knowledge and belief, e
/
ry f' Subscribed and sworn to before ne this i.1 U- day of A .' . .. /. .: , 19 h . t T/ - //a t.a e (Notary Public) RUTH A.OHllNGER MTAAV PUBLIC. ilA*( ~ QH0$ g(geetS540lI Earth 43.' h.19A4. NtlREG-0940 I.A-9
t Attachment to AEP:NRC:1009 NRC Inspection Report 50-315/86029; 50-316/86029 l l NilREG-0940 1.A-10
m
' Attachment AEP:NRC:1009 Page 1 NRC Violation No. I'
" Unit 2 Technical Specification 6.8.1 requires' written procedures;be
~
.A.
-implemented covering applicable procedures recommended in Appendix A of Regulatory Culde 1.33, November 1972, which includes administrative procedures covering procedural adherence.
Administrative Procedure PMI-2010, Plant ~ Manager and Department Head j Instructions", Procedures and Associated Indexes requires that .l instructions and procedures shall be adhered to by all plant personnel.'
- l. Administrative Procedure PMI-2140, Temporary !!odifications, Revision 6 (in effect until July 1,1986) required the use of Attachment'1,- Lifted 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 Itfted 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 were 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 264 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. MIRFG-0940 T.A-11
.+ , , . .. -, . . -. .
4 4
-AEP:NRC:1009: Attachment Page 2
' Technical Specification 3.0.3 specifies that when a Limiting 4
JCondition 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 J reactor trip system breakers closed and the concrol 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." <
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Remnonse to NRC Violation I O . Admission or Denial of 'the Allened 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 th'e 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 t 3' 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 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 of the cables. The cables for N-41 were reconnected i after uncangling 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 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
( 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 ,
- wiring diagram (2-92019 17/NIS Protection Channel II CAB NIS II) was marked up i designating the "as found" configuration of the cables.
4 1 1 i NUREG-09d0 f.A-12
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AEP:NRC:1009 Attachment Page 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 21d 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. 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 hours 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 hours 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 hours, N 42 was disconnected from the reactivity 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 Icad 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. At 2311 hours on July 10 permission was granted to enter Mode 1. During the power increase to Mode 1, it was noted by Operations personne; l that N 41 and N 42 indication was lagging N 43 (Channel III) and N 44 (Channe; 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 no: 1 1 i NUREG-0940 I.A-13
AEP:NRC:1009 Attachment Page 4 uncommon for the power range channels to require adjustment af ter refueling. The channel currents are predicted quantities and are usually adjusted at higher power levels. Mode 1 was reached at 0038 hours on July 11. Reactor ' power was increased to between 8 percent and 9 percent in preparation for turbine roll. At approximately 0110 hours 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 hours 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 hours 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 hours, while troubleshooting N-41, the I&C personnel decided to check the' cable connections on N 42. The I&C person was the same 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, were 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 lif ted 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 hours, I&C 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 hours, 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 NUREG-0940 I.A-14
- . - . . .- . - ... - . .~ . .- .
AEP:NRC:1009 Attachment Page 5 reconnected in the correct configuration. It was then~ verified that N ., s 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
, nanagement, the I&C 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 hours, 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 hours, which reported the circumstances of the interchanged cables but made no determination on the operability of the channels in i
question. The report was received by'the STA on shift at approximately 2400 1 hours. 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 r 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. f The NRC resident inspector was informed, and at 1505 hours on July 14, i 1986 the Shif t Supervisor made the required notification to NRC Operations ! Center via the Emergency Notification System phone. i Based on the above, it is our belief that the violation was the result of a personnel error by an I&C 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 i of the plant with two power range nuclear instrumentation channels inoperable. , l l Corrective Steos That Have Been Takan and the Results Achieved i i The incorrect wiring on tho' 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 i errors on NI 41 and NI 42 and the drawing error on NI-42. Temporary Nodification forms were initiated and approved for N 42 to document the configuration that did not conform to the approved drawings unti' the drawings were revised and issued. Information tags used to idertify the NI cables were removed on July 21, 1986. NUREG-0940 I.A-15
Attachment Page 6 AEP:NRC:1009 Corrective Stans 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 incident 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 Comoliance Vill 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.
NUREG-0940 1.A-16 1 m_
AEP:NRC:1009 Attachment Page 7 Administrative Procedure 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 planc 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." Renoonse to MRC Violation No. II Adminaion or Denial of the Alleaed 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 Steon 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 hours on July 14, 1986.
Corrective Action Which Vill Be Taken to Avoid Further 'liolations See Response to NRC Violation I. Date When Full comoliance Vas 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. NUREG-0940 I.A-17
- _ _ _ - _ _ _ _ _ _ _ _ _ _ I
. - . - _- ._ _ - - _ ~ . - _ - _ ___-- , .- . ~ _ . _ - _
l p g UINTe0 STATES
.c. a NUCLEAR REGULATORY COMMISSION
[
; j namos v 1450 MARIA LANE.SutTE 210 t at WALNUT CREEK CALIFORNIA 94908
% * * " " ,8 MAY 051996
! Docket Nos. 50-528 and 50-529 License Nos. NPF-41 and 46 EA 86-65 , Arizona Nuclear Power Project P. O. Box 52034 Phoenix, Arizona 85072-2034 Attention: Mr. E. E. Van Brunt, Jr. ! Executive Vice President 4 Gentlemen: l l
Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES
- This refers to the routine safeguards inspection conducted by Messrs. D. Schaefer and L. Norderhaug of this office on February 11 - March 13, 1986, of activities.
authorized by NRC License Nos. NPF-41 and NPF-46 for the Palo Verde Nuclear Generating Station (PVNGS), Units 1 and 2. As a result of this inspection, violations of NRC requirements were identified. A copy of Inspection Report i 50-528/86-07 and 50-529/86-06 was sent to you by letter dated April 2, 1986. l These matters were discussed on April 10, 1986 during an enforcement conference ! between Mr. E. E. Van Brunt Jr. , and others of your staff and Mr. J. B. Martin, ! and others of the NRC Region V staff. . I The violations set forth in the Notice of Violation and Proposed Imposition of Civil Penalties demonstrate a continuing lack of management attention to identified
- security problems. The NRC is particularly concerned that after five pre-
! operational and five routine security inspections that resulted in similar j security problems being identified, licensee management did not take ! sufficient actions to correct these problems and prevent recurrence. i To emphasize the importance of fully implementing and maintaining the provisions of your approved PVNGS Security Plan and providing effective management controls in the security program, I have been authorized, after consultation with the i Director, Office of Inspection and Enforcement, to' issue the enclosed Notice of l Violation and Proposed Imposition of Civil Penalties in the amount of One Hundred Thousand Dollars ($100,000) for the violations described in the enclosed
- Notice. These violations have been categorized in the aggregate as a Severity
- Level !!! problem in accordance with the " General Statement of Policy and 4
Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985). The
- base civil penalty for a Severity Level III problem is $50,000. However, the base civil penalty amsunt is being increased by 100 percent because of your prior notice of similar problems and because several of the violations involve multiple examples.
CERTIFE0 MAIL NETUBiIRTIPT REQUESTED l i NUREG-0940 I.A-18
Arizona Nuclear Power Project You are required to respond to this letter and you should follow the instructions specified in the Notice when preparing your response. You should place all Safeguards Information as defined in 10 CFR 73.21 only in enclosures, so that your letter may be placed in the Public Document Room. In your response, you should describe those specific actions taken or planned that are designed to prevent recurrence and to increase the effectiveness of the management of your security program, particularly with regard to ensuring that all commitments in your approved Physical Security Plan are c.et. The material enclosed contains Safeguards Information as defined by 10 CFR 73.21 and its disclosure to unauthorized individuals is prohibited by-Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, with the exception of the cover letter, this material will not be placed in the Public Document Room and will receive limited distributio E The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, u ol 0 - ho . ,. mrT.rn Regional Admin k or4
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalties cc w/ enclosure J. Bynum, ANPP W. F. Quinn, ANPP T. D. Shriver, ANPP W. E. Ide, ANPP C. N. Russo, ANPP cc w/o enclosure: Ms. Jill Morrison, PVIF Duke Railsback, ACC Arthur C. Gehr, Esq l l l l l NUREG-0940 I.A-19
- Arizona Nuclear Power Project po somsaow pwosmix Aaizonaesort rose June 4, 1986 ANPP-36765-EEVB/ACG Mr. James Taylor Director Offi 3 of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 205.;
Subject:
Palo Verde Nuclear Generating Station (PVNGS)
-Units 1 and 2.. -
Docket Nos. STN 50-528 (License.NPF-41) STN 50-529 (License NPF-51) Response to the Notice of Violation, dated May 5,1986, and 4 Request for Mitigation of Proposed Imposition of Civil Penalties File: 86-020-404: 86-A-056-026: 86-B-056-026'
Dear Sir:
~
The five copies of Arizona Public Service Company's Response to the Notice of Violation, dated May 5, 1986, and Request for Mitigation of Proposed' Imposition of Civil Penalties are enclosed. This document consists of seven parts, including-a summary (Part A), five parts (Parts B - F) responding to the several violations cited in the Notice, and one part (Part G) requesting mitigation of the proposed civil penalty. The response admits that the violations cited in the Notice did occur.= The request for mitigation nsserts that:
- a. The proposed increase in the base civil penalty is not supported by the record and is unfair.
j b. The corrective actions taken by the licensee have been prompt and are unusually comprehensive. The letter transmitting the Notice of Violation makes it clear that the proposed increase in the base civil penalty is based upon a perception of "a continuing
- - lack of management attention to identified security problems." This perception is erroncous.
The record of actions taken by management over the past three years demonstrates i .- that management attention has been continuously devoted to security matters. Rather than showing a lack of attention, the record shows the continuous efforts of management to achieve its goal of excellence in the operation of Palo Verde, including the maintenance of an ef fective and efficient security program. NUREG-0940 I.A-20 l
. - ~ - - ._._,.o
Mr. James Taylor, Director Response to the Notice of Violation, dated May 5, 1986, and Request'for Mitigation of Proposed Imposition of Civil Penalties ANPP- 36765
-Page 2 i
i Any other characterization of this~ record is unfair. An increase in the base civil' penalty;under these circumstances would be a contradiction of the stated objective of the NRC's' enforcement policy of "encoraging'improvment of licensee performance."
'In' keeping with the past record showing management's efforts toward achieving
-its goal of. excellence, management has adopted an unusually comprehensive Security Corrective Action Plan.
In addition to' addressing the root causes of the violations' cited in the Notice to prevent recurrence, the Security Corrective Action Plan incorporates: Enhancements of the security maintenance program.
' Enhanced independent, monitoring and auditing of the security plan and its implementation.
I
' Enhanced efforts to involve all site personnel in making the security-program more effective and efficient.
The Security Corrective Action Plan is not limited in its focus to hardware and sof tware elements. It also reflects consideration of human factors that impact on a successful security program.
, On balance, in applying the five factors used in making adjustments of base civil penalties, mitigation of the base civil penalty is warranted because of the unusually comprehensive scope of licensee's Security Corrective Action Plan.
Accordingly, licensee requests that the civil penalty be mitigated in accordance with ,the !!RC's enforcement policy (10 CFR Part 2, Appendix C.). l The enclosed document contains Safeguards Information which must be protected against unauthorized disclosure in accordance with the provisions of 10 CFR 73.21 and is therefore to be withheld from public disclosure in accordance with 10
- , CFR 2.790(d).'Please ensure appropriate steps are taken to safeguard its contents.
Respectfully submitted, [,. Arizona Public Service Company r
, CLLL_ o LLl ,
By: , E. E. Van Brunt, Jr. Executive Vice President Project Director e l NilRFG-0940 T.A-21 I. p.g* . ,ep., g m----o-ty +f--p-,s 9 --ar-seyi--7i--+--vgpwp- m w = w q -
--F - w-v-vwg- Wyy-r w- w yywww--ym&-*v---ev- ymP rw-w'vy y-'rwwyt-m-wpvy-v-= hrwsier sai=--
STATE OF ARIZONA )
) as.
COUNTY OF MARICOPA) I, Edwin E. Van Brunt, Jr., represent that I an Executive Vice President, Arizona Nuclear Power Project, that the foregoing document has been signed by me on behalf of Arizona Public Service Company with full authority to do so, that I have read such document and know its contents, and that to the best of my knowledge and belief, the statements made therein are true. , L MLL 0LM C Lh Edwin E. Van Brunt, Jr. Sworn to before ne this M day of O a y,_o , 1986. 0
-) m ( W ita le L Notary Public My Commission Expires (JfCr#AtlOn Ex$4s April 8,1987 e
m
!!UREG-0940 I.A-??.
.. ._ =.
[. .,*\, UMTEO STATES y a NUCLEAR REGULATORY COMMISSION s I was nwatom. o. c. reses y .... .) , OCT 101986 Docket Nos. 50-528 and 50-529 License Nos. hPF-41 ano NPF-51 EA 86-65 Arizona Nuclear Power Project P. O. Box 52034 Phoenix. Arizona 85072-2034 ATTN: Mr. E. E. Van Brunt, Jr. Executive Vice President Gentlemen:
Subject:
Order Imposing Civil Monetary Penalties This refers to your letter dated June 4,1986, submitted in response to the Notice of Violation and Proposed Imposition of Civil Penalties sent to you by letter dated May 5,1986. The Notice of Violatien described violations found during the physical security inspection conducted by. Region V at Palo l Verde Nuclear Generating Station, Units 1 and 2 during the period February 11 - March 13,1986. After careful consideration of your response, and for the reasons given in i the enclosed Order and Appendix, we have concluded that the violations did , occur as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties. We have also given careful consideration to your request for mitigation of the proposed penalties and have concluded that the penalties should not be mitigated and that escalation of the civil penalties was warranted.
- Accordingly, we hereby serve the enclosed Order on the Arizona Nuclear Power i
Project imposing civil penalties in the amount of One Hundred Thousand Dollars (5100,000). The enclosed Appendix contains details of your security program that have been determined to be exempt from public disclosure in accordance with 10 CFR 73.21 (Safeguards Information). Therefore, those portions of the Appendix will not
; be placed in the Public Document Room and will receive limited distribution.
l The response directed by the accompanying Order is not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork l Reduction Act of 1980. PL 96-511.
,Y , a WV M. Taylor,jrector , ice of Inspection and Enforcement
Enclosure:
Order imposing Civil Monetary Penalties ! with Appendix l NUREG-094n I.A-?3
UNITED STATES NUCLEAR REGULATORY COPWISSION In the Matter of )
)
ARIZONA PUBLIC SERVICE COMPANY ) Docket Nos. 50-528 and 50-529 Palo Verde Nuclear Generating Station ) License Nos. NPF-41 and NPF-51 Units 1 and 2 ) EA 86-65 ORDER IMPOSING CIVIL MONETARY PENALTIES I The Arizona Public Service Company (the licensee) is the holder of Operating License Nos. NPF-41 and NPF-51, issued by the NucleJr Regulatory Comission (theConsiission). These licenses authorize the licensee to operate the Palo Verde Nuclear Generating Station, Units 1 and 2 in accordance with the conditions specified therein. Operating Lichosee No. NPF-41, issued on June 1, 1985, , superseded License No. hPF-34, issued on December 31, 1984. Operating License No. NPF-51, i'ssued on April 23, 1986, superseded License No. NPF-46, issued on December 9,1985. II A routine physical security inspection of the licensee's activities under the licenses was conducted by Region V during the period February 11 through March 13, 1986. As a result of this inspection, it appears that the licensee had not conducted its activities in full compliance with the conditions of its licenses. A written Notice of Violation and Proposed Imposition of Civil Penalties was served upon the licensee by letter dated May 5, 1986. This Notice stated the
- nature of the violations, the requirements of the Comission that the licensee i
MIREG-0940 I.A-2A
2 had violated, and the amount of civil penalties proposed for these violations. A reply dated June 4,1986 to the Notice of Violation and Proposed Imposition of Civil Penalties was received from the licensee on June 5,1986. Upon consideration of the licensee's response and the statement of facts, explanation, and arguments for mitigation contained therein, the Director, Office of Inspection and Enforcement has deterinined, as set forth in the Appendix to this Order, that the penalties proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalties should be imposed. III In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2282, PL 96-295), and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: The licensee pay civil penalties in the amount of One Hundred Thousand Dollars (5100,000) within 30 days of the date of this Order, by check, draft, or money order payable to the Treasurer of the United States and mailed to the Director Office of Inspection and Enforcement, U.S. NRC, Washington, D.C. 20555. IV The licensee may, within 30 days of the date of this Order, request a hearing. A request for hearing shall t'e addressed to the Director, Office NUREG-0940 I.A-25
3 of Inspection and Enforcement, U.S. Nuclear Regulatory Comission, Washington, D. C. 20555. A copy of the hearing request shall also be sent to the Assistant General Counsel for Enforcement, Office of General Counsel, at the same address. If a hearing is requested, the Comission will issue an Order designating the time and place of hearing. Upon failure of the licensee to request a hearing within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings, and if payment has not been made by that time, the matter may be referred to the Attorney General for collection. V In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee was in violation of the Comission's requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties referenced in Section 11 above, and (b) whether, on the basis of such violations, this Order should be sustainea. FOR THE NUCLEAR REGULATORY COMMISSION
//
[ Jam s M. Tayl'r(/ Director
/ Of ice of Ins,section and Enforcement Dated at Bethesda, Maryland thispi%dayofOctober,1986 HUPEG-09a0 1.A-?6
se aseg UNITED STATES
+ *,, NUCLEAR REGULATORY COMMISSION
'r S REGION lil
"[
. j. 79e noostvELT momo
- GLEN ELLVN, ILLINott 60937
**.a* gpp 9 5 3 Docket No. 50-295 EA 86-49 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, IL 60690 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORT NOS. 50-295/86002(DRP); 50-304/86002(ORP) This refers to the inspection conducted from January 27 through February 14, 1986, of activities authorized by NRC Operating License No. OPR-39 for the Zion Generating Station, Unit 1. The inspection was conducted by the NRC Resident Inspector after he was informed on January 27, 1986 by the Operating Assistant Superintendent at Zion that a valve lineup error had resulted in the isolation of the IB auxiliary feedwater pump oil cooler. This matter was discussed on March 31, 1986 during an Enforcement Conference held in the NRC Region III office between Cordell Reed and others of your staff and A. B. Davis and others of the NRC staff. The violation described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty involves your discovery on January 12, 1986 that as a result of testing and maintenance activities, service water to the bearing oil cooler on the IB auxiliary feedwater pump was isolated, rendering the 18 pump inoperable for a period of 22 days, in violation of technical specifications. Although this event appears to be an isolated example, your staff should ensure that non-routine valve alignments are adequately evaluated prior to implementation and properly documented to ensure that after work is completed, systems are returned to operating status. The individual who identified the closed valve is to be commended since this valve was not part of a planned alignment procedure and the improper position was not readily apparent. However, NRC is concerned that after the valve misalignment was discovered and corrected, two weeks passed before anyone realized the full significance of this event. To emphasize the need for you to ensure that adequate valve positioning controls are implemented for safety-related systems, I have been authorized, af ter consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twenty-Five Thousand Dollars (525,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1985) (Enforcement Policy), the violation described in the enclosed Notice has been CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 !.A-27
,. . ~~ f g x
\
g. (
^ g ,3 't Commonwealth Edison Company ,
AFR f 51986 categorized at a Se' verity Level III. The base civil penalty for a Severity s Level III violation is $50,000. The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil s-q penalty has been reduced by 50 percent because you identified and reported the ' violation and because of your good past performance in the area of concern. Further reduction was not applied because after the violation was discovered, you a' failed to realize its safety significance for some time. , You are required to respond to this letter and should follow the instructions < specified in the enclosed Notice when preparing your response. In your \ s response, you should document the specific actions and any additional action . you plan to prevent recurrence. After reviewing your rssoonse to this Notice, x including your corrective actions, the NRC will determine whether further NRC ~ enforcement action is necessary to ensure compliance with NRC regulatory requirements. , , In accordance with 2.790 of[the NRC's " Rules o[ Practice," Part 2, Title 10, Code of Federal Regulation, a copy of this letter, and its enclosures will be placed in the NRC Public Occument Room. \ The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of N nagement and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely ' 1 s
-- AA
[JamesG.Keppler '\ Regional Administrator s
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Inspection Reports No. 50-295/86002(ORP);
No. 50-304/86002(DRP) N cc w/ enclosures: Cordell Reed, Vice i President ' D. L. Farrar, Director of Nuclear Licensing G. Plim1, Plant Manager '
\
NUREG-0940 1,A-28
NOTICE OF VIOLATION AND a-PROPOSED IMPOSITI F 0F CIVIL PENALTY Commonwealth Edison Company Docket No. 50-295 Zion Generating Station, Unit 1 License No. OPR-39 EA 86-49 An NRC inspection was conducted from January 27 through February 14, 1986,. as a result of your identification of a violation of NRC requirecents. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violation and associateo civil penalty are set-forth below: Technical Specification 3.7.2.A.(1) and (2) requires that during plant oper. tion in Modes 1, 2, and 3, three independent steam generator auxiliary feedwater pumps shall'be operable with two motor driven and one steam turbine-driven auxiliary
. feedwater pump. With one motor-driven auxiliary feedwater pump inoperable, the pump must be restored to status within seven days, or the plant must be in Mode 4 within the next 12 hours.
Contrary to the above, from December 21, 1985 until January 12, 1986 with the plant operating in Mode 1, one motor-driven auxiliary feedwater pump was inoperable with the applicable action statement not satisfied, in that the pu'np was not restored to operable status within seven days and the plant was net in Mode 4 within the next 12 hours. This is a Severity Level III violation (Supplement I). (Civil Penalty - 525,000). Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company is ; hereby required to submit to the Director, Office of Inspection anc Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear P.agulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or dental of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved,-(4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcenent, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to NUREG-0940 I.A-79
Notice of Violation APR f 51996 extending the response time for good cause shown. Under the authority of Section 182 of the'Act, 42 U.S.C. 2232, this response shall be submitted under oath or af firmation. Within the same time as provided for the response required above under 10 CFR 2.201, Commonwealth Edison Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Twenty-Five Thousand Dollars ($25,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Er.7orcement. Should Commonwealth Edison Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in u the amount proposed above. Should Commonwealth Edison Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violation listed in this Notice, in whole or in part; (2) comonstrate extenuating circumstances, (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1985), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in rely pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph iwmbers) to avoid repetition. Commonwealth Edison's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated. may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.(.. N FOR THE NUCLEAR REGULATORY COMMISSION
'MA NAFb%
James G. Keppler
" Regional Administrator Dated at Glen Ellyn, Illinois, this 15th day of April 1986.
g M HllREG-0940 I.A-30
Commonwealth Edison cae .5:est Naborai P' ara Ch<a;o tihao s
@ Ch.cago ininois 60690 Addre5S Aepty to Post Other Boa 767
- May 14, 1986 I
i Mr. James M. Taylor office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555
Subject:
Zion Nuclear power Station Units 1 and 2 Response to I&E Inspection Report Nos. l 50-295/86-002 and 50-304/86-002 1 NRC Docket Nos. 50-295 and 50-304 References (a): March 17, 1986 letter from C. E. More11us to Cordell Reed. (b): April 15, 1986 letter from J. G. Keppler l to J. J. O'Connor.
Dear Mr. Taylor:
1 This letter concerns the routine safety inspection of activities at l Zion Station conducted on January 4 through February 14, 1986 by M. M. Holtmer. l L. E. Kanter, and J. N. Kish. Reference (a) indicated that the isolation of service water to the 18 auxiliary pump oil cooler for 22 days appeared to be l in noncompliahce with NRC requirements. This issue was discussed on March 31, l 1986 during an Enforcement Conference held in the NRC Region III office. Reference (b) provided Commonwealth Edison with a Notice of Violation and proposed imposition of Civil Penalty for this event. This event was characterized as a Severity Level III violation and a $25,000.00 civil Penalty l was proposed. Commonwerdth Edison Company's response to the Notice of violation is provided in Attachment 1 to this letter. Reference (b) also expressed the NRC's concern regarding Zion Station's control of non-routine valve :nanipulations. The current system has been examined and found to be adequate for most situations. However, the l system was being inconsistently applied and lacked an effective mechanism for l identifying the alignment in the field. Thus, non-routine valve alignments at ! Zion Station will now be controlled by the positive methods contained in l Commonwealth Edison's Out-of-Service Procedure. l Commonwealth Edison Company has carefully reviewed this event and is concerned about the overall availability of Zion's auxiliary feedwater system. This concern is reflected in the extensive and comprehensive corrective action described in Attachment 1. However, Commonwealth Edison Company believes that this event has been improperly classified as a Severity Level III violation. I NUREG-0940 T.A-31
.v-t Mr. J. M. Taylor May 14, 1986
-A review has been performed of the auxiliary feedwater system's normal operating configuration at a number of the industry's PWRs utilizing information from NUREOs 0611 and 0560. This review has demonstrated that the configuration of the Zion auxiliary feedwater system during the 22 day event provided either equivalent or superior flow capacity and/or redundancy than is provided by the normal auxiliary feedwater configurations at a number of
! operating nuclear power plants across the nation. This fact is inconsistent - with the characterization of this event as being a significant safety violation. By virtue of these plant's continued operation, their auxiliary i
- feedwater systems must provide a sufficient level of redundancy, reliability, and capacity to satisfy the statutory requirement of adequate protection of the public health and safety. Thus, although a number of these plants are being reviewed by the NRC for the adequacy of their auxiliary feedwater systems, the fact of their current operation renders it inconsistent to fine Zion Station for operation for 22 days in a condition equivalent or superior to these operating plants. The imposition of a civil penalty in this instance i effectively penalizes commonwealth Edison for constructing Zion Station with ;
an auxiliary feedwater system design that exceeds the minimum requirements. j
< In addition to the review discussed above, a study was made of past enforcement actions taken in response to violations concerning auxiliary feedwater systems. This study demonstrated clearly that the proposed enforcement action for Zion is more severe than for comparable incidents across the nation. Thus, Commonwealth Edison believes that the enforcement policy delineated in 10 CFR 2.' Appendix C, has not been consistently applied i in this instance.
l l The details of these two studies, and their relationship to the l enforcement policy, are contained in Attachment 2. The conclusion of these assessments is that the isolation of service water to the 18 auxiliary l feedwater pump at Zion station for a period of 22 days is more properly characterized as a Severity' Level IV violation. Reference (b) also expressed the NRC's concern regarding the timeliness of Zion Station's actions following the discovery of this event. Cosumonwealth Edison company believes that Zion station personnel pursued the investigation of this event diligently. This was a complicated event, whose details required considerable effort to unravel. While it is recognized that the Resident Inspector could have been kept more informed as this investigation progressed, any such delay in communication does not have any bearing on the timeliness of Zion's corrective actions nor on the realization of the safety significance of this event. I NUPEG-0940 I.A-32
l Mr. J. M. Taylor May 14, 1986 The enforcement policy allows for mitigation of a proposed civil penalty for both prompt identification and for extensive corrective action. Reference (b) states that further mitigation of this penalty was not applied due to Zion Station's lack of timeliness in dealing with this issue. Attachment 3 discusses these issues in detail and demonstrates that the event was promptly identified and that the corrective actions taken were both timely and extensive. Commonwealth Edison's conclusion regarding this matter is that the enforcement policy allows for more extensive n.tigation than was exercised on this it. sue. For the reasons discussed above, commonwealth Edison Company believes that this event has been improperly categorized as a Severity Level III violation. In addition, notwithstanding our asserticn that this event is a Severity Level IV violation, commonwealth Edison company also believes that the proposed civil penalty should be completely mitigated. Thus, in accord-ance with 10 CFR 2.205.b, we are protesting both the classification of the violation as Severity Level III and the limited mitigation of the proposed l civil penalty. l please direct any further questions to Commonwealth Edison's-Department of Nuclear Licensing. Very truly yours.
. . \ Q '..' , - l Cordell Reed Vice-president in i
Attachments cc: Zion Resident Inspector l J. A. Norris - NRR J. G. Keppler - Region III SUBSCRIBED AND N to beforp me this B day of '/ : O n , 1986
. \j .
~ ~ '~y', ! .,
- f-* , \ o p .1
- Notary Public !
1 t NUREG-0940 I.A-33
ATTACHMENT 1 ZION NUCLEAR POWER STATION UNIT 1 RESPONSE TO NOTICE OF VIOLATION ITEM OF NONCOMPLIANCE As a result of the inspection conducted on January 4 through February 14, 1986, and in accordance with the."Ceneral Policy and Procedures for NRC Enforcement Actions. "10 CFR part 2. Appendix C (1985). the following violation was identified: Technical Specification 3.7.2.A.(1) and (2) requires that during plant operation in Modes 1. 2. and 3. three independent steam generator auxiliary feedwater pumps shall be operable with two motor driven and one steam turbine-driven auxiliary feedwater pump. With one-I motor-driven auxiliary feedwater purp inoperable, the pump must be restored to operable status within seven days, or the plant must be in Mode 4 within the next 12 hours. Contrary to.the above, from December 21, 1985 until January 12, 1986 with the plant operating in Mode 1. one motor-driven auxiliary feedwater l pump was inoperable with the applicable action statement not satisfied, i in that the pump was not restored to operable status within seven days and the plant was not in Mode 4 within the next 12 hours. Corrective Action Taken and Results Achieved l The immediate corrective action was to open ISWO656 to provide a source of cooling water for the IB auxiliary feedwater pump oil cooler. In addition, the remainder of the service water supplies to the Unit 1 auxiliary feedwater pumps were verified to be lined up correctly. Corrective Action Taken to Avoid Further Violation
- 1. Changes to the Unit 1 and 2 SW hydro procedure valve lineups have been instituted to make permanent the valving alignment which ensures SW is provided for both AFW pumps on the opposite unit.
- 2. personnel involved in hydro package review have been made aware of this event and cautioned to ensure attention to detail is given to the review of these packages. However, it should be noted that of the 58 hydro packages reviewed and performed during this and the preceding refueling outage, there were literally thousands of valve positions examined by these reviewers with only this one problem identified. All hydro packages have been re-reviewed since the identification of this problem and no other problem has been found. In addition, these hydro tests are only performed once during each unit's ten-year inspection interval.
Therefore, this is considered an isolated event.
?!UREG-0940 I.A-34
- 3. A Zion Administrative procedure change has been initiated and training to reviewers has been provided to ensure procedure changes clearly state the reason for each change. ,
- 4. The existing non-routine valve lineup procedure is being abolished. All valve manipulations will be controlled by the out of Service procedure. ,
- This procedure will provide more positive control over the plant's I configuration. l
- 5. A review of valve lineup procedures is being conducted to ensure that any components normally supplied with Service Water from the opposite unit .are never inadvertently isolated. Procedure changes will be made to correct any deficiencies.
- 6. A memo'has been provided to all shift supervisors alerting them to the cross connected condition which exists presently in the SW system and which may potentially exist in other " service systems" or conson systems.
- 7. The fact that some components receive their cooling from the opposite unit presents a potentially confusing condition that could lend itself to future errors. Thus, a review of the benefits obtained by allowing one unit's SW system to supply cooling to components on the opposite unit will be conducted.
- 8. Training has been provided to all Rad Waste Foreman on Zion Administrative procedures pertaining to operation. Adherence to procedures was emphasized during this training.
Date When Full Conollance Will Be Achieved Actions #4, 5 and 7 will be completed by June 30, 1986. All other actions have been completed. i . 1641K NUREG-0940 I.A-35
i ATTACNEff 2 SUlWERY Cosumonwealth Edison company has reviewed the auxiliary feedwater systems at many of the nation's operating pWR's and the nation's recent
- enforcement history concerning auxiliary feedwater. These reviews have concluded that the NRC's Enforcement policy has not been properly applied in this instance.
! The NRC's Enforcement policy authorizes the Region to issue a
-Severity Level III violation where a licensee's failure to satisfy an Action l Statement in the time allotted by the Technical Specification results in a i I
significant violation of a limiting condition for operation (LCO) (10 CFR part 50, App. C. Supplement I.C.1). However, the Enforcement policy also distinguishes between LCO violations of varying significance. A less significant violation of an LCO is characterized as a Severity Level IV l l (Supplement I.D.1). Thus, the proper classification of a Technical specification LCO violation depends heavily on the safety significance of the event. Edison has reviewed auxiliary feedwater operations at other plants and civil penalties for similar incidents to establish a framework for evaluating the significance of this event. As susmarized above, these comparisons show that: 1- operation of the Zion plant with one pump inoperable still left Zion with capacity and/or redundancy that was either equivalent or superior to the capacity and/or redundancy available during the normal operation of several other plants; and < 2- the escalated civil penalty is significantly more severe than any other penalty levied in comparable situations. Thus, the circumstances of this event and previous evaluations of the significance of similar events show that this event did not have a safety significance warranting a Severity Level III violation. The appropriate classification for this violation is severity Level IV. DISCUSSION The number of auxiliary feed water pumps at other Westinghouse plants and system capacities at those plants are enumerated in Table I. That Table shows that Zion's normal operating configuration, 3 auxiliary feed water pumps having a total capacity of 400% of required flow, joita several other Westinghouse plants at the high end of the spectrum of capabilities at all operating Westinghouse plants. More importantly, that Table also shows that the normal operating conditions for four Westinghouse plants provide less flow capacity or redundancy than was available at Zion during this incident. Five additional plants have normal operating configurations that provide equivalent flow capacity and/or redundancy. l l NUREG-0940 1.A-36
J s l During the Zion incident, 2 pumps capable of providing 300% of required auxiliary feedwater were available. By contrast, under normal operation, San onofre-1, and Prairie Island have 2 pumps available, and are capable of providing only 200% of required flow. Turkey Point has available only 1 1/2 pumps capable of providing 300% of flow. Yankee Rowe has 1 pump I with 100% capacity as its normal auxiliary feedwater system lineup. The continued operation of these four plants implies that the temporary operation of Zion with 2 pumps available and capable of providing 300% of flow was
'consistenti,sith the adequate protection of public health and safety.
1' A review of combustion-Engineering plants reinforces this conclusion. Table II enumerates the number and capacities of the auxiliary feed water pumps at those plants. Four of.those plants operate with only two pumps with a range of pump capacities from 200% to 400%. Thus, the pump configuration at Zion during the incident was right in the middle of the operation of pump capacities for these combustion-Engineering plants. Again, it follows that operation of Zion in this configuration was consistent with the adequate protection of public health and safety. If 13 plants can run normally with equivalent or less system capability and/or redundancy than was available at Zion during the incident, then this incident cannot be considered a significant safety matter for the purposes of the Enforcement Policy. Therefore, the incident at Zion was improperly classified as Severity Level III. This conclusion is supported by comparing the civil penalty proposed for Zion with civil penalties previously imposed in other incidents involving auxiliary feedwater systems. A compendum of those civil penalties is provided in Table III. That Table shows that the proposed civil penalty for Zion is more severe than any other civil penalty for a comparable incident. In no other case was 300% capacity still available during the incident. This information is pertinent because the proper classification of a Technical i Specification Lco violation depends heavily on the safety significance of the event. l In addition, in every other case leading to escalated enforcement no l i more than one pump was available. Thus, in all other cases of escalated
' enforcement there was no redundancy in the available pumps. This critical factor distinguishes the Zion event for which two pumps were still available.
At Zion, pump redundancy was still available throughout the incident. Clearly, this makes the Zion event fundamentally different from previous Severity Level III events involving loss of auxiliary feedwater. Therefore, classification of the Zion event with these previous events resulted in an inconsistent application of the Enforcement Policy. Accordingly, the Zion event should be reclassified as Severity Level IV. l l 1641K I NUREG-0940 f.A-37
ATTACIMENT 3 The NRC has stated in references (a) and (b) that it believes that Zion station was slow to realize the full significance of this event. Specifically, the inspection report transmitted with reference (a) stated on page 6; The licensee was slow to realize the significance of this event, in that it was discovered on January 12, 1986, and was processewi as a routine deviation report (DVR) until approximately January 27, 1986,
' when the Operating Assistant Superintendent detemined that this event could have represented a significant reduction in the margin of safety, and informed the NRC resident inspector. The licensee usually informs the resident office issnediately when significant events occur. The fact that the licensee inforined the resident inspector indicates that they were beginning to treat this as a more serious matter.
In add $ tion, reference (b) stated; However, NRC is concerned that after the valve misalignment was discovered and corrected two weeks passed before anyone ret.lized the full significance of this event. Reference (b) later statad; Further reduction was not applied because after the violation was discovered, you failed to realize its safety significance for some time. The above statements indicate that the NRC is correlating the 15 day time period between January 12 and January 27 with a perceived' delay in the recognition of the significance of this event. On the contrary, Commonwealth Edison believes that Zion station realized immediately the potential significance of this event. We acknowledge that the Resident Inspector could have been kept better informed of the investigation during this 15 day time period. However, this delay in communication does not have any bearing on the timeliness of Zion's corrective actions nor on the realization of the safety significance of this event. The immediate corrective action upon discovering the event was both timely and comprehensive from a safety standpoint. The service water cooling flow was immediately restored to the IR auxiliary feedwater pump and the service water supplies to the other auxiliary feedwater pumps were verified to be correct. When these actions were completed, the event's effect on reactor safety was terminated. The Unit 1 auxiliary feedwater system had been restored to a fully operable status. This occurred on January 12, 1986. The only information available to plant personnel on January 12, 1986 was the closed condition of valve 15WO656. Since this valve had not been associated with any maintenance or hydrotest activities, there was no indication as to the initiating mechanism of this event. Thus, there was no indication regarding the event's duration. NUREG-0940 I.A-38
1 However, station personnel 34;4diately recognized the need to determine the total duration of the a$rvice water isolation. From the time of the initial reviews of the deviation report, the potential for this event to be a technical specification violation was clearly understood by station personnel. Efforts were immediately initiated to determine the total time of isolation, so that the classification of this event could be accurately-established. It should be noted that in order for this event to be reportable ! under 10CFR50.73.2.i.B. the total time of isolation would have to exceed the 7 ) days allowed by the technical specifications. - As discussed at the Enforcement Conference held on March 31, 1986, the time period between January 13, 1986 and January 25, 1986, was spent engaging in extensive interviews, discussions, and research with numerous plant personnel. This investigation uncovered the root causes, personnel involved, initiating dates, and durations of the closure of both ISWO656 and ISWO660. In addition, the involvement of the service water system hydrotest valve line up was uncovered and thoroughly researched during this time period. Commonwealth Edison acknowledges that the Resident Inspector could have been informed of the progress of this extensive investigation during this time period. However, the NRC has incorrectly identified this lack of involved 3nt of the Resident Inspector as a failure to realize the safety significance of this event. The perception of a logical tie between this lack of communication and Zion station's perceived inability to recognize the significance of this event is incorrect. As discussed above, Zion Station personnel immediately recognized the potential of this event on January 12, 1986. The intervening two weeks was spent diligently investigating the details of this complicated event. The immediate corrective action taken in response to this event was to restore the Unit 1 auxiliary feedwater system to a fully operable status. This was the proper action to take and terminated this event. The additional corrective actions taken are discussed in Attachment 1. These 8 actions are
-extensive and are specifically directed at the contributing causes of this event to preclude additional similar violations in the future.
For the reasons discussed above, Commonwealth Edison Company believes that this event was identified promptly. The required reports were submitted within the mandatcry 30-day time frame. In addition, the corrective action taken in response to this incident was both prompt and extensive. Thus, there is considerable opportunity for additional mitigation of the proposed civil penalty that has not been exercised on this issue. 1641K f NUREG-0940 I.A-39
[ 'o
~g UNITED STATES ! o NUCLEAR REGULATORY COMMISSION
{ ,I WAsmGTON, D. C. 20055
\*..../
Docket No. 50-295 License No. OPR-39 EA 86-49 Comonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, IL 60699 I Gentlemen:
SUBJECT:
COMMONWEALTH EDISON COMPANY - ZION GENERATING STATION, UNIT 1 WITHDRAWAL OF PROPOSED CIVIL PENALTY This refers to your letter dated May 14, 1986 in response to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by t our letter dated April 15, 1986. The Notice describes a violation associated l with the isolation of cooling water to an auxiliary feedwater pump oil cooler and was reviewed by the NRC during an inspection conducted at your facility
- during the period January 27 - February 14, 1986.
In your response you admitted the violation occurred but believed it should have been categorized as a Severity Level IV violatior, instead of a Severity Level III. In addition, you gave reasons why you believe the proposed civil penalty should be further mitigated. Af ter careful consideration of your response, we have concluded, for the reasons set forth in the enclosed Appendix, that a sufficient basis was provided for changing the severity level of the violation. Accordingly, the violation set forth in the April 15, 1986 Notice has been changed from Severity Level III to Severity Level IV and the proposed $25,000 civil penalty has been withdrawn. No response to this letter is required since Comonwealth Edison Company responded to the Notice in its May 14, 1986 letter and described corrective actions that had been taken and will be taken. We will review the effective-ness of these corrective actions during future inspections. Our records will be changed to reflect that the Severity Level of the violation set forth in the April 15, 1986 Notice has been modified as described above. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I . A-4 0
Consonwealth Edison Company In accordance with 10 CFR 2.790, of the NRC's " Rules of Practice " Part 2, Title 10, Code of Federal Reculations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. Sincerely, J mes M. Tay1 x ~
, Director Office of In ection and Enforcement
Enclosure:
Appendix fittPEG-0940 I.A-41
d APPENDIX l The licensee's May 14, 1986 response to the April 15, 1986 Notice of Violation I and Proposed Imposition of Civil Penalty (Notice) for the Zion Nuclear Power i Station admits the violation occurred as stated in the Notice; however, the licensee believes the severity level of the violation should be reduced from a Severity Level III to a Severity Level IV. In addition, the licensee's response stated that the NRC Enforcement Policy permits more extensive mitication than was used in the Notice. The violation is restated below followed by a sumary of the licensee's response, the NRC's evaluation, and conclusion. Restatement of Violation Technical Specification 3.7.2.A.(1) and (2) requires that during plant operation in Modes 1, 2, and 3, three independent steam generator auxiliary feedwater pumps shall be operable with two motor driven and one steam turbine-driven auxiliary feedwater pump. With one motor-driven auxiliary feedwater pump inoperable, the pump must be restored to status within seven days, or the plant must be in l Mode 4 within the next 12 hours. l Contrary to the above, from December 21, 1985 until January 12, 1986 with the l plant operating in Mode 1, one motor-driven auxiliary feedwater pump was inoperable with the applicable action statement not satisfied, in that the ! pump was not restored to operable status within seven days and the plant was not in Mode 4 within the next 12 hours. l This is a Severity Level III violation (Supplement I). (Civil Penalty - $25,000) l Sumary of the Licensee's Response l ! The licensee reviewed the normal operating configurations for auxiliary feed-I water (AFW) systems at a number of Pressurized Water Reactors throuchout the country and concluded that the configt; ration of the Zion auxiliary feedwater system with one AFW pump inoperable provided either equivalent or superior flow capacity and/or redundancy to that provided by the normal auxiliary feedwater configuration at a number of operatino nuclear power plants. The licensee believes it is being penalized for constructina Zion Station with an auxiliary feedwater system design that exceeds minimum NRC requirements. In addition, the licensee reviewed past enforcement actions taken for violations concerning the auxiliary feedwater system. The licensee concluded that the proposed enforcement action for Zion was more severe than for comparable incidents. Based on these reviews, the licensee believes the isolation of service water to the 18 auxiliary feedwater pump at the Zion Station for a period of 22 days is more properly characterized as a Severity level IV violation. The licensee's response also stated the event was promptly identified, the corrective actions were both timely and extensive, and the enforcement policy allows for more extensive mitigation than was exercised in this case. The licensee further contends that Zion Station realized immediately the potential significance of this event. t l l l l NUREG-0980 T.A-42
Appendix 2 NRC Evaluation of the Licensee's Response In reaching the decision to issue the April 15, 1986 Notice of Violation and Proposed Imposition of Civil Penalty, the NRC staff considered a number of factors, including the importance of this system to assure adequate cooling of the reactor and the root cause of this event which involved personnel errors , and a failure to consistently follow procedures. These personnel errors ' included: (1) the radwaste foreman apparently closed Valve ISW 0656 and ! neither he nor the oncoming shift engineer initiated a non-routine valve lineup sheet to track this activity, (2) connunications between the radwaste foreman and the oncoming shift engineer were vague and unspecified, (3) some shift engineers were not aware of the normal lineup for the AFW lube oil coolers and this apparently contributed to,the misconception that shutting'a
" crosstie" would not affect the other unit, and (4) the procedure for non-routine valve lineups has not been consistently applied.
The NRC staff recognizes that the Zion Station auxiliary feedwater system continued to satisfy the single failure criterion even with one AFW pump inoperable. However, the licensee is required to operate and maintain the auxiliary feedwater system, a significant accident mitigation system, in accordance with the regulatory requirements in the Zion Technical Specifications. ,
.The NRC ' agrees that the' safety significance of the Zion event was minimized because of the redundancy and capacity of the remaining AFW pumps. Two AFW pumps remained operable with a total capacity of 300 percent of the design flow required from the AFW system. The NRC evaluation of the Zion event' shows, as was' asserted by the licensee, that the Zion event was of. less safety significance than of other AFW system violations for which escalated enforcement actions were taken. Further, the NRC considers the corrective actions taken by the licensee appropriate for the safety significance of the event.
Therefore, after careful evaluation of these factors and the discussion presented in the licensee's letter, the NRC staff has concluded that, although the viola-tion did occur as stated, it was of less safety significance than originally; considered. Although personnel errors were the cause of the violation, we note that the licensee has perfonned 58 hydrostatic tests during the last Unit 1 and 2 outages and this is the only example of a valve lineup error that was not identified by the licensee during the review process. Accordingly, j the violation has been more appropriately determined to be a Severity Level IV l violation. Conclusion The NRC staff believes that a reduction of the Severity Level from III to IV is warranted and that the $25,000 civil penalty previously proposed be withdrawn. Since the proposed civil penalty has been withdrawn, there was no further consideration of the licensee's request for additional mitigation, t Ni! REG-Ooa0 T.A-43
uselTED STATES [ma asey,b*,o NUCLEAR REGULATORY COMMisstON 3' g R EGIOce le j 8 j 101 MARIETTA STREET. N W ATLANT A. GEORGI A 3o323 e 0,
% . J'. . *j JUN 0 2 586 Docket No. 50-369 License No. NPF-9 EA 86-52 Duke Power Company ATTN: Mr. H. B. Tucker, Vice President Nuclear Production Department 422 South Church Street Charlotte, NC 28242 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY
,(INSPECTION REPORT 50-369/86-04; 50-370/86-04)
This refers to an NRC inspection conducted from January 6 - February 28, 1986, of activities authorized by License Nos. NPF-9 and NPF-17 for the McGuire Nuclear l Station, Units 1 and 2. The inspection included the performance of an operational safety verification and a special review of certain operating events. As a result of this inspection, failures to comply with NRC regulatory requirements were identified. The findings were discussed with those members of your staff identified in the referenced inspection report and at an Enforcement Conference I held at the NRC Region II Office on February 28, 1986. The enclosed Notice of Violation and Proposed Imposition of Civil Penalty involves a failure to meet the Unit 1 Technical Specification (TS) requirements in that a Limiting Condition for Operation (LCO) was exceeded and appropriate measures were not taken. In addition, while the LCO Action Statement was in i effect, the plant entered Operational Modes 2 and 3 in violation of the TS requirements. Specifically, following a reactor trip and safety injection (SI) on November 2,1985, motor operators for the Unit 1 Volume Control Tank's (VCT) isolation valves INV-141 and INV-142 failed in the closed position. Subsequent to the failure, plant staff manually opened the valves. Duke Power management erroneously decided that because these valves were not specifically addressed in the TS and were not a part of any required flow path, the unit could be restarted with the valves in the open position without violating the TS. Accordingly, the licensee restarted Unit 1 on November 2, 1985 and entered Modes 2 and 3 before the valves were repaired on November 4, 1985. After NRC inspectors brought the matter to its attention, Duke Power Company confirmed on January 15, 1986 that the unit had been operated in violation of TS 3.5.2 which requires "an operable flow path capable of taking suction from the Refueling Water Storage Tank (RWST) on a safety injection signal and automatically transferring suction to the containment sump during the recirculation phase of operation." CERTIFIED MAIL RETURN RECEIPT REQUESTED FUREG-0940 1.A-44
Duke Power Company. 2 JUN O 21986 The NRC considers this violation significant because both trains of a safety-related system were in a degraded condition while in Mode 2. These valves were required to isolate the VCT at the initiation of a SI signal so that the SI pumps would initially take suction from the RWST. With these valves open and inoperable, water from the VCT with lower boration levels would be pumped into the reactor coolant system. In addition, the VCT only has enough water to last approximatly 18 minutes into the safety injection. After the water supply is exhausted, the hydrogen used for overpressure could be drawn into the suction of the SI pumps that potentially may result in gas binding The staff recognizes that certain , manual actions could be taken to isolate the VCT However, specific procedures were not in place for these actions and neither the Final Safety Analysis Report for McGuire, Unit I nor the TS basis assumes such actions. To emphasize the importance of identifying and correcting plant conditions that are in violation of TS requirements and to ensure that plant actions do not adversely affect the ability of safety systems to perform their required functions, I have been authorized, after consultation with the Director, Office of Inspection 1 and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985) (Enforcement Policy), the violation described in the enclosed Notice has been categorized as a Severity Level III violation. The escalation and mitigation factors in the Enforcement Policy were considered, and no adjustment of the base civil penalty amount has been deemed appropriate. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, i including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. The responses directed by this letter and the' enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. NUREG-0940 I.A-45 l
Ouke Power Company 3 JUN O 21986
-Should you have any questions concerning this letter, we will be glad to discuss them with you.
Sincerely, he ~'K v J y- Nelson Grace R'egional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Inspection Report Nos. 50-369/86-04 and 50-370/86-04 cc w/encIs:
T. L. McConnell, Station Manager l l l NUREG-0940 I.A-46
I NOTICE OF VIOLATION AND PROPOSED IMPOSITI5N OF CIVIL PENALTY i Duke Power Company' Docket Nos. 50-369 and 50-370
'McGuire Nuclear Station License Nos. NPF-9 and NPF-17 EA 86-52 i During NRC inspections co'nducted ~ from January 6 - February 28, 1986, violations of NRC requirements were identified. In accordance with the " General Statement' of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"),
1 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below.
-Technical Specification 3.5.2 requires for Modes 1, 2, and 3 that two independent emergency core cooling system (ECCS) subsystems shall be operable with each subsystem. comprised of one operable centrifugal charging pump, one operable safety injection (SI) pump, one operable RHR heet exchanger, one operable RHR pump, and an operable flow path capable of taking suction from the' refueling water storage tank (RWST) on a safety injection signal and
' automatically transferring suction 'to the containment s6ap during the recirculation phase of operation.
~
With both ECCS subsystem flowpaths inoperable, Technical Specification 3.0.3 applies, which requires that except as provided in the associated requirements, within'one hour, action shall be-initiated to place the unit in a mode in which thefspecification does not apply.
' Technical Specification 3.0.4 requires-that entry into an operational mode or other specified condition shall not be made unless'the conditions for the Limiting Condition for Operation are met without reliance on provisions contained in the ACTION requirements.
Contrary to the above, during the period beginning at 9:00 p.m. on November
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2i 1985 until 7:30 p.m. on November 4,1985, the plant entered Modes 2 and 3 with both trains of the ECCS subsystems- for Unit 1 inoperable in' that the safety injection pumps would initially take suction from the volume control tank (VCT) instead of the RWST and the capability to automatically transfer suction from the RWST to the containment sump did not exist. This is a Severity Level III violation (Supplement I). (Civil Penalty - $50,000) Pursuant to 10 CFR 2.201, Duke Power Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D. C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice a written statement or explanation including for the violation: (1) admission or dental of the violation, i NUREG-0940 I.A-47
Notice of Violation 2 (2) the reasons for the violation if admitted, (3) the corrective steps which have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of. Inspection and Enforcement, may issue an Order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, the response shall be submitted under oath or i affirmation. l Within the same time as provided for the response required above under 10 CFR 2.201, Ouke Power Company may pay the civil penalty by letter addressed to the Director, Of fice of Inspection and Enforcement, with a check, draft, or money order payable i to the Treasurer of the United States in the cumulative amount of Fifty Thousand
- Dollars ($50,000) or may protest imposition of the civil penaliy in whole or in i part by a written answer addressed to the 01 rector, Office of Inspection and l
Enforcement. Should Duke Power Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order impcsing the civil penalty in the alnount proposed above. Should Duke Power Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, i such answer may: . (1) deny the violation listed in this Notice in whole er in l part, (2) demonstrate exter.uating circumstances, (3) show error in this N2tice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V(B) of 10 CFR Part 2 Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate text by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. 0 uke Power Company attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty. Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMISSION
. .L~
J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this 1 day of June 1986 NUREG-0940 1.A-48
DuxE POWER GOMPANY P.O. BOX 33189 CHARLOTTE N.C. 98E49 HAL5.TUCEER TELErnown m ePteeeerT PO4) 3D4331 emeten Peoescwoom July 2. 1986 Director. Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555
Subject:
McGuire Nuclear Station Docket Nos. 50-369 and 50-370 EA 86-52
Dear Sir:
Pursuant to 10CFR 2.201. please find attached a response to the violation identified in the subject Enforcement Action. Although Duka Power is admitting that the subject violation occurred, we do not believe that a Civil Penalty is warrested. Attachsent I contains the response to the violation Attachment 2 contains a discussion of mitigating factors. Very truly yours. 4 k Hal B. Tucker JBD/32/jga Attachment ze: Dr. J. Nelson Grace Regional Admissitrator U.S Nuclear Regulatory Commission Region II Suite 3100 101 Marietta Street
. Atlanta, Georgia 30332 Mr. W.T. Orders NRC Resident Inspector McGuire Nuclear Station NUREG-0940 I.A-49
-ATTACEMENT 1:
DUKE F0WER C003'ANY McGUIRE NUCLEAR STATION RESPONSE TO NOTICE OF VIOLATION (EA 86-52). (INSFECTION REPORT 50-369/86-04; 50-370/86-04) violation, Severity Level III EA 86-52 Technical Specification 3.5.2 requires for Modes 1,'2, and 3 that two inde-pendent emergency core cooling system (ECCS) subsystems shall be operable with each subsystem comprised of one operable centrifugal charging pump, one operable safety injection (SI) pup, one operable RER heat exchanger, one operable.RER pump, and an operable flow path capable of taking suction from the refueling veter storage tank (RUST) on a safety injection signal and automatically transferring suction to the containment emp during the recir-culation phase of operation. With both ICCS subsystem flowpaths inoperable Technical Specification 3.0.3 applies, which requires that except as provided in the associated require-monts,'within one hour, action shall be initiated to place the unit in a mode in which the specification does not apply. Technical Specification 3.0.4 requires that entry into an opsretional modo or other specified condition shall not be made unless the conditions for the
-Limiting Condition for Operation are met without reliance on provisions contained in the ACTION requirements.
Contrary to the above, during the period beginning at 9:00 p.m. on November 2, 1985 until 7:30 p.m. on November 4, 1985, the plant entered Modes 2 and 3 with both trains of the ECCS subsystems for Unit 1 inoperable in that the safety injection pumps would initially take suction from the volume control tank (VCT) instead of the INST and the capability to automatically transfer suction from the RWST to the containment sump did not exist.
Response
- 1. Admission or denial of the alleged violation:
Duke Power agrees that the violation occurred as stated in LER' 369/86-03, dated February 10, 1986.
- 2. Reasons for violation:
The violation occurred due to personnel error. It was (erroneously) determined that no Technical Specifications were violated and no safety concerns =were unanswered due to the inoperability of 1NY-141A and 1NY-142B when the decision to start up was made. This determination was based upon the fact that these valves are not addressed in the Technical Specifications. As these valves were not addressed in the Technical Specifications, personnel determined that the required flowpath of Technical Specification 3.5.2 was unaffected and that the NV (Chemical and Volume Control) system was capable of performing its design func-tion. The operability / degree of degradation was addressed in the Enforcement Conference of February 28, 1986. NUREG-0940 I.A-50
- 3. Corrective steps which have been taken and the results achieved:
The valves were repaired and returned to service on November 4, 1985. On January.'15, 1986, a memorandum uns sent to all licensed operators concerning the incident. This memorandum discussed the specific incident and stated:
"In the future when determining the operability of a flow path for systems covered by Tech Specs, ensure all valves in the subject system
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that are energized from a vital source are capable of performing their designed function. These valves may not be in the ECCS flow path, but may protect that flow path from a degraded flow condition or other important design consideration sot covered in Tech Specs."' A functional review has been initiated of the design purpose of each motor operated valve (MOV) which receives an Engineered Safety Features
- (ESF) signal. This inforn.ation will also include the consequences of such a valve being out of its safety position and inoperable.
It should also be noted that procedures were in place to assure manual accions should these valves have been called upon to function during this time. Procedure EP/1/A/5000/01 (Safety Injection), step D.2.C addresses the group 4 monitor lights (which include indication for 1NV-141 and 1NY-142) and includes the step " manually align equipment as required". This would have ensured that the valves would have been closed manually should they have been called upon to function while they were electrically inoperable. No similar incidents have occurred at McGuire since this incident, as none had happened before.
- 4. Corrective steps which will be taken to avoid further violations:
When the functional review of the MOV's which receive an ESF signal is complete. (see item 3), it will be reviewed with all licensed personnel. A Department Directive is being developed to apply to all of Duke Power's Nuclear Stations. This directive will address the operability of a system based on its subsystems and components. As an interim measure to the Department Directive, all operators have been instructed to perform a careful review in regards to system operability as discussed in the memorandum to all licensed operators as discussed above in number three. A new Technical Specification interpretation (as discussed below), coupled with the information on MOV's that receive an ESF signal will form the McGuire specific implementation of this directive. As mentioned above and discussed in Mr. H.B. Tucker's (DPC) letter to Dr. J. Nelson Grace (NRC/RII) dated March 4, 1986, a new Technical Specification interpretation on the determination of operability will be NtlREG-0940 I.A-51
developed. This interpretation will reference the listing of MOV's that receive an ESF signal, as appropriate, which will be included in the operator training program and in the Technical Specification reference manual.. ! 5. Date when full compliance will be achieved: ( Duke Power Company McGuire Nuclear Station, will complete the training or licensed personnel with regard to the Motor Operated Valves which receive an ESF signal by November 1,1986. The Department Directive will be in place by February 1, 1987. The new Technical Specification l interpretation will be in place by March 1, 1987. 1 ( l l l l 1 1 r I l l NilREG-0940 I.A-52
l ATTACEMENT 2 DUKE POWER COMPANY McGUIRE NUCLEAR STATION RESP (EISE TO PROPOSED CIVIL PENALTT While Duke Power agrees the violation occurred, we do not feel that a Civil
~ Penalty is warranted in this instance. The operators were aware of the inoperability of the valves and acted accordingly. Several factors should be considered that indicate that while .the valve operators were inoperable, manual manipulation of the valves could be depended upon, should a safety injection occur.
In the June 2,1986 letter transmitting the Notice of Violation and Proposed Implementation of Civil Penalty, NRC states that "The Staff recognizes that certain manual actions could be taken to isolate the VCT. However, specific procedures were not in place for these actions..." (emphasis added); contrary to this, procedural controls were in place to ensure valve alignment, manually if necessary. Attached is page 3 of procedure EP/1/A/5000/01,
" Safety Injection". Step D.2 specifies to check the ESF monitor light panels; subetop e specifically states that Se and St components in group four are to be lit. If the proper response is not obtained (group four lit), the procedure directs the operators to " manually align equipment as required".
Valves 1NV141 and 1NV142 are indicated on monitor panel four, the indicator being lit when the valves are closed (panel diagram included, the whole panel should be lit for a safety injection). With the valves open and the actuators inoperable with power removed, the monitor panel would show the valves as open (the last position of the limit switches) indicating to the operators that the valves needed to be manually aligned. It should be noted that the emergency procedure is based upon a generic Westinghouse Emergency Response Guideline which has been approved by the NRC. The lower boration level of water in the VCT relative to the RUST is not a safety concern. The boron concentration in the VCT would be approximately that of the reactor coolant system, and thus would not affect reactivity which would be controlled by the control rods. In addition, only the centrifugal charging (NV) pumps would be drawing from the VCT, with the RUST as a parallel suction when suction pressure from the VCT and Rust were equal. The Safety Injection (NI) pumps and residual beat removal (ND) pumps would taka suction from the RUST should system pressure decrease to allow injection from these pumps, 1520 peig for the NI pumps and 195 pois for the ND pumps. Also, the safety analyses of the event has shown that the NV pumps will not become hydrogen bound for at least 18.25 minutes following the initiation of a safety injection. This allows sufficient time for manual actions. Two separate " dry runs" plus the real situation on November 2,1985 indicate the valves can be closed in 14 - 18 minutes (including dress out time). Since the operators were aware that the breakers for INY-141 and 142 were red tagged open for repair, dress out requirements could be waived and the time required to close the valves would be approximately five minutes. NUREG-0940 I.A-53
I ATTACIDENT 2 Further investigation into this incident has revealed that although repair per-sonnel were at the valves _ the majority of the time of the repair, these personnel were not at the valves continuously while the valves were inoperable. During the period of time 'the repair personnel were at the valves, telephone comunication was available between the control room and the valves that would have allowed control room personnel to contact the repair personnel to manually close the other valve. The two valves are in serias, and one valve was always capable of being manually closed. With these factors in place, the . conclusion is that while the violation did occur in that these ,two valves were not capable of automatic closure as designed, no loss of safety function would occur as it was always possible to close the valves manually before hydrogen binding of the pumps would occur thus maintaining the design safety function of the valves. On this basis Duke Power believes that a Civil Penalty is not warranted in this case and requests mitigation of the proposed find. l l I l - i i l l l \ 1. l NUREG-0940 1.A-54 l l
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SEP 1 c 1986 Docket No. 50-369 License No. NPF-9 EA 86-52 Duke Power Company ATTN: Mr. H. B. Tucker, Vice President Nuclear Production Department 422 South Church Street Charlotte, NC 28242 .M Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTY This refers to your letters dated July 2 and 22,1986 in response to the Notice of kiolation ano Proposed Irnposition of Civil Penalty (Notice) sent to you by jg our letter dated June 2,1986. Our letter and Notice described a violation of technical specification requirements in which a limiting condition for operation was exceeded and appropriate measures were not taken. This violation was identified by the NRC resident inspector during an inspection conducted on January 6-February 28, 1986 of activities authorized by NRC Operating License NPF-9 for McGuire Nuclear Station, Unit 1. The staff completed its review of your responses in which you admit that the violation occurred as stated in the Notice, but you do not believe that the proposed civil penalty is warranted. After careful consideration of' your responses, we have concluded, for the reasons given in the-enclosed Order Imposing Civil Monetary Penalty and Appendix, that the violation did occur as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty and that you did not providt in your responses a sufficient basis for mitigating or remitting the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Duke Power Company imposing a civil penalty in the amount of Fifty Thousand Dollars ($50,000). In accordance with Section 2.790 of the NRC'sb Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The response directed by the accompanying Order is not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely.
, f m..
mes M. Tay1 , Director
/ Office of Inspection and Enforcement CERTIFIED MAIL -
RETURN RECEIPT REQUESTED - 6~" - HUREG-0940 I.A-55 g m
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of Duke Power Company Docket No. 50-369 (McGuire Unit 1) License No. NPF-9 EA 86-52 ORDER IMPOSING CIVIL MONETARY PENALTY I Duke Power Company (the licensee) is the holder of Operating License No. NPF-9 (the license) issued by the Nuclear Regulatory Comission (the Commission /NRC) on January 23, 1981. The license authorizes the licensee to operate McGuire Unit 1 in accordance with conditions specified therein. II A safety inspection of the licensee's activities under the license was copducted by the NRC from January 6 - February 28, 1986. As a result of this inspection, it appeared that the licenree had not conducted its activities in full compliance with NRC requirements. A Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was served upon the licensee by letter dated June 2,1986. The Notice stated the nature of the violation, the provisions of the NRC's require-ments that the licensee had violated, and the amount of the civil penalty proposed for the violation. The licensee responded to the Notice by letters dated July 2 and 22, 1986. NUREG-0940 I.A-56
III Upon consideration of the licensee's response and the statements of ract, explanation, and argument for mitigation of the proposed ~ civil penalty contained therein, as set forth in the Appendix to tthis Order, the Director, Office of Inspection and Enforcement, has determined that the violation occurred as stated and that the penalty proposed for the violation designated in the Notice of Violation and proposed Imposition of Civil Penalty should be imposed. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energ/ Act of 1954, as amended (42 USC 2282, pL 96-295), and 10 CFR 2.205, IT IS HEREBY.0RDERE6 THAT: The licensee pay a civil penalty in the amount of Fifty Thousand Dollars ($50,000) within thirty days of the date of this Order by check, draft, or money order payable to the Treasurer of the United States and mailed to the Director, Office of Inspection and Enforcement, U. S. Nuclear Regulatory Connission, Washington, D.C. 20555. V The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director, Office of Inspection and Enforcement, at the above address. A copy of the hearing request NUREG-0940 1.A-57
shall also be sent to the Assistant General Counsel for Enforcement, Office of the General Counsel, U. S. Nuclear Regulatory Commission Washington, D.C. 20555. If a hearing is requested, the Commission will issue an Order designating the time and place of the hearing. Upon failure of the licensee to request a hearing within thirty days of the date of this Order, the provisions Af this Order shall be effective without further proceedings. If payment has not been made by that time .the matter may be referred to the Attorney General for collection. t ) In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee violated NRC requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty, and (b) whether, on the basis of such violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY C0pmISSION s M. Tay1 , Director fice of In etion and Enforcement Dated at Bethesda, Maryland this /Qbay of September 1986 NUREG-0940 I.A-58
APPENDIX On June 2, 1986 a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for a violation of an NRC requirement. Duke Power Company's responses to the Notice were provided in letters dated July 2 and 22,1986. A restatement of the violation, a sussiary of the licensee's responses, the NRC staff's evaluation of the licensee's responses, and the staff's conclusions are set forth below. Restatement of the Violation Technical Specification 3.5.2 requires for Modes 1, 2, and 3 that two independent emergency core cooling system (ECCS) subsystems shall be operable with each subsystem comprised of one operable centrifugal charging pump, one operable safety injection (SI) pump, one operable RHR heat exchanger, one operable RHR pump, and an operable flow path capable of taking suction from the refueling water storage tank (RWST) on a safety injection signal and automatically transferring suction to the containment sump during the recirculation phase of opera tion. With both ECCS subsystems flowpaths inoperable, Technical Specification 3.0.3 ! applies, which required that except as provided in the associated requirements, within one hour, action shall be initiated to place the unit in a mode in which the specification does not apply. Technical Specification 3.0.4 requires that entry into an operational mode or other specified condition shall not be made unless the conditions for the. Limiting Condition for Operation are met without reliance on provisions contained in the ACTION requirements. Contrary to the above, during the period beginning at 9:00 p.m. on November 2, 1985 until 7:30 p.m. on November 4,1985, the plant entered Modes 2 and 3 with both trains of the ECCS subsystems for Unit 1 in% /able in that the safety injection pumps would initially take suction fru tr.e volume control tank (VCT) instead of the RWST and the capability to automatically transfer suction from the RWST to the containment sump did not exist. This a Severity Level III violation (Supplement I). (Civil Penalty - $50,000) Susunary of the Licensee's Responses Duke Power Company, in its responses, admits that the violation occurred as stated in the Notice, but believes the civil penalty is not warranted and requests mitigation of the proposed ciyil . penalty. The licensee states that pladt personnel were aware of the inoperability of the valves and acted accordingly. The licensee believes that although the valve operators were inoperable and the valves were not capable of automatic closure as designed, there were several factors that should be considered regarding the manual manipulation of the valves had a safety injection occurred. N11 REG-0940 1.A-59
Appendix 2 One of the factors submitted for consideration was the existence of a procedure which could have resulted in the manual closure of valves INV-141 and 1NV-142,
. if a safety injection had occurred. Step D.2 of procedure EP/1/A/5000/01, " Safety Injection," required manual valve alignment, if necessary, by directing the operator to check the ESF monitor light panels and to " manually align equipment ; as required." The licensee's safety analysis shows that the charging pumps could potentially become hydrogen bound approximately 18.25 minutes after initiating safety injection, allowing sufficient time for manual actions..
The licensee also stated that the lower boration level of water in the VCT as compared to the RWST is not a safety concern. The boron cuncentration in the . VCT would be approximately that of the reactor coolant system and would not affect ' reactivity which would be controlled by the control rods. 1 NRC Evaluation of the Response ; The NRC staff has reviewea the licensee's responses and concludes that no new
- 3 information has been presented which was not known to the staff at the tirne the Notice of Violation and Proposed Imposition of Civil Penalty was issued.
The staff notes that in the evaluation of this incident, tha licentee places - considerable reliance on manual actions to assure the safety function of the charging system for safety injection. The staff recognizes that the verification
- of the closure and, if necessary, manual alignment of the VCT outlet valves upon the initiation of safety injection is required.by procedures and that there may
- have been enough time to perfom the necessary manual actions.. However, the staff does not typically acknowledge manual actions in design-basis accident analyses tnat require the charging system to operate automatically. Furthemore, with regard to the licensee's determination that the baron concentration of the VCT is not a safety concern cased on the control of reactivity by the control rods, the injection of borated water of a sufficient . boron concentration is to counter potential operational events. Examples of such events are
- the failure of two or more control rods to insert following a reactor trip, an unexplained or uncontrolled reactivity increase, and an inadequate shutdown margin. The higher boron concentration of the RWST relative to the reactor coolant system is in part to ensure the avcilability of negative reactivity control.
The staff considers this violation to be significant because both trains of the charging system were in a degraded condition while the VCT outlet valves were open. The degraded condition of the charging system is cause for significant concern. In cate the staff recognizes that (1)gorizing certain emergencythe incident as awere procedurgs Severity Level in pFace whichIII violattun, could have led to the identification and closure of the required valves, (2) that plant personnel were aware that the VCi valves were inoperable although they were not aware that this violated 'a technical specification, and (3) that aralyses showed that the charging pumps would not become inoperable for approxisMcly 18 minutes after the initiation of safety injection. If the charging system had been detemined to be unable to perform its intended safety function rather than being in a degraded condition, this incident would have been categorized a higher severity level. Therefore, the staff believes the violation was appropriately classified as a Severity Level III violation. 1 NUREG-0940 I.A-60
Appendix 3 In considering mitigation of the civil penalty, although Duke Power Company requested mitigation of the proposed civil penalty, it failed to specifically address the five factors in Section V(B) of 10 CFR Part 2 Appendix C, which describes the bases for mitigation or escalation of a civil penalty. The five factors involve: prompt identification and reporting, unusually prompt and extensive corrective actions, past performance in the area of concern, prior notice of a similar event (escalation only), and multiple occurrences of a violation (escalation only). In evaluating these factors, the NRC considered that (1) there was not prompt identification of the violation in that the NRC identified this violation to the licensee approximately two months after the occurrence of the incident (2) the corrective actions taken were not unusually prompt in that some of the corrective actions proposed by Duke Power Company will not be in place until 1987, and (3) the licensee's past performance at the McGuire facility in the area of plant operations is considered poor based on the Systematic Assessment of Licensee Performance (SALp) Category 3 ratings in the area of plant operations for the periods ending August 31, 1984 and February 28, 1986 and two escalated enforcement actions taken in 1984 and 1985 related to the failure to maintain the containment spray and upper head injection accumulator systems in an operable condition. The factors of prior notice of a similar event and multiple occurrences were not considered appropriate for escalation of the civil penalty. Therefore, the staff believes that the civil penalty was appropriately assessed without mitigation or escalation. Conclusion The violation occurred as stated in the Notice and the licensee has not provideo an adequate basis for either mitigating or remitting the proposed penalty. Accordingly, a civil penalty in the amount of Fifty Thousand Dollars (550.000) should be imposed. NUREG-0940 1.A-61
- _ _ _ _ _ _ _ _ _ _ _ \
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\, ,...../ AUG 121066 Florida Power and Light Company <
ATTN: Mr. C. O. Woody Group Vice President . Nuclear Energy Department P. O. Box 14000 Juno Beach, FL 33408 Gentlemen:
SUBJECT:
CONFIRMATORY ORDER AND NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES: EA 86-20 (
REFERENCE:
INSPECTION REPORTS 50-250/85-32 AND 50-251/85-32, 50-250/85-40 AND 50-251/85-40, 50-250/86-02 AND 50-251/82-02, 50-250/86-11 AND 50-251/86-11, 50-250/86-26 AND 50-251/86-26) ! A Safety System Functional Inspection'(SSFI) was conducted by the Office of Inspection and Enforcement (IE) during the periods August 26-30 and September 9-13, 1985, and a followup inspection was conducted by Region II during the periods November 4-8 and 18-22,1985 of activities at the Turkey Point Nuclear Plant, Units 3 and 4 authorized by NRC Operating License Nos. DPR-31 and DPR-41. Other inspections were also conducted by Region II during the period January 6-10 and February 17 - May 15, 1986. The focus of some of these. inspections was.the auxiliary feedwater system (AFW) and the supporting back up nitrogen system. As a result of these inspections, failures to comply with NRC regulatory require- 1 ments were identified. Accordingly, Enforcement Conferences to discuss these matters were held in the NRC Region II Office on January 8 and 31,1986 and at the Turkey Point site on May 9, 1986. Item I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (NOV) involves significant weaknesses identified in your design control progra.T:. These violations ' indicate that you had not exercised adequate control to ensure that changes required as a result of system modifications were appropriately translated into operating procedures, drawings, system descriptions l and design basis document:i. Most of these violations affected the AFW and back-up nitrogen systems. The NRC staff considers these violations significant because operability of the back-up nitrogen system is essential to ensure that l l the AFW can perform its intended function upon the loss of the non-safety grade J instrument air system. The weaknesses identified in your program could lead to degradation or complete loss of the safety functions of these systems. Item II of the enclosed NOV involves the failure to satisfy the requirements of 10 CFR 50.59. In several cases, adequate safety evaluations were not perfonned for the effects of: (1) cnanges irede which could have led to AFW steam supply vent failure at low steam pressure conditions; (2) temporary system alterations CERTIFIED MAIL RETURN RECEIPT REQUESTED l NllPEG-0980 ' A-69
_ ~ . _ - . _ . . __ . . _ _ _ _ _ _ i l Florida Power and Light Company 2 l l pertaining to the removal .of the AFW governor speed control system; and l
-(3) temporarily adding loads to an engineered safety features electrical bus i which could have overloaded the emergency diesel generator supplying that bus. !
- These examples are considered significant because of the repetitive weaknesses i
' demonstrated in this area including three previous escalated enforcement actions involving 10 CFR 50.59 review deficiencies. It is apparent that the previous j corrective actions you had taken in this area were not adequate.
Item III of the enclosed NOW involves two significant violations of Technical Specification (TS) Limiting Conditions for Operation (LCO). On January 2, 1986, radiography personnel identified three AFW steam supply stop check valves as unacceptable per the acceptance criteria of Test Request 001-86. These valves were then inoperable and the system should-have been declared inoperable. The operability of the valves was not adequately evaluated and an LCO was not entered as required by Technical Specification (TS) 3.8.5. On January 7,1986, an NRC inspector questioned the operability of the valves. At that time the , valves were acknowledged to be inoperable and Unit 3 was then shut down and Unit 4.was placed in a 72 hour LCO as required by TS 3.8.5. Unit 4 was subsequently shut down on January 10, 1986. This violation is considered . particularly significant in that all functions of the valves should have been questioned when the problem was initially identified on January 2,1986. It was not until January 7,1986 that your engineering organization evaluated the i radiographic report and determined that the disc guide studs were bent or broken. The second technical specification vfolation occurred when on February 12, 1986, I the Unit 3 reactor was taken critical with only three safety injection pumps i operable instead of four as required by TS 3.4.1.4. Item IV in the enclosed NOV identifies weaknesses in your procedural control i program. These violations involve failures to establish or implement adequate procedures, and to properly control the revision and distribution of safety-related procedures. These examples indicated that your procedural control program was not fully effective. j Item V of the enclost.d NOV involves the failure to conduct adequate load capacity testing and monthly surveillance tests of safety-related batteries as required and the failure to conduct adequate preoperational load capacity tests of these same batteries. This violation is significant because surveillance and preoperational testing did not demonstrate the operability of the batteries as required by TS 3.7. In addition, examples of weaknesses involving your i corrective action program were identified in the performance of your maintenance activities. This is significant as previous problems were also identified in I this area. l ! Item VI of the enclosed NOV involves failures to take prompt and comprehensive i corrective actions once deficiencies were identified by you and the NRC. Inadequate corrective actions were taken with regard to: :(1) the adjustment i of cooling water flow to heat exchangers due to low flow problems without an evaluation of the resulting change in flow to other components also served by the cooling water system; (2) the potential for an intake cooling water valve not to close as intended on a loss of power or control air which was identified in [. November 1984 but was not properly evaluated until February 14, 1986 at the NUREG-0940 T.A-63
t l Florida Power and Light Company 3 urging of the NRC; and (3) the misinstallation of component cooling water (CCW) piping for the Unit 4 safety injection pump coolers which caused these coolers to be dependent on the Unit 3 CCW trains. Adequate safety evaluations and ; administrative controls were not established to assure that the Unit 3 CCW system operated with sufficient redundancy when Unit 4 was operating and Unit 3 was shut
'down. As a result of.these failures to perform adequate evaluations and to take adequate corrective actions in response to identified deficiencies, systems did ; not satisfy their design requirements under certain conditions. These examples indicate that although you-have shown great initiative in identifying potential safety problems, you must demonstrate the same degree ~of initiative in evaluating and correcting problems once they are identified.
After consultation with the Comission 'I have decided to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Three Hundred Thousand Dollars ($300,000) for the violations described in the-enclosed Notice. The six violations have been categorized as Severity Level III violations' or problems in accordance with the NRC Enforcement Policy,10 CFR Part 2.-Appendix C (1986). The base civil penalty for each Severity Level III violation is 550,000. Escalation of the penalty on-the basis of your prior poor performance was considered., However, the NRC recognizes that you have initiated extensive actions to examine all safety systems and to identify and correct problems at Turkey Point. Indeed, some of the violations cited'in this package were identified as a result of these actions. The NRC is encouraged by the programs you have recently instituted and believes these measures are necessary to improve operations at the Turkey Point facilities. Therefore, the
' staff has decided not to escalate the penalty. We are concerned by the numbers j of violations identified and we consider this civil pensity enforcement action I important to emphasize the significance of these violations and to emphasize the l need for you to continue to improve your management controls in all phases of the operation of the Turkey Point facility. Thus, no mitigation of the penalty has been proposed.
The Phase II Assessment Program you have developed is to be implemented in conjunction with the Turkey Point Performance Enhancement Program. This program will examine other safety-related systems to determine whether problems exist in these systems that are similar to those identified in the AFW system. Because we believe that your commitments to this program are significant and must be fully and effectively implemented, we are issuing the enclosed Confirmatory Order confirming your commitment to implement the extensive corrective actions to which you have comitted.~ The Order confirms your comitment to schedule the actions set forth in your Phase II Assessment Program (FP&L letter L-86-112 and L-86-197) and to submit regular progress reports to the NRC to ensure that these actions are implemented expeditiously. You are required to respond to the enclosed Notice and you should follow' the instructions specified therein when preparing your response. Your response should:specifically address the corrective actions taken or planned with regard to the violations described in the enclosed Notice. In your response, appropriate reference to previous submittals is acceptable. NilREG-0940 1.A-64
Florida-Power and Light Company 4 In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title 10. Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The response directed by this letter and accompanying Notice is not subject to the clearance procedures of the Office of Management and Budget as required by l the Paperworg Reduction Act of 1900, PL 96-511. Sincerely, 3 Las, /_ J s M. Taylo Director ffice of Ins ection and Enforcement
Enclosures:
- 1. Confirmatory Order
- 2. Notice of Violation and Proposed Imposition of Civil Penalties cc w/encis.:
C. M. Wethy, Vice President C. J. Baker, Plant Manager L. W. Bladow, Plant QA Superintendent J. Arias, Jr. , Regulatory and Compliance Supervisor 4 i NUREG-0940 I.A-65
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of FLORIDA POWER AND LIGHT L';MPANY Docket Nos. 50-250 and 50-251 (Turkey Point Nuclear Plant, License Nos. DPR-31 and DPR-41 Units 3 and 4) EA 86-20 CONFIRMATORY OftDER I The Florida Power and Light Company (FP&L, the licensee) is the holder of Facility Operating License Nos. DPR-31 and DPR-41 (the licenses) which authorize the operation of the Turkey Point Nuclear Plant Units 3 and 4 at steady state power levels not in excess of 2200 megawatts thermal (rated power). The licenses were originally hsued on July 19, 1972 for Unit 3, and April 10, 1973 for Unit 4. The facility consists of two pressurized water reactors located at the licensee's site in Dade County, Florida. Based on recent NRC inVction activities and the enforcement history at the Turkey Point Plant, the NRC has concluded that FP&L has not maintained effective management controls in the operation of its facilities. Inspections conducted August - November 1985 and January - May 1986, identified significant deficiencies in various plant systems, including the Auxiliary Feedwater and Back-up Nitrogen systems, the 125-volt vital batteries, the Component Cooling Water system, and the Emergency Diesel Generator system. These deficiencies included inadequate control of Plant Changes / Modifications, surveillance, preoperational and functional testing, and independent verification. 10 CFR 50.59 deficiencies, a HUPEG-0940 I.A-66
2-continuing problem at Turkey Point, and two significant violations of Technical Specifications involving the Auxiliary Feedwater System and Safety Injection Pump operability were also identified. These concerns have been expressed to FP&L management during various management and enforcement conferences. Violations l - associated with these problems are described in the Notice of Violation and Proposed imposition of Civil Penalties also being issued on this date. Previous enforcec?nt history related to the Auxiliary Feedwater System and its Nitrogen Back-up System irdicate that licensee management has been ineffective I l in resolving identified deficiencies. Previous escalated enforcement actions l issued in 1984 and 1985 (EA 84-41. EA 84-121, and EA 85-80) involved deficiencies similar to those identified during the recent inspections, including examples of failures to control Plant Change / Modifications, to perform adequate safety evaluations in accordance with the requirements of 10 CFR 50.59, to implement independent verification as required, and to establish or implement adequate procedures. The number of problems which have occurred involving the control and operability of the Auxiliary Feedwater and Nitrogen Back-up systems have raised serious concerns over the control and operability of other safety-related systems which have not received the level of NRC inspection and attention that the Auxiliary Feedwater and Nitrogen Back-up systems have received. As a result of problems identified during 1984, FP&L established the Turkey Point Performance Enhancement Program to improve the operation of its facility and to correct the deficiencies identified. A Confirmatory Order was issued on July 13, 1984 to confirm the implementation of this corrective action program. j NUREG-0940 f.A-67 l t . - , .. -
Because of the NRC's concerns regarding the acequacy of the Performance Enhancement Program due to the extent of the recent problems identified at the Turkey Point facilities, FP&L presented information to the NRC on January 8, 1986 describing management actions taken and planned to correct deficiencies identified during the Safety System Functional Inspection and the Region 11 follow-up inspections. A comprehensive program was then developed to assess the operability of other safety systems. A description of this program was presented to the NRC in a management meeting on February 26, 1986. The details of this program were described in FP&L Letter L-86-112 and its enclosures dated March 19, 1986 and FP&L Letter L-86-197 dated May 19, 1986. The management actions described in this letter appear responsive to the concerns of the NRC regarding the licensee's failure to maintain effective management controls in the operation of its facilities. Therefore, in view of the extent of the deficiencies identified in the recent inspection activities and the enforcement history at the Turkey Point Plant, I have determined that the public health, safety ano interest require that the actions set forth below be confirmed by an immediately effective Order to ensure that they are implemented expeditiously. This Order supersedes the Confinnatory Order of July 13, 1984 since it confirms the implementation of the Turkey Point Performance Enhancement Program including the Phase II Assessment Program as described in FP&L Letters L-86-112 and L-86-197. The provisions of 10 CFR 50.109(a)(2) and (a)(3) are not applicable ! since this Order is necessary to ensure that the facility is in compliance with regulatory requirements and to bring the facility into conformance with written commitments by the licensee. NUREG-0940 I.A-68
III Accordingly, pursuant to Sections 103, 1611, 1610, and 182 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR 2.204 and 10 CFR Part 50. IT IS HEREBY ORDERED EFFECTIVE IMMEDIATELY THAT:
- 1. The licensee shall continue to implement the Turkey Point Performance Enhancement Program (TPPEP) (Revision 1) and the connitments outlined in its letter dated April 11, 1984 that were included in the Enclosure to the Confirmatory Order of July 31, 1984 and shall continue to implement the later additions to the TPPEP discussed in FP&L Letter L-84-265 of September 28, 1984 and modified by FP&L Letter L-84-275 of October 3, 1984. The licensee shall not extend the scheduled times for completing the tasks described in the TPPEP without the approval of the Region II Administrator.
- 2. The licensee shall initiate the Phase II Assessment Program, as described in FP&L Letter L-86-112 and its enclosures dated March 19, 1986 and FP&L Letter L-86-197 dated May 19, 1986 as part of the TPPEP. The Phase II Assessment Program will include reconstitution of the system design bases, detailed inspections including walkdowns of the systems, comprehensive reviews by the Safety Engineering Group, and assessment of the Configuration Control Program. The licensee shall periodically update the Phase II Assessment Program and shall not change the completion dates contained in FP&L letter L-86-112 without approval of the Region II Administrator. The systems to be covered in the Phase II Assessment areas include:
i NilREG-0940 I.A-69
.-S-
- a. Safety In.iection, including low and high pressure, active and passive injection;
- b. Emergency Power, including Vital dc, 4160 and 480-volt ac supplies, and the Emergency Diesel Generators;
, c. Reactor Protection, including sensors or transmitters;
- d. Main Steam Isolation, including safety relief valves; i e. Component Cooling Water and Inteka Cooling Water;
- f. Containment Systems, including normal and emergency coolers, emergency containment filters, containment isolation, and containment sprays;
- g. Radiation Monitoring System, including process and area;
- h. Instrument Air
- 1. Chemical and Volume Control System (Emergency Boration)
- 3. The progress of the Phase II Assessment Program will be described in monthly reports to NRC Region 11 so that confirmatory inspections of the progress can be conducted. The licensee shall periodically (approximately l quarterly) present a written status report to the Region !! Administrator on the other TPPEP areas. This status report shall adoress the implementa-tion of the existing program tasks, including the plans and schedules for
. completing each section of the task elements. The licensee shall also include all plans and schedules for implementing each recommendation resulting from the implementation of the TPPEP. For any' recommendation which the licensee decides not to implement, an evaluation which supports i
l NUPEG-0940 f.A-70 l l ! t .-
that decision shall also be included. The licensee shall notify the Region II Administrator if it intends to alter any of the plans and schedules for implementation of the recommendations resulting from the TPPEP.
- 4. The licensee shall notify the Region II Administrator, within 30 days following the date of this Order, of any action item tasks associated with either tne original Confir.natory Order (EA 84-55) or this Order for which scheduled completion dates preceding the date of this Order have not been met and have not yet been reported, and establish for those tasks new completion dates which 'are acceptable to the NRC Region II Administrator.
IV The Region II Administrator may relax or terminate any of the provisions set forth in Section III of this Order for good cause shown by the licensee. V The licensee or any other person whose interest is adversely affected by this Order may request a hearing on this Order. Any request for hearing on this Order shall be submitted within 30 days of its issuance to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. A copy of the request shall also be sent to the Assistant General Counsel for Enforcement at the same address. A REQUEST FOR A HEARING SHALL NOT STAY THE IMMEDIATE EFFECTIVENESS OF THIS ORDER. NIIPFA-0940 T.A-71
_7-If a hearing is to be held, the Connission will issue an Order designating the time and place of any such hearing. If a hearing is held, the issue to be considered at such hearing shall be whether this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION
.m M.y J s M. Taylorgirector ffice of Inspection and Enforcement Dated at Bethesda, Maryland.
thisljl3f-dayofAugust1986. NllREG-0940 1.A-72
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Florida Power and Light Company Docket Nos. 50-250 and 50-251 Turkey Point Units 3 and 4 License Nos. OPR-31 and DPR-41 EA 86-20 As a result of inspections conducted August 26-30. September 9-13, November 4-8 and 18-22, 1985, and January 5-10 and February 7 - May 15, 1986 violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1986), the Nuclear Regulatory Comission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below:
- 1. 10 CFR Part 50, Appendix B, Criterion III as implemented by the approved Florida Power and Light Company Topical Quality Assurance Report (FPLTQAR) 1-76A, Revision 8. Topical Quality Requirement (TQR) 3.0, Revision 4 and Appendix B, Revision 7 requires that design changes, including field changes, be subject to design control measures commensurate with those applied to the original design and that these design control measures assure that applicable regulatory requirements and the design basis are correctly translated into specifications, drawings, procedures, and instructions.
FPLTQAR 1-76A, Appendix C, Revision 7 specifically commits, with exceptions not relevant here, to American National Standards Institute (ANSI) N45.2.11-1974, Quality Assurance Requirements for the Design of Nuclear Power Plants, and to Regulatory Guide 1.64, Revision 2 Quality Assurance Requirements for the Design of Nuclear Power Plants, which endorses ANSI N45.2.11-1974. ANSI N45.2.11-1974 specifies that design activities be prescribed and accomplished in accordance with procedures of a type sufficient to assure that applicable design inputs are correctly translated into specifications, drawings, procedures, or instructions. Appropriate quality standards must be Identified, documented, and their selection reviewed and approved. Changes from specified quality standards, including reasons for the changes, must be identified, approved, documented, and controlled. Design changes must be justified and subjected to design control measures comensurate with those applied to the original design. Contrary to the above, the Safety System Functional Inspection (SSFI) and the NRC Region II followup inspections identified that: A. At the time of the inspections, design inputs had not been correctly translated into operating procedures, as demonstrated by the examples below.
- 1. Off-Normal Operating Procedure (ONOP) 0208.11, Annunciator Test-Panel I - Station Service, was not revised to include appropriate i
l l l NUREG-0940 I.A-73 l i
. . .~
Notice of Violation operator action in the event of a low pressure alarm on the nitrogen back-up system. Plant change / modification (PC/M) 80-117 Upgrade Auxiliary Feedwater Suction, Discharge, and Steam Supply Piping, which was completed for Unit 3 on May 24, 1983 and for Unit 4 on December 16, 1983, modified the nitrogen back-up system such that operator action was required in the event of a low pressure alarm to ensure the continued operability of the auxiliary feedwater (AFW) system in-the event of a loss of the normal instrument air supply.
- 2. Emergency Operating Procedure (EOP) 20003, Steam Generator Tube Rupture, directed control room operators to isolate the steam supply from the faulted steam generator to the AFW turbines by shutting:the associated motor-operated isolation valves using the hand switches in the control room. However. the motor-operated isolation valves could not be closed from the control room to
' isolate a faulted steam generator when an AFW automatic initiation signal existed. When initially isolated, a subsequent AFW automatic
' initiation signal would reopen the motor-operated isolation valve. Because of these design features. alternate methods should have -' been evaluated to isolate a faulted steam generator from the AFW steam supply, f
- 3. Procedure 7300.2, AFW System Flow Control Valves Instrument Air /
Nitrogen Back-up System Operation, indicated operators had 15 minutes to valve in standby nitrogen bottles after a low pressure annunciator alarm. However,-the AFW system description and design basis allowed only ten minutes for the operators to take the required action. t' . Shared Auxiliary Feedwater System System Description and Design 4. ! Basis, Revision 1. dated January 31, 1985 (AFW System Description), j requires that 286 GPM of auxiliary feedwater flow must be delivered to each unit within three minutes in the event of a two-unit trip with only one AFW pump available. However Emergency Operating procedures 20004, Loss of Offsite Power, Revision dated August 23, 1985, and 20007, Total Loss of AC, dated August 26, 1985, did not assure that control room operators could balance AFW flows to the required 286 GPM for each unit within three minutes in the event i of a two-unit trip with only one AFW pump available as required by the System Description.
- 5. ONOP-103, Control Room Inaccessibility, dated August 7, 1985, did not address local control of Train 2 AFW flow control valves (FCVs) i or local control of the AFW pumps even though local control of
' Train 2 is required when only the "B" AFW pump is operable and is
- necessary when an AFW pump trips when the control room is inaccessible.
I NUREG-0940 I.A-74 w _ _ ___ _
-Notice of Violation 8. At the time of the inspections, design inputs had not been correctly translated into drawings. A change to PC/M 80-117 reset the nitrogen back-up system control pressure from 55 psig to 80 psig. However, the nitrogen.back-up system P&ID 5610-M-339 was not revised to reflect this change in pressure control valve setpoints applicable to valves PC-3-1706, PC-3-1708. PC-4-1705 and PC-4-1709.
C. At the time of the inspections, appropriate quality standards were not' correctly translated into procedures or drawings, as shown by the~ following two examples.'
- l. PC/M 80-117 indicated that electrical and instrumentation equipment associated with the nitrogen back-up system was safety-related. However, this equipment was not included in Quality Instruction QI-2.3A, Classification of Structures, Systems, and Components (Q-List). This equipment was therefore not being treated as safety-related by maintenance personnel and was not included in the periodic surveillance and calibration program.
- 2. Low pressure signals from pressure switches PS-3-2322 and PS-3-2323 shared a corrunon field wire and were neither designed nor considered safety-related even though current safety-related emergency operating procedures require action by the operator upon receipt of the nitrogen low pressure alarm.
D. At the time of the inspections, design inputs were not correctly translated into the system description and design basis documents as demonstrated by the following examples.
- 1. The AFW System Description indicated that an tir signal was supplied by a differential pressure controller which was set to maintain a minimum pump discharge pressure approximately 125 psi higher than the steam supply pressure. However, this design feature was disconnected. -
- 2. The AFW System Description indicated that when instrument air pressure dropped below 55 psig, cneck valves open to automatically supply back-up nitrogen. However, as a result of PC/M 80-117, the pressure control valves were set at 80 psig.
- 3. The AFW System Description involving operator action in response to a Icw pressure alarm in the nitrogen back-up system, at the time of the SSFI, referenced intended operation of the system before PC/M 80-117 was performed. The described action violated the single failure criterion, and was not appropriate for the current system configuration.
- 4. The AFW System Description does not define how long the AFW system may operate without operator action. No guidance was provided to establish ope,ating lirrits on the available nitrogen supply.
NUREG-0940 I.A-75
Notice of Violation E. As of the time of the inspection, design changes were not subjected to design control measures comensurate with those applied to the original design as two design changes to the AFW system caused an oscillation problem with the AFW FCVs when in the automatic mode of operation. 'These design changes involved: (1) a removal from service of the differential pressure controller and (2) a reduction in AFW flow from 600 GPM to 373 GPM. The resultant FCV oscillations created an increase in the nitrogen consumption rate. The increased consumption invalidated the design criteria for the nitrogen back-up system low pressure alarm setpoint which was set to allow 15 minutes for operator action to restore the nitrogen supply to the AFW FCVs. F. Quality Instruction 3.1, Control of EPP Design, Revision 2, dated October 9, 1979, in Section 5.5(4), requires that during the processing of the design by the discipline (s), various design and safety analyses are required. These analyses must be documented in legible and reproducible form by the engineer performing them. Notwithstanding this instruction, the licensee failed to adequately document assumptions and design inputs in calculations dated November 15, 1979 for the low level alarm setpoint on the condensate storage tank that would prevent a low pump suction pressure from occurring. This is a Severity Level III problem (Supplement I). (Cumulative Civil Penalty - 550,000 assessed equally among Violations A-F.) II. 10 CFR 50.59(a) allows the holder of a license to make changes in the facility as described in the Final Safety Analysis Report (FSAR) without prior Comission approval unless the proposed change involves a change in the Technical Specifications or is an unreviewed safety question. 10 CFR 50.59(b) requires the licensee to maintain records of changes in the facility or procedures, incluoing a written safety evaluation providing the basis for determining that the change does not involve an unreviewed safety question. Contrary to the above, the licensee failed to meet the requirements of 10 CFR 50.59 in that at the time of the SSFI and NRC Region 11 followup inspections: A. The licensee failed to perform an adequate safety evaluation for PC/M 80-117 in that an analysis was not performed of the consequence of an AFW steam vent valve failure to close and the ability of the auxiliary feedwater pump to supply sufficient feedwater flow at reduced steam generator pressures as described in FSAR Section 9.11.2, Auxiliary Feedwater Pumps.
- 8. The licensee failed to perfonn an adequate safety evaluation for Temporary System Alterations (TSA) 3-84-11-75,3/4-84-99-75,3/4-85-08-75, and 3/4-84-100-75 pertaining to the removal of the AFW governor speed control system as described in FSAR Section 9.11.2, Auxiliary Feedwater Pumps. The safety evaluation did not evaluate the mechanical reliabilib of the AFW system being operated under a constant speed condition.
l l NIIREG-0940 1.A-76
Notice of Violation C. The licensee failed to perform a safety evaluation for the consequences of the addition of electrical loads on a 4 KV engineered safety features bus. These additional loads should have been evaluated as to the capability of the emergency diesel generators to carry the increased loads as described in FSAR Section 8.2.3. This is a Severity Level III problem (Supplement I). (Cumulative Civil Penalty - $50,000 assessed equally among Violations A-C.) III. A. ' Turkey Point Technical Spe'cification 3.8.5.a requires that for single unit operation, with one of the two required independent auxiliary feedwater trains inoperable, the inoperable train must be restored to ortrabie status within 72 hours or the reactor shut down and the reactor coolant temperature reduced below 350*F within the next 12 hours. Technical Specification 3.8.4.b requires that for dual nuclear unit operation, two independent auxiliary feedwater trains and a third pump capable of being powered from, and supplying water to, either train must be operable when the reactor coolant is heated above 350*F.
-Technical Specification 3.8.5 requires that during power operation, if any of the conditions of 3.8.4 cannot be met, the reactor shall be shut down and the reactor coolant temperature reduced below 350*F, unless certain conditions can be met.
Contrary to the above, the Limiting Condition for Operation (LCO) -for Technical Specification 3.8.5 was exceeded on January 2,1986, when two Unit 3 and one Unit 4 AFW steam supply stop check valves (119 and 219 and 319, respectively) were found to be inoperable. The condition of the valves was identified on January 2,1986 as unacceptable by radiography personnel per the acceptance criteria of Test Request 001-86. Although both Units 3 and 4 were operating at above 350*F, no actions were taken by licensee personnel until January 7, 1986, when the results of the radiographs were questioned by an NRC inspector. B. Technical Specification 3.4.1.4 requires that the reactor not be made critical, except for low power physics tests, unless four safety injection pumps are operable. Contrary to the above, on February 12, 1986, the Unit 3 reactor was taken critical for power operations when only three safety injection pumps were operable. Low power physics tests were not being performed. This is a Severity Level III problem (Supplement I). (Civil Penalty - 550,000 assessed equally between Violations A and 8.) NUREG-0940 I.A-77
Notice of Violation ~IV. A. Turkey Point Technical Specification 6.8.1 requires that written procedures and administrative policies be established, implemented, and maintained that meet or exceed the requirements and recommendations of Sections 5.1 and 5.3 of ANSI N18.7-1972. Section 5.1 requires, in part, that instructions provide a clear understanding of operating philosophy and management policies. In particular, written administra-tive policies must be provided to control the issuance of documents, including changes, that prescribe activities affecting safety-related structures, systems, or components, such as operating procedures, test procedures, equipment control procedures, maintenance or modifi-cation procedures, and refueling procedures. These policies must assure that documents, including revisions or changes, are reviewed for adequacy and approved for release by authorir.ed personnel and are distributed to and used by the personnel performing the prescribed o activity. Technical Specification 6.8.1 also requires that written procedures and administrative policies be established, implemented, and maintained that meet or exceed the requirements and recomendations of Appendix A of NRC Regulatory Guide 1.33, " Quality Assurance Requirements (Operations)." Regulatory Guide 1.33, Appendix A requires that certain safety-related activities be covered by written procedures, including procedures for combating emergencies and other significant events. Contrary to the above, the SSFI and the. NRC Region II followup inspections identified, at the time of the respective inspections, that: 1.. Surveillance Maintenance Instruction 0-SMI-059.1, Inside Containment Instrument Independent Verification, and 0-SMI-059.2, Outside Containment Instrument Independent, Verification, dated July 30, 1985, specify requirements for providing assurance that safety-related instrumentation was properly aligned when the instruments were returned to service following unit outages. Notwithstanding, these instructions were inadequate because they failed to provide assurance that safety-related instrumentation was properly aligned when the instruments were returned to service following maintenance or calibration while the plant was in an operating mcde.
- 2. Administrative Procedure 0103.3, Control and Use of Temporary System Alterations (TSAs), dated January 31, 1984, Section 5.8, requires that the Plant Nuclear Safety Committee (PNSC) be responsible for reviewing applicable nuclear safety-related temporary system alterations within fourteen days of the Plant Supervisor-Nuclear approval date.
NUREG-0940 T.A-78
Notice of Violation .Notwithstanding this procedure, the PSNC failed to review TSAs 84-11-75, 3/4-85-8-75, 3/4-84-99-75 and 3/4-84-100-75 pertaining to the removal of AFW governor speed control systems within the prescribed time period. These TSAs were not reviewed by the PNSC until six months after the Plant Supervisor-Nuclear approval date. B. 10 CFR Part 50, Appendix B, Criterion V and VI as implemented by the approved FPLTQAR 1-76A, Revision 8. TQR 5.0, Revision 5 and TQR 6.0, Revision 3 requires.that measures be established to control the issuance of documents, such as instructions, procedures, and drawings, including changis thereto, which prescribe activities affecting quality. These measures assure that documents, including changes, are reviewed for adequacy and approved for release by authorized personnel and are distributed to and used at the location where the prescribed activity is performed. Contrary to the above. the licensee failed to ensure that procedure 3/4-0P-018.1, Condensate Storage Tank, a safety-related procedure, was approved for release by authorized personnel and appropriately distributed to and used at the location where the prescribed activity was-performed. This is a Severity Level III problem (Supplement I). ~ (Civil Penalty - 550,000 assessed equally between Violations A-B.) V. A. Turkey Point Technical Specification 4.8.2 requires for station betteries that:
- 1. Monthly each battery be given an equalizing charge, and afterwards specific gravity and voltage readings be taken and recorded for each cell. Water must be added to restore normal level and total water use is to be recorded. Complete visual inspection of the batteries must be made monthly.
- 2. Annually, a load test must be performed.
Technical Specification 3.7, Electrical Systems, requires that neither reactor may be started from cold shutdown unless four batteries and associated DC systems are operable and four out of six battery chargers are operable. - Contrary to the above:
- 1. From August,1985 until the time of the SSFI and Region 11 followup inspections, the licensee failed to conduct adequate monthly surveillance testing on the 125 volt station batteries as required by Technical Specification 4.8.2 to demonstrate the operability requirements of Technical' Specification 3.7.
NUREG-0940 I.A-79
Notice of Violation 2. At the time of the inspections, the licensee had failed to conduct adequate station battery load capacity tests as required by Technical Specification 4.8.2 to demonstrate the operability requirements of Technical Specification 3.7. B. 10 CFR Part 50, Appendix B, Criteria V and XVI, as implemented by the approved FPLTQAR 1-76A, Revision 8. TQR 5.0, Revision 5 and TQR 16.0, Revision 4, require: (1) that activities affecting quality be prescribed by and accomplished in accordance with documented instructions or procedures, and (2) that significant conditions adverse to quality be promptly identified and corrected and the cause of the condition and the corrective action taken be documented and promptly reported to the appropriate levels of management.
- 1. Contrary to the above, Nonconformance Report 85-206, dated December 5, 1985, required a search for the missing valve parts (three disc guide studs and one thrust washer); however, no documented basis was provided for justification to consider the system operable when the missing parts were not found and both units were subsequently returned to service.
- 2. Florida Power and Light interoffice correspondence dated February 25 and March 25, 1981 indicated the potential that a single valve, 3-20-428 for Unit 3, and 4-20-428 for Unit 4, could isolate two redundant condensate storage tank level transmitters.
Contrary to the above, the licensee failed to implement adequate administrative procedural controls subsequent to this discovery in 1981 to ensure that these isolation valves were adequately controlled in the open position.
- 3. a. Administrative Procedure ADM-0-]90.19, Control of Maintenance on Nuclear Safety-Related and Fire Protection Systems, dated May 21, 1985, required that applicable post-maintenance testing be defined on the Plant Work Order (PWO) to ensure proper post-maintenance functioning of the equipment.
Section 8.1.5 requires a Quality Control review of completed PW0s to ensure post-maintenance testing has been conducted. Contrary to the above, at the time of the SSFI and Region II followup inspections, the licensee had failed to implement these procedural requirements in that most instrumentation and control and electrical safety-related PW0s were completed without documentation of adequate post-maintenance testing. In addition, the licensee failed to provide adequate procedures in that Administrative Procedure A0M-0-109.28 Mechanical Test Control (Post Maintenance), dated August 21, 1985, addressed only mechanical maintenance with no provisions to ensure that post-maintenance testing associated with instrumentation and control and electrical PW0s was conducted. NUREG-0940 I.A-80
Notice of Violation b. Administrative Procedure 0-ADM-701, Plant Work Order Preparation, Section 5.8.1.8, dated July 12, 1985, requires that the root cause of, equipment failures he identified on completed Plant Work Orders. Contrary to the above, at the time of the SSFI and the Region II followup inspections, the licensee had failed to identify the root cause of equipment failures on a majority of several hundred completed safety-related PW0s which were reviewed. This is a Severity Level III. problem (Supplement I). (Civil Penalty - $50,000 assessed equally between violations A and B.) VI. 10 CFR Part 50, Appendix B. Criterion XVI as implemented by the approved FPLTQAR 1-76A, Revision 8, and TQR 16.0, Revision 4, requires that conditions adverse to quality be promptly identified and corrected. A. Contrary to the above, the licensee did not take promr.t and adequate corrective actions in that after it was determined in January 1986 that Component Cooling Water (CCW) flow through the Residual Heat Removal (RHR) heat exchangers appeared to be less than the minimum 4,000 GPM assumed in the accident analysis, CCW valves 748A and B were repositioned from 30% open to full open on February 24, 1986. This was done without evaluation or testing of the adequacy of flow to the other components served by the CCW system. Unit 3 continued to operate at 100% power from February 24 to March 3 with indeterminate CCW flow rates to the engineered safety features components. B. Contrary to the above, after determining in November 1984 that intake cooling water (ICW) valve CV-2201 might not be capable of closing upon a loss of power and/or a loss of its control air supply, the licensee failed to take timely corrective action in that the safety significance of this condition was not evaluated until February 13, 1986. The failure of valve CV-2201 to close would prevent, in some circumstances, sufficient ICW flow from reaching the CCW heat exchangers which, in turn, could prevent the engineered safety features equipment from performing as intended. After the February 13, 1986 evaluation, the licensee again failed to take appropriate corrective action in that no analysis was done regarding ICW system operability or TS limiting condition for operation compliance until NRC Region 11 management questioned operability in a February 14, 1986 telephone call with plant management, thereby prompting that these areas be addressed. C. Contrary to the above, in 1980 it was identified that the Unit 4 Component Cooling Water (CCW) trains for the connon Unit 3/4 high head safety injection (SI) system "B" pumps were incorrectly installed and poter.tially incapable of providing adequate SI pump cooling. NUREG-0940 I.A-81
Notice of Violation As of the inspection on February 17 - May 5,1986, this condition had not been corrected nor were adequate compensatory controls implemented. Rather than correct the piping discrepancy, the Unit 3 CCW trains to the SI coolers were used exclusively. Technical Specifications allow single train CCW system operation for a unit in cold shutdown and SI pumps are only recuired for a unit which is critical. Consequently, on at least twu cccasions between August and October 1981 with Unit 3 in cold shutdown and Unit 4 critical, only one train of CCW was available for cooling the SI pumps. Therefore, the SI pumps were susceptible to single failure induced inoperability, in that loss of-the Unit 3 CCW train would have disabled all SI pump coolers preventing the SI system from performing its intended safety function. This is a Severity Level III problem (Supplement I). (Civil Penalty - 550,000 assessed equally among Violations A-C.) Pursuant to provisions of 10 CFR 2.201, Florida Power and Light is hereby required to submit to the Director. Office of Inspection and Enforcement, U.S. Nuclear Regulatory Comission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region II, within 30 days of the date of this Notice, a written statement or explanatiu, including for each violation: (1) admission or denial of the .iolation; (2) the reasons for the violation if admitted; (3) the corrective steps which have been taken and the results achieved, (4) the corrective steps which will be taken to avoid
'further viciations; and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the
. Director 0ffice of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act. 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
Within the same time as prov_ided for the response required above unoer 10 CFR 2.201, Florida Power and' Light may pay the civil penalties by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount'of Three Hundred Thousand Dollars (5300,000) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should 51orida Power and Light Company fail to answer within the t%e specified, the Director, Office of Inspection and Enforcement will issue an c,rder imposing the civil penalties in the amount proposed above. Should Florida Power and Light Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violation listed in this Notit: in whole or in part, (2) cemonstrate extenuating circumstances, (3) show error in this Notice, or (4)'show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, , such answer may request remission or mitigation of the penalties. 1 NUREG-0940 I.A-82
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Notice of Violation ' In requesting mitigation of the proposed penalties, the five factors addressed in Section V.8 of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Florida Power and Light Company's attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COM4ISSION
/
J B/ s M. Taylor Director ffice of Inspection and Enforcement Dated at 8ethesda, Maryland, this /2Nay of August 1986. NUREG-0940 I.A-83
P o 90x t'1CCD A/.0 3c,hu- (_ 3 : va FLQAID A PCy c a 4 L.c,w - , af p f. , , OCTOBUl 01 S L-86-389 Mr. James M. Taylor, Director Office of Inspection and Enforcement ~~ . United States Nuclear Regulatory Commission Washington, D. C. 20555 Re: Turkey Point Units Nos. 3 and 4 Docket Nos. 50-250 and 50-251 EA 86-20
Dear Mr. Taylor:
In accordance with 10 CFR 2.201, this response is submitted to your letter of August 12, 1986, transmitting a Confirmatory Order and Notice of Violation (NOV), with respect to our Turkey Point facilities. We have carefully examined the NOV and as a result of our review of the issues involved, we do not believe it oppropriate to contest the NOV. Therefore, our check in full payment of the assessed penalty is enclosed. As I advised you in my letter of September 3,1986, requesting an extension of time to file this response, we wished to review the NOV carefully to assure ourselves that the corrective actions properly addressed the basic issue (s) underlying each matter. Accordingly, in Appendix 1, we have described the programmatic improvements in place or planned, together with their associated schedules in each of the six basic areas identified in the Notice of Violation: l (1) Design Control (2 50.59 Evaluations
- (3) Technical Specification Compliance
- (4) Procedural Controls (5) Control of Maintenance Activities, and (6) Timeliness of Corrective Action.
I believe you will find in reviewing Appendix i that the corrective actions completed or planned, not only address the violations, but are designed to ensure l effective management control by addressing their underlying causes. Because the corrective actions are extensive, going beyond the specific violations, we plan to use on Integrated Living Schedule (ILS), where appropriate, so that both the NRC's staff and FPL's monogement con carefully monitor FPL's progress and make such l odjustments os may be necessary to assure that oppropriate priorities are assigned to each task.1/ l l -*/ FPL has initiated discussions with the NRC Staff regarding formal adoption of on ILS by license amendment. PEOPLE. . SERVING 9EOPLc NilREG-0940 1.A-84
Mr. James M. Taylor, Director L-86-389 Page two The specific examples cited in each of the six oreas are discussed in Appendix II. Specific corrective measures to meet those identified deficiencies cre also included in the some ottochment together with references to documents previously filed with the NRC. This response and its associated programs have been carefully reviewed by FPL monogement; the necessory resources have been allocated to the effort and represent a commitment on the part of FPL monogement to its successful completion. We believe that the first task of management is to assure quality in every .ospect of FPL's operations and this is reflected in a corporate-wide commitment to a Quality improvement Program (OlP) in which FPL's Nuclear Energy Department has played a lead role. These concepts, adopted from techniques utililzed in Japanese industry, emphasize the use of data onolysis to assign priorities, determine roat causes of problems and formulate corrective ac tions. We believe that implementation of the OlP program at Turkey Point will assist in the improvement in significant performance indicators, including reduced equipment failures and unplanned challenges to protective systems. We believe that Turkey Point, as reflected in the recent SALP report, has been headed in a positive direction for the post year. The impetus provided by the Safety System Functional Inspection has, os noted in your letter of August 12, 1986, caused further improvements to be mode. We plan to work with the NRC to achieve our mutual goal of ensuring the margin of safety in the operation of Turkey Point is maintained. Accordingly, we would welcome your comments and suggestions, if any, on any aspect of the programs set forth in this response. Very truly yours, f C.O.W Group Vi President Nuclear Energy COW /gp Enclosure Attochments (2) i cc: Mr. Victor Stello, Executive Director for Operations, USARC Dr. J. Nelson Groce, Regional Administrator, Region 11, USNRC l l [ NUREG-0940 f.A-85
Re: Tu'rkey Point Unit Nos. 3 and 4 Docket Nos. 50-250 and 50-251 EA-86-20 APPENDlX 1 Basic Violations and Programmatic Corrective Actions I. Desian Control A. Summary of NRC Finding: Design changes were not subjected to 2 oppropriate design control measures. For example, system modifications were not always oppropriately' translated into operating procedures, drawings, system descriptions, and design basis documents. Quality standards were not always translated into procedures and drawings. Calculation assumptions and design inputs were not always oppropriately documented. Violations in this crea were identified primarily ~ in the Safety System Functional Inspection (SSFI) of the auxiliary feedwater system (AFW) at Turkey Point. B. Underlyino Cause: As a matter of background, the Turkey Point units were designed and constructed at a time when many current standards did not exist or were interpreted differently. Regulatory changes during the 1970's, especially offer the TMI accident, required significant additions and modifications to nuclear plant systems. In addition to these modificati .ns, the Turkey Point units replaced all six steam generator tube sheets and tubes, rebuilt the steam generators moisture separators and installed two full flow condensate polishing systems. This volume of work overstressed FPL's resources. The consequence of this condition was on inconsistency between the as-built modifications, drawings, procedures and personnel training. C. Programmatic Corrective Action: FPL is applying the lessons learned from the AFW 55FI to its conduct of a comprehensive review of select systems chosen on fl.e basis of the importance of their role in safely shutting down the reactor or mitigating design basis occidents. Phase i of this effort hos been completed, as previously discussed in FPL Letter L-86-112, dated March 19, 1986. Phase 11 is under way. The select systems covered by the program will be systematically analyzed. */ As described in our letter, L-86-ll2, dated March 19, 1986, the work for each system includes: (1) Establishing design criteria to be used in preparing the system design basis (e.g., single failure criterion, redundancy, electrical separation);
*/
Consistent with the requirements and schedule relief provisions of the order occompanying the NOV, the milestones for the select systems review are expected to .be incorporated in the Integrated Living Schedule (ILS) in occordance 'with their respective priorities and FPL's resources. I i I , N!! REG-0940 I.A-86
(2) Assembling current design and performc:ce information on each system from the FSAR, Plont Data Book, Tech Specs and other sources; (3) Reviewing each system ogainst applicable regulatory requirements; (4) Reviewing as-built system design drowings and other documents to ossure consistency between the documents and the system design basis; (S) Reviewing calculations on<t engineering studies to verify that the . system design bases are adequately supported by engineering 1 calculations and/or analyses; (6) Performing independent design verification of the selected system designs; and (7) Performing walkdowns os necessary to confirm that system configuration is consistent with the established design basis. This' program will facilitate design modification evoluotions and analyses of existing systems by establishing a readily accessible basis against ' which future modifications con be evoluoted. It will also support the configuration control program. The process of making changes to the plant will also be subject to more formal controls than in the post. Under a new program, a Standard Engineering Design Package is required for plant modifications, incorporating written instructions for the use of a Safety and Regulatory Reference Guide, a Functional Design Reference Guide and a Design Verification Reference Guide. The use of these guides will help to ensure that assumptions and inputs are adequately identified, correctly selected and properly incorporated into the design documentation. Each Standard Engineering Design Package includes a listing of drowings and a checklist for other documents that require revision as o result of the modification. This also helps to ensure maintenance of on occurate "os-built" plant design record. The Institute of Nuclear Power Operations (INPO) has requested permission to incorporate FPL's Standard Engineering Design Package for nuclear plants into its document of industry " good proctices." These new controls are reflected in a manual entitled " Standard Engineering Design Package for Nuclear Plants." Use of the manual will help to avoid the possibility of inadvertently offecting unmodified portions of a system being changed or related systems. Under the manual, the review cycle for each plant modification involves prior meetings among Operations, Training, Technical and other offected departments to identify offected plant procedures and the need for new or modified procedures. Administrative controls require that such t procedures are written or changed as necessary and assign specific responsbilities for accomplishing these tasks. Furthermore, o Design Integration Review Team of engineers currently reviews plant e 2 l i fillREG-0940 I.A-87
modification designs developed by either FPL or contractor engineering organizations. Reorganization of the engineering function and the increased staffing of both the engineering and technical organizations at Turkey Point have enhanced the effectiveness of the design control program. In early 198o o Site Engineering Monoger was oppointed, who reports directly to the Turkey Point Site Vice President. To resolve and incorporate the changes made to the units over 100 engineers and technical support staff were assigned to the Turkey Point site on a temporary basis. These organizational and staffing improvements have enabled the engineering organization to respond more effectively to requests for engineering assistance by having a dedicated Turkey Point site engineering group. The number of system engineers in the Technical Department has more than doubled with the addition of seven engineers, thereby reducing the number of systems assigned to each engineer and increasing the level of attention to design control with respect to each individual plant system. D. Date When Full Compliance Will Be Achieved: The draf t report of the design basis reconstitution for the original scope of the Select System Review Program has been prepared. Af ter review and verification activities are complete, required modifications will be subsequently scheduled for implementation to take maximum advantage of the opportunities afforded by normal refueling outoges, where oppropriate, and will be reflected in the Integrated Living Schedule. The entire program, including further verification steps and walkdowns, should be completed by the end of the next Unit 4 refueling outage or in accordance with the ILS if issued as port of the license amendment process. The manual for the Standard Engineering Design Pockage hos been issued and is currently in use for plant modifications. 3 i NUREG-0940 f.A-88
II. 50.59 Evaluations A. Summary of NRC Findinas: Sofety evoluotions of plant design . modifications were not always adequately conducted and the need for the evoluotion of some plant modifications pursuant to 10 CFR 50.59 was not always recognized. B. Underlyina Cause Modifications performed in the mid 1970's were evoluoted in accordance with the existing industry stondords for 50.59 ) evaluations. The current industry standards for these 50.59 evoluotions ' call for more formal and rigorous evoluotions. This concern arises out of the fact that, as one of the notion's older nuclear plants, Turkey Point hos been subject to an unusually large number of modifications. Inodequocies in the coordination of some temporary or permanent modifications have contributed to a failure, at times, to recognize the i need for, and conduct of, odequate 10 CFR 50.59 evaluations. These
- problems have been extensively addressed since the SSFl.
C. Proarammatic Corrective Action: The improved visibility of the site engineering organization and the increased engineering sinffing levels described in Appendix 1, Sections I and VI, have enabled site engineering l to conduct more rigorous, timely and controlled evoluotions of permanent and temporary plant modifications during this year, in addition, the increased staffing and organization controls are intended to avoid the possibility of making inadequately reviewed modificottons. The mere presence of this increased engineering staff will, we believe, also help to sensitize others to the procedures which must be followed , in connection with modifications. 1 i In generating a Standard Engineering Design Pockoge for plant modifications, engineers use a Safety and Regulatory Reference Guide and a Functional Design Reference Guide to help ovoid the possibility of , overlooking any relevant off-normal operating condition. The FPL Power Plant Engineering Department must concur with each Standard Engineering Design Package that is generated for o plant modification. Additional control of temporary system alterations hos been achieved
- through a site procedure revision requiring the Shif t Technical Advisor 4 to determine the necessity for on Engineering review under 10 CFR 50.59.
l Training of technical personnel and monogement attention to the
- implementation of the new and more formal plant modification process j will ensure that necessary safety evaluations are identified and conducted in a timely manner.
D. Date When Full Compliance Will Be Achieved: Corrective actions have , been completed, except for the upgraded procedure for plant { modifications which is currently under review and tentatively scheduled for issuance in October 1986. 4 4 ! 4 1 i : i NtfREG-0940 I.A-89 l
111. Technical Specification Comptionce A. Summary of NRC Finding: Instances were identified in which there were - inadvertent noncomptionces with Limiting Conditions for. Operation (LCO). In each case, there was a failure to recognize that certain plant equipment required for service pursuant to plant technical specifications was inoperable. B. Underlyino Cous_e: The dif ficulty experienced is attributoble, in port, to: (i) inadequate procedures for identifying equipment taken out of service for inspection or repairs; (2) inadequate engineering review of non-conforming conditions; and (3) complexities and/or lack of definition in the present technical specifications which are being updated and improved. C. Programmatic Corrective Action: With respect to inadequocies in procedures for identifying inoperable systems, procedures have been modified and implemented for issuing the clearances required to safely remove equipment from service for inspection or repair. The previous procedures provided for o process that grouped clearances for common systems with those for Unit 3. These procedures have been modified to separate clearance control for common systems from that for Unit 3 and Unit 4. A more aggressive approoch to maintenance activities discussed in item V below will reduce the tendency, noted in the most recent SALP report on Turkey Point, "to operate around maintenance problems" by "on the spot changes" or compensating actions. The expansion of the site engineering organization discussed in Section I of this response, the OA corrective oction program discussed in Section VI and site engineering procedures now being implemented should also assist by providing more consistent, formal and timely engineering review of non-conforming conditions. An additional feature hstituted this post year is that the Turkey Point Regulation and Compi.once Group is ovallable to provide guidance to the operating stof f on issues of Technical Specification Compliance. The System Operability Reviews are completed, which provides the component level requirements associated with system operobility. This extensive program provides a major resource to assist the plant departments in making operobility determinations, which will in turn positively of feet Technical Specification compliance. Finally, as the Commission is aware, FPL has just submitted to the NRC a comprehensive revision of the technical specifications for Turkey Point making them more compatible with those used on newer plants. This extensive effort hos been described by the NRC Staff in the most recent SALP report for Turkey Point as being of " greater mognitude and scope than any similar initiatives at other utilities." D. Date When Corrective Action Will Be Complete: The foregoing changes have been completed, although further enlargement of the on-site engineering stof f is contemplated. S NilREG-0940 I.A-90 l i i
. ., -- ,- .---y -,----r - --
.. . - . -. .- - --~ ~ .- - . . . - . .-
1 i f - A IV. Procedural Control A. Summary of NRC Findina: As a result 'of the SSFI and a Region 11 follow-up inspection, concerns were identified with respect to the ',' odequacy of procedures -and their controls, including the technical review of procedures prior to their release and dissemination. B. Underlyino Cause: As one of the notion's older generation of nuclear plants, Turkey Point's procedures were revised and supplemented on on 4 "os needed" basis over the years. They were not necessarily prepared by 1 . skilled, professional technical writers, i C. Pronrommotic Corrective Action: As the Commission is aware, FPL, os > part of its PEP program, hos included a Procedures Upgrade Program (PUP) entailing the revision and writing of procedures in the oreos of odministration, normal and emergency operations, os well as i surveillance and maintenance. The PUP is largely based on INPO guidance and good practices. This upgrading process hos been described to the NRC in previous communications.
; The PUP effort is being performed by contract technical writers under j the supervision of FPL. Heavy emphasis is being plo:ed on human j factors to assure that procedures are " user friendly." The entire offort is governed by a writer's guide and a set of PUP procedures. The program was initiated over two years ogo.
To ensure that procedures are understandable and consistent, a standard ! format is utilized and technical writers will frequently talk with people l who are responsible for implementing procedures and observe operations I in the field. Draf ts of procedures are reviswed by the offected ! departments; their comments are resolved and a revised draf t may be circulated once more (particularly in the case of a major revision) to ensure that the resolution of comments hos been satisfactory. Procedures are reviewed (including a formal 50.59 review by ! engineering as necessory) by GC personnel, by the offected " i departments, by GA personnel os appropriate, and by the Plant Nuclear i Safety Committee. New or revised procedures must be approved by the i Plant Manager before being issued and distributed to users. As noted in 4 the NRC's most recent SALP report on Turkey Point "the pre. i implementation review process is extensive and includes input from l knowledgoble stoff members." l The PUP - Document Control interfoce has been substantially upgraded over the post year. A process exists, for example to ensure that ' l revisions to procedures are accompanied by necessory transition j documents and concellation letters. The details of the PUP - Document l Control interface are addressed in Appendix 11, Section IV.B. i Compliance Is clearly facilitated by having uniformly written, clear j procedures to which personnel are trained. In recognition of the need to upgrade training materials to reflect the current and future procedure revisions, the Training Department hos increased stoffing requirements l from 35 to 58 personnel with 45 of the 58 positions filled and i 6 I i { NUREG-0940 1.A-01 I i i
7 implemented a computerized trotning materials dato bose. These changes will improve configuration control of training materials including system descriptions. FPL's management is most sensitive to the fact that, os noted in the recent SALP report and the instant NOV, instonces of inattention to procedures have occurred. The Company has token very severe odministrative personnel actions in such instances and will continue to do so. Even more important is the instillation of oppropriate ottitudes in this respect, and we believe the PUP program hos had a markea influence on personnel at Turkey Point. Both operations and maintenance personnel are reluctont to oct without proper procedural guidance and, as noted in the recent SALP report, the PUP program has had the effect of " reducing misinterpretations and personnel errors." D. Date When Full Comotionce Will Be Achieved: The schedule milestones are set forth more completely in the Performance Enhancement Progrom. i i 7 NUREG-0940 f.A-92
V. Control of Maintenance Activities A. Summcry of NRC Findina: Various maintenance octivities, including operability testing, were not always conducted in accordance with vendor requirements, procedures or documented instructions, and maintenance f ailed, in some instances, to promptly identify, correct and document significant conditions adverse to quality. B. Underlyino Cause: Maintenance procedures, including those for both preven tive maintenance and post-mointenance activities, required improvement. In addition, inadequocles in the documented system design basis and plant change packages resulted in a failure in some instances to specify necessary post-mointenance testing requirements. C. Programmatic Corrective Action: The maintenance organization is currently undertaking o number of programs to enhance the effectiveness of maintenance activities. Programmatic improvements includes organization changes, increases in staffing, development of maintenance procedures, development of a formalized preventive maintenance program, incorporation of pnst-maintenance requirements into procedures, training in the arcos of mechonicol, electrical and I & C molntenance, and implementation of a computerized work order system. A preventive maintenance section has been formed within the maintenance organization as the fourth functional arco, joining mechanicol, electrical and I & C. In addition, o permanent engineering stoff of six engineers has been assigned to the maintenonce organization to assist in field analysis of root causes. Maintenance procedures are being revised and numerous new procedures are being written, particularly in the preventive and post-mointenance areas. These will improve the level of control over maintenance activities and enable the maintenance organization to incorporate the INPO Guidelines on Molntenance. The Analytical Based Preventive Maintenance Prog om (ABPM)is being developed to improve equipment reliability. The ABPM entails input from both industry and plant historical dato, and research and analysis by Plant Senior Maintencnce Discipline Supervisors. Innovative features of the program include consideration of predictive monitoring, plant aging effects, operobility requirements such as possible LCO considerations, and equipment quollfication requirements. The ADPM progrom is currently under development, and upon completion, plant operating equipment will be covered and a significant number of new procedures will have been generated. As on additional control on the , preventive maintenance procedures, they will be reviewed by the Plant Nuclear Safety Committee. ' FPL has developed a new criterio document that provides generic guidance for post-mointenance testing requirements on mechanical, electrical and I & C equipment. 00 sed on this generic guidance, 8 NijP%-0940 !.A-93
existing procedures are being revised and new procedures generated as necessary to incorporate post-mointenance requirements into applicable maintenance procedures. When the decision was mode in August, 1984 to obtain INPO occreditation, maintenonce training was moved from the maintenance orgonization to the site training deportment. A training program, potterned on the IWO guidelines, hcs been established with the goal of enhoncing training for each of the molntenance personnel. This training program along with the issuonce of the new ond revised procedures, porticularly - in the areas of preventive maintenance and post. maintenance octions, will enable molntenance personnel to effectively implement the new programs. A new Nuclear Job Planning System (NJPS) hos been established to provide computerized planning control of Plant Work Order (PWO) issvonce and trocking through the NJPS. This file will enable the maintenance organizution to trock the history of individual items to identify precursors to malfunction and failure more effectively. In addition, several odditional job planners have been added to the NJPS to improve the timeliness of PWO issvonces. D. Date When Full Comollance Will Be Achieved: Organizational and stoffing changes to improve the preventive maintenance and root cause analysis functions have ofready been Implemented. The other programmatic corrective actions described above and their schedules are incorporated in the Performance Enhancement Program. 6 9 NtlREG-0940 I.A-94
VI. Timeliness of Corrective Action A. Summary of NRC Findina: Although FPL has shown great initiative in identifying potential safety problems, corrective actions have not always been implemented in o timely and comprehensive way. B. Underlyino Cause: This concern is largely the result of limited lines communications between the Turkey Point site and the Juno Beach-based engineering organization, os well as the need for more on-site engineering support. Historically, certain non-conformance reports (NCRs) could not be dispositioned on-sites likewise, requests for engineering assistance (REAs) had to be transmitted to, and processed by, the Juno Beach engineering organization. C. Proarommotic Corrective Action: There has been a significant increase in the on-site engineering force at Turkey Point. The Site Engineering . function now reports directly to the Site Vice. President. The increased presence and visibility of the on-site engineering function has allowed , NCRs and REAs to be dispositioned more promptly without the attendant communciations difficulties created by distance between the site and the corporate engineering group of Juno Beach. To address the concern of satisfying operobility requirements while identified deficiencies are being evolvoted, o proposed site engineering procedure is being finalized. This procedure will formalize the requirements and responsibilities associated with determining the impact on operability and reporting of deficiencies. As port of this process, safety evoluotions by the Power Plant Engineering are initiated when oppropriate. The duties of the Technical Department system engineers are also discussed in o new site engineering procedure, which is in the final stage of review. These individuals will be considered the plant experts for their assigned systems, and would be expected to stay current on outstanding deficiencies being reviewed so that external evoluotions are not postponed without regard for safety significance. The corrective action program is audited by the site OA organization which is accountable for assuring implementation of the program in occordonce with applicable procedures. As noted below, unless dispositioned within 10 days, NCRs generated by OC and Requests for Corrective Action (RCA) are entered on a computerized commitment trocking system (CTRAC). Beginning in July,1985, the frequency of OA oudits of the corrective oction program (in port using the CTRAC system) is now done quarterly, instead of semi annually. The OA organization is now trending the performance of the corrective oction program and reporting those trends on a quarterly basis. In addition, the new Performance Monitoring Group within the OA organization is more deeply involved in on-going activities of the Plant Staff and thus, provides more effective reol. time monitoring of those activities including corrective actions. 10 NUREG-0940 1.A-95
Other procedures developed by the site OC organization within the post year require that NCRs and RCAs be resolved within 10 days or, if not, that they be entered on the CTRAC system with on opproved schedule for corrective action. If the corrective oction connot be completed in accordonce with the schedule, on extension may be requested in writing to the OA Superintendent. The QA Superintendent may grant only one extension up to thirty days. Subsequent requests con only be approved b/ the Director of GA. These changes have contributed to o more effective, operationally focused corrective action program which con be monitored on essentially a real-time basis and regularly audited to assure proper implementation. j D. Date When Full Comollance Will Be Achieved: The corrective actions described above ore now implemented. i J k I I t iI i i i tillPEG-0940 1.A-96 , 1
APPENDlX 11 l Specific Violations and Corrective Actions j l. Desion Control A.
- l. Item 1.A.I involves the failure to modify on Off. Normal Operating Procedure (ONOP) to reflect a change in the Upgraded Auxiliary Feedwoter System which had been mode in 1983.
Reasons for the Violation _: There was inadequate coordination between the Power Plant Engineering and Nuclear Energy Deportments to ensure updating of procedures to reflect plant changes and modifications. Corrective Action and Date When Full Comollance Will Be Achieved: The procedure in question, ONOP 0208.11, Annunciator List-Ponel1 Station Service, was changed to clorify immediate operator actions in the event of this alorm. It was opproved by the Plant Nuclear Safety Committee (PNSC) on October 29, 1935. Further, EOP's have been revised to require operators to shif t flow control volves to monvol from automatic control within 3 minutes of AFW octuation. Plant Change / Modifications (PC/Ms) 85-130 (Unit 3) and 85-131 (Unit 4), AFW Discharge Flow Control Volves Upgrades have been implemented. These modifications replace the existing AFW volve trims with trims sized for operation at the revised setpcInt and to limit flow through a stuck open volve. The trim change improves the volve performance and reduces volve oscillations. Reduction of volve oscillations will reduce backup nitrogen supply consumption. Limiting AFW flow through a stuck open volve ensures odequate feedwoter flow l Is ovalloble to the operating steam generators und will prevent i overpressurization of the containment building if the volve sticks open concurrent with a steomline break. As noted in Appendix 1, new procedures and programs have been initiated to ensure that PC/Ms are appropriately incorporated in operating procedures. Prior to initiotion of the PC/M design activity, Power Plant Engineering and Nuclear Energy schedule on operability review meeting. This review ensures that Engineering is provided with the necessory system operating information. This inter-department coordination will ensure that the pertinent plant procedures are identified, reviewed and modified to reflect the new system configuration. Administrative Procedure AP 0190.15 (7/24/86) Plant Changes and Modifications" requires the Nuclear Startup Department to verify with the Plant Operation Supervisor that new procedures are written and old procedures are modified where oppropriate. Administrative Procedures AP 0109.1 (6/5/86) Preparation, Revision and Approval of Procedures" and O.ADM-100 (6/13/86) Procedure Preparation, Review and
- Approvol" Identify specific responsbilities for preparing and reviewing
- procedures and procedure changes to ensure that Information is complete and correct.
l 12 i MfREG-0940 I.A-97
- 2. Item I.A.2 involves a deficiency in on Emergency Operating Procedure (EOP) which required on action (shutting volves) to be taken from the control room, but this action would have been overridden in certoin operational situations.
Reason for the Violation: l'he procedure EOP 20003 " Steam Generator Tube Rupture" was not reviewed in a systematic fashion to ensure that inconsistencies between the system design and the procedure were identified and corrected. As a result, the procedure foiled to reflect a design feature which would have prevented the operators from isolating the AFW steam supply from the offected steam generator under certain operating conditions, os required by the procedure. Furthermore, operators were not trained to utilize alternote means to achieve the necessary isolation. - Corrective Action and Date When Full Compliance Will Be Achieved: All operators received the necessory training during the fall of 1985. An on the spot change (OTSC) to EOP 20003 was mode during the some period, reflectir,g the alternate means of isolating the AFW from o faulted steam generator. In addition, os noted in Appendix 1, Section I, the AFW system, os well os the other systems subject to the Design Basis Reconstitution Program, is being reviewed to ensure consistency between the design basis and other documents, such as procedures. The vastly expanded training program will Indoctrinate Turkey Point personnel with respect to these new or updated procedures. As in the cose of I.A.I., new controls have been established to ensure that design inputs are correctly f ronslated into operating procedures. ( 3. The example illustrates on inconsistency between a procedure (7300.2), which allowed 15 minutes without operator action, and ]' the AFW system description and design bases, which allowed only 10 minutes without operator action. Rensons for the Violation: Procedure 7300.2 "AFW System Flow Control Volves Instrument Air / Nitrogen Backup System Operoflon," was not systematically reviewed to ensure consistency among the design basis, the system description, and associated training materiots. Because of the inadequate operator training and Incorrect procedural Information ovollable, the team locked assurance that oppropriate operator action would be token in the event of a low nitrogen pressure annunclotor clarm following a loss of Instrument cir. Correctiva Action and Date When f*ull Comotionce Will be Achieved: Procedure 1300.2 was revised as port of PC/M 80.ll7. The revision reflected the nitrogen system being split into two Independent trains and provided operator guidance in the event of a low pressure clorm. The nitrogen setpoint hos been changed to allow operator action to restore additional nitrogen supplies. I 13 NUREG 0940 1.A-98
r e i- ; ! The programmatic corrective octions described in the response to I.A.2. l will also. help to ensure that the system design basis is correctly ; j reflected in procedures and training materials. I
- 4. The AFW system description indicated that 286 CPM of AFW flow be delivered to each unit within three minutes with only one pump i l
ovoilable. However, the EOP's did not ensure that control room personnel would balance flows os required within the ollowed time. Reasons for the Violation: The procedures EOP 20004 (Loss of Offstle Power) and 20007 0.oss of All A.C. Power) failed to provide the information reflected in the system description with respect to the need to balance AFW flow with only one pump available. l Corrective Action and Date When Full Compliance Will be Achieved: A , revision to Emergency Operating Procedure 20004, doted December 26, ; ! 1985, and Emergency Operating Procedure 20007 provides guidance to ' l assure the required AFW flow is provided in the event of a two unit trip. The Emergency Operating Procedures (EOPs) have been rewritten to incorporate the recommendations of the Westinghouse Emergency i Response Guidelir.es (ERCS). The generic ERCS have been reviewed and opproved by the NRC. This was done in response to Supplement I ' to NUREG 0737,~ ltem I.C.I. Other programmatic corrective actions described in the response to 1.A.2 ore Intended to prevent similar recurrences.
- 5. Procedure 0-ONOP.103, " Control Room inaccessibility," did not odequately cover local control of AFW Train 2 even though the l design is such, that local control is required in certain specified I
conditions. Reasons for the Violation: The procedure 0-ONOP.103 had not been systematically reviewed to ensure that it oddressed a design basis l requirement to provide local control of the AFW pumps. j Corrective Action and Date When Full Comotionce Will Be Achieved: Procedure O.ONOP.103 hos been revised as follows:
- 1. Prior to taking any operator actions at Train i of the Af"W System, the operator is directed to check the AFW flow gauges to L determine train operability and report the findings to the Plant ;
i Supervisor . Nucleor. l
- 2. A PC/M hos been completed to make the Instrument olr Isolation volves for Train 2 of the AFW System easier to operate. A procedure change hos been mode to incorporate the PC/M information into the procedure.
- 3. Instructions and setpoints have been incorporated to provide j guidance to the operator on how to obloln proper flow to the j steam generators utilizing a single AFW pump.
l j 14 i I l NI' REG.0940 1.A-99
- 4. Instructions have been incorporated to address boloncing of the AFW System flow to provide the necessary flow rate to each unit in the event only one pump is operable concurrent with a dual unit trip and both units requiring ouxillory feedwater.
- 5. Instructions and setpoints have been incorporated to provide instructions to the operator for locally resetting and restorting a tripped AFW pump.
ONOP's are omong the procedures that will be revised and upgraded as necessary in the PUP to ensure consistency with the system design basis, os described in Appendix 1, Section IV. Other programmatic corrective octions described in the response to I.A.2 are intended to prevent similar recurrences. B.
- l. A change was mode to certain pressure control volve setpoints, but it was not reflected on the oppropriate P&lD.
Reasons for the Violation: Due to on administrative oversight, the change was not incorporated on the referenced drawing. Corrective Action and Date When Full Comollance Will Be Achieved: Revision 17 of Drawing 5610.M.339 and Revision 8 of the associated instrument index sheet 5610.M.3ll Sht.155 have been issued to reflect the current setpoint of 80 psig. See Appendix 1, Section I for o description of programmatic corrective octions that are Intended to prevent similar recurrences. The Standard Engineering Design Pockage requires a listing of those drawings requiring update in order to maintain the os. built plant record. Administrative Procedure AP 0190.15 (7/24/86)' Plant Changes and Modifications" identifies responsibility for initioting drowing inclusion (new drawings) and revisions (old drawings). C.
- l. Item 1.C.l involves a failure to incorporate nitrogen bock.up system equipment in the appropriate Quality Instruction (JPE.OI.
2.13 A), although it was sofety related. Accordingly, for maintenonce purposes, it was not being treated as safety related. Reasons for the Violation: This violation is attributoble to failure to adequately reflect design changes in a current O l.ist. Corrective Action and Date When Full Comollonce Will Be Achieved: Power Plont Engineering has developed Ovality Instructions (Gls) which define the requirements for modifications to and updating of the Turkey Point O t.lst. These instructions require that o O.L.ist impact review be performed for all Turkey Point Plant Changes / Modifications (PC/Ms). They further provide the engineer with specific guidance on the mechonics of preporing changes to the computerized O.L.ist Data Base. 15 I l l l NUPEG-0940 f.A-100
FPL hos updated the G-List to the now-current document. Power Plant Engineering will maintain the O-List as a "living document" for future PC/M's generated for Turkey Point. This will be done through the use of the Stondord Engineering Design Pockage described in Appendix 1, Section I, which includes on "Affected Document Checklist" to clearly identify those documents such as the O. List requiring revision. Additionolly, the PC/M pockage cover sheet clearly provides the appropriate quality classificotton of the change or modification.
- 2. Certain switches were not designed or considered safety related although EOPs required operator oction upon receipt of signols (nitrogen low pressure olorm) octivated by those switches.
Reasons for the Violation: Design modifications for the Auxiliary Feedwater System utilized the pressure switches and annunclotion system Installed under the original plant construction, which were neither designed nor maintoined os nuclear safety-related. As a result, FPL believed that the separation criterio for these components were not changed from the original design basis of the plant. Corrective Action and Date When Full Compliance Will Be Achieved: FPL has since determined that this system will be redesigned as port of the Auxiliary Feedwater System upgrode which involves the oddition and relocation of the Auxiliary Feedwater Nitrogen Stations. This redesign will consist of the installotion of new quellfied pressure switches, Indicators and wiring thereto. A pressure switch of each station will be alarmed in the Control Room with a trouble light and will be of a safety grade design. PC/M 85-176 (Unit 4), nitrogen station additions and relocation, has implemented these changes on Unit 4, by means of a partial turnover. PC/M 85175 fo 'Jnit 3 is scheduled to be completed during the next Unit 3 refueling out, je. Applicable programmatic corrective action entails the use of the Standard Engineering Design Pockage described in Appendix 1, Section I, which includes on "Affected Document Checklist" to clearly identify those documents such as the O-List requiring revision. Additionally, the PC/M pockage cover sheet clearly provides the oppropriate quollty classificotton of the change or modification. D. Items I.D.I to I.D.4 all involve on inconsistency between system descriptions and the system design bases.
- l. The AFW System Description Indicated that on oir signal was supplied to o differenflol pressure controiler to maintoln a certoln pump discharge pressure, but this design feature was disconnected. (l.D.l)
- 2. The AFW System Description provided that check volves would open automatically when Instrument air pressure dropped below 55 psig. As o result of a lont modification, however, the volves were set to open at 80 ps . (l.D.2) 16 tillREG-Ondo I.A-101
f I i 3. Operator action described in the AFW System Description violated [ the single failure criterion and was inoppropriate for the current l system configuration. (1.D.3)
- 4. The AFW System Description did not define either the length of l
time the AFW system could operate without operator action or i- the operating limits on the ovollable nitrogen supply. (l.D.te) Reasons for the Violations: The program in ploce for review and l updating of system descriptions to reflect plant changes or i modifications on a current basis was not sufficiently systematic and comprehensive. In addition, ougmentation of the trotning was necessary to accomplish the necessory review and updating. Corrective Action and Date When Full Comollonce Will Be Achieved: ! Discrepancies between the AFW System description and the design basis ( hove ~ been corrected. Although this specific item oddresses a system i description prepared on a one time basis, FPL hos implemented a systematic and comprehensive progrom for review and updating of the , system descriptions used for training purposes. A total of 61 System
- Descriptions required review and updating. Priorities were established for the updating progrom. $2 of 61 System Descriptions have alteody been updated. The remolning 9 will be complete by November 1,1986.
The ' Trotning Department hos Instituted a Training Information Monogement System (TRIMS) to ensure molntenance of configuration control of trotning materials, including System Descriptions, such that they reflect future plant changes or modificottons. The TRIMS program identifies the specific trotning materlois that must be updated, us ng u system of change Indicators such as PC/Ms, procedure changes, Technical Specification changes and user feedbock. The Standard Engineering Design Pockage review cycle described in j Appradix 1, Section I, also provides for interfo:es with the Trotning l Depor fment. t E. Design changes were mode which entailed on try:rease in the nitrogen consumption rote. This had the offect of invalidating the design for the nitrogen back-up system which was set to allow I$ minutes for operator ( oction to restore the nitrogen supply. ! Roosons for the Violation: FPL's response to inspection Report 85 40, URI 85 40 22 noted cortoin foetual differences from NRC's description of the problem. However, it is clear that on oppropriate procedure for testing the system following its modification would have Identified the increase in the nitrogen consumption rate or the need for additional flow control volve trim. Corrective Aetion and Dot, When Full Comollonce Will Be Aehleved: A r procedure to dynamicolly test the nitrogen back-up system was propored and issued. Thl test will identify any detrimental effects on i nitrogen consumption created by modificatons to the AFW system. As [ stated in I.A.1, odditional volve trims have been odded which reduce nittogen consumption. I7 NIN Orl40 f.A-10? l
I l l The Standard Engineering Design Pockoge and AP 0190.15 formalize controls and reviews of design changes in order to avoid inodvertently l offecting unmodified portions of the system or related systems. i 1 F. Item 1.F involves inadequate compliance with o Ovolity Instruction in that assumptions and design inputs used in calculations for establishing the low level olorm setpoint in the condensate storoge tonk were not odequately documented. Reasons for the Violation: Applicable instructions did not provide o , suf ficient requirement for documenting calculational ossumptions. ! Corrective Action and Date When Full Complionce Will Be Achieved: As to the specific calculation, FPL was able to confirm that the results ', of the original calculation were correct. However, the underlying ossumption was inadequately documented. Ooolity Instructions have been revised to provide enhanced controls for documentaton of calculational ossumptions cod inputs for both internal and contractor. developed calculations. The Standard Engineering Design Package includes Instruction to document methods, assumptions and results so that a competent engineer could of a later date independently verify the results. The Design Verificotlon Reference Guide now being employed in verifying (independent review) the design inputs, design process and results provides guidance that the assumptions and inputs be odequately identified, correctly selected and properly incorporated. , i t l ! i
?
L l 18 NURf'G 04 0 t.A 103
ll. 50.59 Evoluotions A. Item II.A involves on inadequate safety evoluotion of a plant change (PC/M 80-117) in that the safety evoluotion did not analyze the operation of the system under the lowest steam operating conditions. Roosons for the Violottom FPL believed that the maximum steam pressure in the AFW system was the bounding cose for the ronge of system operaton for the purpose of the safety evoluotion performed. Therefore, no 50.59 evoluotion was performed for the lowest steam operating condition. In addition, the safety evoluotion was performed
; by a vendor organizoton and was not independently reviewed by FPL. !
f Corrective Action and Date When Full Comollonce Will Be Ac hieved: In , response to NRC concerns, o confirmotory analysis hos been performed of the lowest steam operating conditions (at the time the RHR System Is put into operation) which hos confirmed previous engineering l Judgement. This analysis is documented in Calculation MO8-462 02, doted October ll,1985. The analysis demonstrated and confirmed 4 odequate steam supply to the Auxillory Feedwater pump turbines in the i event of a complete failure of the steam vent line. , 4 FPL Instructions for ossuring the proper review of plant chonges or modifications are also being updated. Standard Engineering Design Package proporation employs a Safety and Regulatory Reference Guide and a Functional Design Reference Guide to ensure that oppropriate occident scenarios are addressed. The Design Verification Reference . Guide (Independent review) otso provides guidance for requesting the Engineering Technical Licensing Section concurrence with the package. AP 0190.15 requires the Turkey Point Technical Department to i l i Independently review PC/Ms and the Plant Nuclear Safety Committee (PNSC) to independently review PC/Ms for unreviewed safety questions. ! D. Item l1.0 involves on Inodequate safety evoluotion for Temporary ! System Alteroflons (TSAs) in that the scfety evoluollon did not consider t i the rnechanical reliability of the AFW system being operated under o j i const mt speed condition.
! Reasons for the Violation: A safety evoluollon was conducted for these I T5As in accordance with AP 0103.3. However, the mechanical reliability of the pumps operating of a speed within the prevlously onolyzed operating range was not addressed. Reviews of TSAs were not ,
, odequately formalized nor was provision mode for review of she !
- necessary technical level.
l Cnerective Action and Date When Full Comollance Will Be Achieved l To enhonce monogement control of T5A evoluotions, the procedure (0-l ADM.503) hos now been changed to that TSAs for equipment in service ! will b6 reviewed by the PNSC prior to Instollation. l in addition. 0-ADM.503, " Control and Use of Temporary System ) Alteroflons," was revised to incorporate o determination on the port of l ! the Shif t Technical Advisor as to the necessity for on Engineering i review under 10 CFR 50.59. l l 19 ! 1 } i ! NttRtti.OrlAf1 I,A-104 l i
C. In order to perform certain work, the Turkey Point units were placed in a configuration that required the diesel generator (EDG) loads to remain below 2750 kw. An appropriate 50.59 evoluotun was conducted of operatons under these conditions in support of the JCO. Subsequently, the configuration was changed to add additional loods to the EDG without a further 50.59 evoluotion. Reasons for the Violation: Plant personnel relied upon a procedure, 3(4)-OP-006, "480 Volt Switchgear System to support PCM 83-155 (Appendix R Modifications)," which did not have o caution that cross-tie breakers should be rocked out and tagged to prevent a cross-tie which could overlood the EDG. However, the Operations Department had taken on additional conservative measure, not required by the EDG loading evoluotion, JPE-L-86-59, Revision I, of de-energizing the 4D normal containment cooler (powered from the 48 480 volt load center) and taking it out of service on a clearance, in addition, with Unit 4 in cold shutdown, certain engineered safety feature equipment (not required for Unit 3 operation) was also taken out of service to prevent operation. Therefore, it was felt that the EDG loading limits would not be exceeded. Corrective Action and Date When Full Compilance Will Be Achieved: A safety evoluotion of the April 14, 1986 olignment of the 40 loads and their offect on total EDG loading was performed by our Engineering Department. The results of this evolvation indicated that the conservative measure taken by the Operations Department resulted in on octual reduction of design basis occident EDG loading by 43 KW during the time the 40 lood center was cross-tied to the 4A load center. Therefore, the evoluotion concluded that the loading on the EDGs would not have exceeded the limits specified in the EDG looding evoluotion, JPE.I. 86 59, Revision 1. 3(4).OP 006 hos been revised to incorporate o caution in the infrequent operatons section of the procedure that states that unless both units are in a cold shutdown, the 480 volt lood center cross.tle breakers shall be rocked out and togged in accordance with AP 0103.4, "In Plant Equipment Clearance Orders." These breakers may be closed only in accordonce with Technical Specifications, o safety evoluotion, or os directed by the Technical Support Center Staff when activated under the emergency plon. Af ter this incident, cleoronce togs were placed on the 480 volt tie breakers to preclude recurrence. A letter was issued to Plant Supervisors-Nucleor, emphasizing that no electrical system cross connects between trains con be mode without first discussing the new olignment with the Engineering Deportment. The programmatic corrective actions described in Appendix I, Section ll oddress the underlying cause of this event. Those changes highlight employee indoctrination and the use of the Chongo Review Team, Plant Review Doord and Plant Nuclear Sofety Committee, to review modifications to plant systems and components in a more formal manner. 20 Pllpr0-0940 f A-105
111. Technical Specification Compliance A. An LCO was exceeded when certain steam supply check volves were found inoperable upon examination by radiographic techniques. Reasons for the Violation: The results of the radiographs Indicated that the steam supply volves were unocceptoble due to bent guide studs. At that time Engineering judgement concluded that no operability concern existed. Based on this, flee volves were not declared inoperable. Corrective Action and Date When Full Compliance Will Be Achieved: Corrective actions for the finding were described in LER 250-86-001 transmitted to the NRC vio FPL letter L-86-54 dated February 14, 1986. The following updates to those e,orrective actions are provided. Plant Change / Modification (PC/M) 86-009, Auxillory Feedwater Steam Supply Volve Replacement, was completed for Unit 4 during the recently completed refueling outoge. This PC/M replaced the existing motor operated solid wedge gate volves with a motor operated globe volves, installed tilting disc check volves both upstream and downstream of these motor operated globe volves, removed the existing downstream stop check volves, and converted the existing upstream stop check volves into manually operated globe volves. PC/M 86-011 will perform the some modifications for Unit 3 during the 1987 refueling outoge for that unit. Programmatic corrective actions include the improvement of procedures for identifying inoperable systems and clearonces required to safely remove equipment from service for inspection and repair. In addition, the expansion of the site engineering organization and the enhanced QA corrective action program described in Appendix 1, Section VI, ensure o more consistent, formal, and timely review of non-conforming conditions. B. Unit 3 was takeri critical for power operations offer o shif t turnover with three safety injection pumps operable; the Tech Specs require that four pumps are operable in these circumstonces. Reasons for the Violation: Due to o personnel oversight during the review of the Unit 4 clearances, o Unit 4 safety injection pump was doctored back in service although its discharge volves were closed. A temporary lif f of the pump's breaker was opproved, but the volves were never released, because it was assumed they would be opened prior to criticality. Corrective Action and Date When Full Compliance Will Be Achieved: The need to follow through on tasks and to conduct proper shif t turnovers was re.emphostred to the operators. The operators were cierted to the difficulties ossociated with assuming on oction will be token, without following up to ensure it was actually done. 21 ) NilREG-0940 f.A-106
The clearance procedure, AP0103.4, was completely revised, providing a streamlined, more user-friendly process for writing and handling cleoronces. As o result of this revision, there are now three clearance books -- one for each Unit, os before, and a third for common equipment,- to ease the reviewing process. Additionally, cleororse numbers are now listed in the equipment out of service book, os per the latest revisions to AP0103.4 and AP0103.2. . i 4 i e t 22 NUREG-0940 f.A-107 l
IV. . Procedural Controls A. l. Item IV.A.l involves on inadequacy in the maintenance instructions in that they did not assure that safety-related instrumentation was properly oligned under certain conditions. Reasons for the Violation: The applicable instructions, 0-SMI-059.1, were insufficiently detailed for purposes of the particular maintenance ac tivity. , Corrective Action and Date When Full Complionce Will Be Achieved: Procedure 0-ADM-031 Undependent Verification) dated July 12, 1985, Step S.3.1 requires independent verification of the removal and return to service of components controlled by equipment clearance orders. Procedure 0-ADM-107 dated October 25,1985 (Writer's Guide for Maintenance Procedures), Step S.8.4.C give directions for independent . verificotton for preparing maintenance procedures. As part of the PEP maintenonce octivities, maintenance and surveillance procedures are being revised to incorporate instrument olignment independent verifications. As noted in Appendix 1, Section IV, FPL hos on extensive Procedure Upgrade Program (PUP) in place to revise and upgrade procedures, including maintenonce procedures, on a plant wide basis.
- 2. Item IV.A.2 involves several instances in which the Plant Nuclear Safety Committee failed to review certain TSAs within the time required by the procedure.
Reasons for the Violation: Administrative controls did not identify a single point of responsibility for ossuring timely PNSC reviews of TSAs. Corrective Action and Date When Full Compliance Will Be Achieved: Shif t Technical Advisors (STAS) now have the responsibility for assuring that TSAs are prepared and evoluoted properly (including 50.59 considerations). O-ADM-503 was revised to clarify the responsibility for timely review of TSAs by the PNSC. The revision also enhances the adminstrative documentation and controls ossociated with TSAs. This coordination of the TSA preparation, evoluotion and review through a single point of contact provides assurance that TSAs are processed promptly. B. Item IV.B involves a failure to ensure that a sofety-related procedure (relating to the condensate storage tank) was opproved for release by authorized personnel and appropriotely distributed in occordance with established procedures. Reasons for the Violation: This problem occurred due to the complexity of the specific change. in this cose several procedures were being issued to replace one old procedure. Because one of the replacement procedures was undergoing review by a different section of the plant stoff, the old procedure was inadvertently conceled before the replacement procedures were officiolly issued. 23 fillPEG-0940 I.A-108
Corrective Action and Date When Full Compliance Will Be Achieved: The principal corrective action is the establishment of a PUP-Document Control interface to handle the need to have fast and reliable transmiltol of new precedures and associated documentation from PUP to Document Control so that Document Control con distribute the procedures to users throughout the plant. The interface is primarily one dedicated writer who hond corries material from PUP to Document Control on on as needed basis (usuolly daily or more of ten). New procedures and procedure changes are assigned a unique number by PUP for trocking purposes. A tracking system has been set up to ensure that the procedures and documents offected by a new procedure are transmitted to Document Control as a package. This helps ensure that the correct documents / procedures are revised as required. 24 PUPEG-0940 1.A-109
- g. .. - ~ --=
~. -. .
'h w-
-V.'. i Controf of Maintenance Activities 3
A.
-1. Item V.A involves a , failure to ' perform prescribed ' monthly surveillance tests ' on batteries as required by technical
. specifications.
Reosons for the Violation: TVendor'mointenance requirements were not incorporated in Plant Operating Procedure 96M.I. Corrective' Action and Date When Full Comotionce Will'Be Achieved: I Plant Operating Procedure 96M.1, dated December 4,1985 was revised
~
to require specific gravity correction for electrolyte temperature and level. This procedure was also revised to contain acceptance criteria for the specific gravity readings. This procedure change had been
; planned prior to the inspection, but had not been completed.
- On a programmatic level, the Standard Engineering Design Package os described in Appendix 1, Section I, provides guidelines and detailed references to startup ' testing procedures, vendor maintenance requirements, and periodic testing requirements os recommended by the equipment vendors, required by Technical Specifications or desired by
(~ the engineer. i i 2. Item V.A.2 involves failure to perform odequate battery lood tests
- as required by Tech Specs.
! Reasons for the Violation: FPL considers that the one-holf hour battery ' service test is odequate to demonstrate that the bottery is capable of performing its intended safety function. This is based on the assurance described in the bases for the Technical Specification that, considering any single failure, bottery charging current should be supplied in one. half hour or less. ! t
! Corrective Action and Date When Full Comollance Will Be Achieved:
This requirement will be reviewed through the Select System Review ' and the schedules ossociated with that effort will apply. ,
- B.
i 1. It was noted on on NCR that a search was required for three missing volve parts; the parts were not found and no documented -
- basis was generated to establish the operability of the system
' when the units were returned to service. Reasons for the Violation: The main contributor to this item was , i inadequate procedural guidance in the oreo of documentation required
- j. prior to unit restort or exiting LCOs. In porticular, this relates to NCR
'< dispositions that offect equipment and/or system operability.
Correction Action and Date When Full Compliance Will Be Achieved f New and more extensive controls have been implemented to assure both j- prompt resolution of NCRs and that the NCR has been resolved before 4 nonforming equipment that has previously been declared out of service ' is returned to service. ! 25 l l NUREG-0980 1.A-110
. . , - - - ,- - , - - , . . . , . , - . . . . . , - , - . - - - _ - . . - - - , , , . . . . . - . . - ~ . , . . - - . _ , , , . - . - - . . - - - . . . , - ~ -
Procedure AP. 0190.12, "Non-Conforming Material, Ports or Components" has been revised to require satisfactory NCR disposition for o nonconforming part or component that hos been declared out of service prior to returning the part or component to service. The GC department is responsible for ensuring satisfoctory NCR resolution. In addition, o OC Hold Point will be added to PWOs requiring NCR disposition prior to returning the offected component to service.
- 2. Personnel were aware of a potential condition in which a single volve for each unit could isolate two redundant condensate storage tank level transmitters. There was, however, failure to implement odequate procedural controls, to ensure that these volves would be controlled in the open position.
Reasons for the Violation: The design basis for the addition of the redundant condensate storage tank level indication, installed under PC/M 80-77, was based on the connection to the tank being a possive portion of the system which allowed the redundant monitors to be on a common top. This approach was considered acceptoble of the time because a single possive failure of this line or the isolation volve is not a design basis for Turkey Point. Corrective Action and Date When Full Compliance Will Be Achieved: The design modification process has been substantially improved since the time this modification was implemented in recognition of the need to coordinate changes in the plant with operations and maintenoce personnel, os described in Appendix 1, Sections I and 11. The program for the review of proposed plant modifications has recently been enhanced to ensure that the effects on operating documents, procedures and administrative controls are occommodated in the design prior to approval of the PC/M by the Plant Nuclear Safety Committee (PNSC). Engineering personnel are also currently on distribution for the piant operating procedures. This provides the design engineer wilh a better insight into the octual operation of the system and the potential impact of modifications of the system. Also, utilization of the Standard Engineering Design Pockage provides more rigorous controls en the PC/M evoluotion process. 3.o. Item V.B.3.o identifies failures to implement procedural requirements for documentation of post-mointenance testing in I & C and electrical safety-related plant work-orders (PWOs). Also o procedure for post-mointenance testing addressed only mechanical maintenance with no provision for post-mointenance testing ossociated with I & C and electrical PWOs. Reasons for the Violation: Maintenance procedures were not suf ficiently formalized to ensure adequate post-mointenance testing and related documentation. Corrective Action and Date When Full Compliance Will Be Achieved: AP 0190.28, ' Post Maintenance Test Control" guidance, was revised to cover I & C and electrical maintenance activities, os well as mechanical maintenance. The Post Maintenance Guidance Document, issued in 26 N11 REG-0940 I.A-111
September 1985, has been incorporated into AP 0190.28 for criteria guidelines in establishing post maintenance testing on applicable maintenance procedures and PWOs. 3.b. Item V.B.3.b involves failure to identify root causes of equipment failures on a large number of safety-related PWOs. Reasons for the Vioiotion: There were some inodequocies in the system for identifying, tracking, and evoluoting root causes of equipment failures. Corrective Action and Date When Full Compliance Will Be Achieved: Journeymen, Supervisors and GEMS personnel have been directed to ensure that the " Analysis of the Cause or Reason" section of PWOs is completed. As stated in inspection Report 85-40 (Poge 4) "the inspecfor reviewed IS safety related PWOs completed since the SSF inspection and noted that all 15 had the root cause section completed as required." As noted in Appendix 1, Section V, the NJPS program hos been vastly expanded. The Nuclear Job Planning System (NJPS), the development of which has been underway since the inception of PEP, requires on identical section to be completed on the CRT screen. These actions have enhanced root cause identificotton and oppropriate corrective action implementation. NJPS outomatically catalogs system equipment history. A total of six field engineers have been added to the three maintenance disciplines to enhance corrective actions offer root cause identifications. The inspection report also credited the Turkey Point Event Response Team (ERT) for its copobility to identify root cause of foi!vres which should " subsequently reduce the repetitive failures that have occurred at the Turkey Point Plant." Finally, the inspection report recognizes that "the automated PWO program which will provide trending information, the automated PM program, and the performance based maintenance training program, should also contribute to a reduction in repetitive equipment failures on a long-term basis." (IR 85-40, Page 4) i 27 NUREG-0940 I.A-112
VI. Timeliness of Corrective Action A. -Item VI.A involves a failure to take prompt and adequate corrective action offer it was determined that CCW flow through RHR heat exchangers appeared to be below that assumed for accident onalysis purposes. CCW volves were repositioned from 30% to full open, but this was done without evoluotion or testing of.the adequacy of the flow to other components served by the CCW system. Reasons for the Violation: In this specific instance, it had been a long- - standing practice et Turkey Point to operate with the CCW discharge isolation volves for the RHR heat exchangers in a throttled position. Therefore, Unit 3 was not shutdown immediately upon receipt of the safety system review results indicating a potential inodequate flow. A preliminary evoluotion was conducted to reposition the volves that addressed increased flow to the RHR heat exchangers and pump runout concerns. However, due to on oversight, the evoluotion did not address , 1 the effects of the change in CCW flow to other components. This was o - preliminary evoluotion only and additional reviews and testing were done before the evoluotion was completed. Corrective Action and Date When Full Compliance Will Be Achieved: The corrective actions which specifically address this example are described in Turkey Point Unit 3 LER 2504-009. t i Programmatic corrective actions to prevent similar recurrences are , described in Appendix 1, Section VI. In particular, the augmented site ; engineering organization will provide more timely resolution and tracking of outstanding engineering evoluotions. B. Item VI.B involves m extended delay in evoluoting the safety significance of the failure of an intake Cooling Water (ICW) volve to L close on loss of power and/or its ~ control air supply. After the evoluotion was performed, no - analysis was done of ICW system i operobility or LCO compliance until questioned by Region 11. Reasons for the Violation: A request for a 10 CFR Port 21 evoluotion was considered adequate and a separate operability evoluotion or Port 50.59 evoluotion was not conducted. Procedures did not always ensure that the safety significance of plant-identified deficiencies and the resulting impact on plant operability were reviewed .in a timely fashion. In addition, procedures in place did not always provide for odequate tracking of engineering evoluotions to ensure their timely completion. 1 'i Corrective Action and Date When Full Compliance Will Be Achieved: The corrective actions which specificolly oddress this example are described in Turkey Point Unit 3 LER-250-86-008 and FPL's response, L-86-2il dated May 16,1986, to inspection Report 250-86-10 and 251-86-10. In addition, programmatic corrective actions are intended to prevent similar recurrences as described in Appendix 1. Section VI. New , I 28 i NIJREG-0940 I.A-113
corrective action progrom controls ensure that on operability review is performed in a timely manner and then additional evoluotions are performed as identified. C. Although a piping installation error in the Unit 4 Component Cooling Water (CCW) trains for the common Unit 3/4 high head safety injection system (SI) was identified in 1980, it was not corrected, but in+ tead, the Unit 3 CCW trains to the SI pump coolers were used exclusively. Under certain conditions, the Si pumps on at _ least two occasions were susceptible to single failure induced inoperability. Reasons for the Violation: Procedures did not always ensure that the safety significance of identified plant deficiencies and the resulting impact on plant operobility were reviewed in a timely fashion. In addition, procedures in place did not olways provide for odequate tracking of engineering evoluotions to ensure their timely completion. Corrective Action and Date When Full Compliance Will Be Achieved: Procedural controls have been implemented to ensure CCW train redundoney, depending upon system olignment, with one unit in cold shutdown and one unit at power operations. During the Unit 4 refueling outage o piping modification was made to correct the reverse flow condition. - In addition, os noted in Appendix 1, Section 11, engineers are now required to generate o Standard Engineering Design Package for plant modifications. In doing so, they utilize- a Sofety and Regulatory Reference Guide and a Functional Design Reference Guide to help to avoid the possibility of overlooking any relevant off-normal operating condition. Furthermore, new instructions under development provide detoiled guidance to engineers conducting 10 CFR 50.59 evoluotions. 29 l l MllREG-0940 1.A-114 l l
UNITED STATES [,e nego,]o, NUCLEAR REGULATORY COMMISSION
'O . REGION il j 101 MARIE i TA STR E E T. N W ATL ANT A. GEORGI A 3C323
% , , ;'. . # APR 281986 Dccket Nos. 50-250 and 50-251 License Nos. OPD-31 and CPR 41 EA 86-38 Florida Power and Light Corparv ATTN: Mr. C. O. Vcody Grouc Vice President Nuclear Eneroy Department P. O. Box 14000 Juno Beach, FL 33408 Gentlemen:
SUBJECT:
NOTICE OF VI0'.AT!0N AND PROPOSED IMPOSITION OF C!VIL PENALTY (NRC INSPECTION REPORT N05. 50-250/86-04 AND 50-251/86-04) This refers to the Nuclear Regulatory Commission (NRC) inspection conducted on January 15-16, 1986, at the Florida Power and Light Comoany (FP&L) Turkey Point Nuclear Power Plant. The inspection was conducted to review the circumstances associated with an unauthorized entry of a olant worker into a high radiation area. The individual received an unplanned OCCuDational radiation exposure of 0.5 rem. The event, which occurred on January 8, 1986, when the individual entered the Traversing Incore Probe (TIP) area to cerform maintenance on a TIP drive unit, was reported to the NRC by a member of your staff the following day. During the entry, the worker's survey instrument malfunctioned as a result of radiation levels in excess of 1 R/hr in the area, the maximum radiation level measurable by the instrument. Although the exposure received by the individual during the entry was not in excess of the regulatory limit, a substantial potential for such an exoosure existed. An Enforcement Conference was held on January 31, 1986, with you and members of your staff during which the exposure, associated violations, the causes, and your corrective actions were discussed. Numerous procedural violations occurred before and during the worker's entry. The violations included failure to notify health physics personnel prior to operation of the incore detectors, performing work outside the scope of the plant work order, failure to have two persons present during the entry, and failure to keep the worker's exoosure within the limits established by the radiation work permit for the ,iob. Further, the worker's foreman failed to provide adequate instructions on the plant work order for the maintenance tasks to be oerformed by the worker. The worker also received inadequate training in the use of the radiation survey instrument issued to him to control his exposure while in containment. As a resul' of inadequate CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-115 ,.
1 Florida Power and Light Company instructions given to the worker, he failed to reccgnize that the instrurent , i malfunctioned when the radiation levels exceeded the upoer limits of the instrument. Consequently, the worker received a whnia body exposure of approximately 0.5 rem while working in a radiation field of 6 R/hr. The worker was within a foot of an estimated radiation field of 65-70 R/hr and octentially could have received a much hioher exposure. In February 1984, a Notice of 'liolation and Proposed Imposition of Civil Peralty was issued for a similar incident at your facility insolving two workers enteHng the reactor sump erea (reactor cavityl at a time when the retractable incore detector thimbles were withdrewn and the sump was classified as a locked high radiation area. One worker received 1.3 rem and the other werner receivec 0.20 rem during their s*ay in the area (about 1 minutel. Subsequently, the civil penalty was mitigated completely because your corrective actions apoeared to be extensive and comprehensive. However, it appears that implementation of these corrective actions was not as effective as it should have been. Adherence to procedures forms a basic framework for providing effective, consis-tent radiological controls for work in high radiation areas. Short of providing direct, continuous health physics coverage for each and every task, these proce-dures serve as the formal mechanism for initiating necessary communications between various plant workers and the health physics support group. This convunication results in appropriate radiological support for the maintenance / surveillence activities. Bypassing these procedures and thus failing to comply with the radiological precautions in them seriously weakens the health physics control program established to protect the workers. It is the licensee's responsibility to ensure that these procedures are adhered to. To emphasize the importance of proper instruction and supervision of individuals performing work activities in high radiation areas, I have been authorized, after 4 consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Peralty in the amount of Fifty Thousand Dollars ($50,000) for the violations set forth in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level III violation or problem. The base civil penalty for a Severity Level III problem is $50,000. The staff considered increasing the base civil penalty amount because of the similarity of this most recent event to the 1984 incident and to ircidents against which the NRC previously has cautioned all licensees to take preventive measures (e.g., Infonnation Notice 8?-51 " Overexposure in Reactor Cavities," December 1982). However, because FP&L reported the event upon its discover", even though it was not required to be reported, and has apparently taken extensive corrective actions, I have decided not to escalate the base civil penalty. Strong enforcement action will be taken if further violations in this area occur. l NUPEG-0940 I.A-116
Florida Power and Light Company -3 APR 2 8 586 You are required to respond to this letter and sbculd follow the instructions specified in the enclosed Notice when preparinq vour response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. Af ter reviewing your response *.o this Notice, including your proposed corrective actions, the NDC will determine whether further NRC enforcement action is necessary to ensure compliance with NPC regulatory requirements. In accordanre with Section 2.790 of the NQC's " Rules of Practice," Part 2, Title 10 Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Notice are not sub.iect *o the clearance orncedures of the Office of Manacement and Budget as reouired by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely,
, N---t'h
, . Nelson Grace Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Inspection Report Nos. 50-250/86-04 and 50-251/86-04 cc w/encls:
C. M. Wethy, Vice President Turkey Point Nuclear Plant C. J. Baker, Plant Manager Turkey Point Nuclear Plant R. J. Acosta, Plant QA Superintendent J. Arias, Jr., Regulatory and Compliance Supervisor 4 i i NUREG-0040 1.A-117
NOTICE OF VIOLATION AND ' P90 POSED IMPOSITI F 0F CIVIL PENALTY Florida Power and Light Company. Docket Nos. 50-250 and 50-?51 Turkey Point Units 3 and 4 License Nos. OPR-31 and C00 41
'EA 86-38 During the Nuclear Regulatory Comission (NRC) inspectier conducted on January 15-16, 1986, violations of NRC requirements were. identified. The violations involved the licensee *s failure to properly train a worker to use a radiation survey instrument and failure to folkw olant procedures. 'n accordance with the " General Staterent of Policy and Procedure for.NRC Enforcement Actions,"
10 CFR Part 2. Appendix C (1985), the. Nuclear Reculatory Connission proposes to l impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, l as amended (Act), 42 U.S.C. 2282, PL.96-295, and 10 CFR .1.205. The violations and F associated civil penalty are set forth below: A. 10 CFR 19.12 requires that all individuals working in or frequenting ary portion of a. restricted area shall be instructed in precautions or procedures to minimize their exposure and in the purposes and functions of protective devices employed. Contrary to the above, instructions given to a worker who entered the. Traversing Incore Probe (TIP) drive. area of Unit 3 containment on January 8, 1986, with a radiation survey instrument with which he was to assess the radiation hazards that may be present did not include methods of detecting instrument failures and actions to be taken if the instrument was susDected of failure. The individual remained in the TIP drive srea for 5 minutes and was unaware that the instrument was not responding properly because of the high radiation levels in the area. B. Technical Specification 6.8.1 requires that procedures be established, implemented, and ::intained consistent with Appendix A of Regulatory i Guide 1.33, Revision 2 February 1978. 3 Regulatory Guide 1.33, Appendix A Revision 2, February 1978, requires procedures for radiation protection, maintenance, and operation.of nuclear instrument systems.
- 1. Procedure 190.19, Control of Maintenance on Nuclear Safety Related and Fire Protection Systems, Paragraph 8.3, requires thorough documentation of disassembly / troubleshooting on plant work orders (PW0s). When all discrepancies and problems have been identified, work is to be stopped and the foreman / supervisor is required to clearly define the problem and corrective actions on the PWO in a step-by-steo fannat.
J
; NUREG-0940 I.A-118
Notice of Viniation Contrary to the above, on January 6, 1986:
- a. An Instrument and Control (I&C) technician failed to thorou @ly document the disassembly and treublesncoting of the Unit 3 i:P' i driva er the pWO.
- b. An I&C technician failed to stop work when the discreoarctas and
-orcblems outlined on the DWO had been identified and Derforced work nutside the scope of the instructions of-the DWO.
C. The IAC Forecan failed to clearly define the problam anri corrective action on the PWO in a step-by-step format.
- 2. Procedure'12407.2. incore Flux Detector Drive Mechanism and Detector Peolacement, requires that health physics perform a thorough survey after'the detector has been fully withdrawn, that two persons be present at all times while perfnrming maintonance inside containment, and that workers not exceed the exposure limits established by health physics'en the radiation work permit.
Contrary to the above, on January 8, 1986:
- a. ' A survey'of the Unit 3 TIP drive area was not performed by health physics after the TIP was withdrawn from the reactor core.
- b. Two persons were not present'during the IAC technician's second containment entry to perform maintenance on the "A" TIP drive,
- c. The I&C technician failed to keep his exposure witnin limits
~e stablished by the radiation work permit.
- 3. Procedure 12404.1, Normal Operation of Incore Moveable Detector System, requires that Nuclear Plant Operations and Health Physics Operations be notified before operating the incore detector.
Contrary to the above, on January 8, 1986. Health Physics Operations was not notified before the operation'of the incore detector. Collectively, these violations have been evaluated as a Saverity Level III problem (Supplement IV). Cumulative Civil Penalty - 550,000 assessed equally among the violations. Pursuant to 10 CFR 2.201, Florida Power and Light Company is hereby required to submit to the Director, Office of Inspection and Enfnrcement, U. S. Nuclear Regulatory Comission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice a written statement or explanation including for each violation: (1) admission or denial of the violation, (?) the reasons for the violation if admitted, (3) the corrective steps which have been taken and NIIPEG-0940 T.A-119
\
Notice of Violatior . the results achieved (4) corrective steps which will be taken to avoid further violations, and (5) the date when full comoliance will be achieved If an adequate reply is not received within the tire specified in this Notice, the Director, Office of Inspection and En'orcement, may issue an order to show cause why the license should not be rodified, susoended, or revoked or why such other action as may be preper should not be taken. Consideration may be civan to extending the response time for good cause shown. Under the authority of Section 182 of the Act 42 U.S.C. 2232, the response shall be submitted under oath or affirmation. Within the same time as provided for the 'psoonse required above under 10 CFR 2.201, Florida Power and Light Cetpany may Day the civil peralty by letter addressed to the Director, Office of Inspection and Enfnrcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Fifty Thousand Dollars ($50,000) or may protest impositior-of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement, Should Florida Power and Light Company fail to answer within the time specified, the Director. Office cf Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Florida Power and Light Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting ritigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of Florida Power and Light Company is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty. Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the cenalty, unless compromised, remitted, or mitigated may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION
, 0M
/ J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia thisdday of April 1986 NUPEG-0940 I.A-170
FLORID A POWER & LIGeti COYP ANY MAY 2 8 tus L-36-215
\1r. James M. Taylor, Director Office of Inspection and Enforcement U. S. Nuclear Regulatory Commission Washington, D. C. 20555
Dear Mr. Taylor:
Re: Turkey Point Units 3 and 4 Docket Nos. 50-250 and 50-251 Notice of Violation and Proposed Im:osition of Civil Penalty (EA 36-33) Florida Power & Light Company (FPL), pursuant to 10 CFR 2.201, files the attached response to the Commission's Notic : of Violation and Proposed imposition of Civil Penalty (EA-36-33), dated April 23,1986. Factual details supporting FPL's denial with respect to the asserted violations are set forth in the attachment to this letter. In brief, they establish that the alleged violation and potential for overexposure did not occur as a result of any failure on the part of FPL to properly train a worker on the use and range of radiation survey instruments or of any failure on the part of FPL to instruct the worlier to follow plant procedures applicable to the operations which are the subject of the violation. To the contrary, the procedures in place were adequate; the worker in question was fully trained and aware of those procedures; his failure to comply therewith was in deliberate and willful violation of his instructions. Other deviations which followed were the necessary consequence of that violation.
\1oreover, it seems clear from the letter of April 23, 1936, transmitting the instant Notice of Violation that, although the Commission had regarded the corrective actions which FPL put into effect beginning in 1933 to have been " extensive and comprehensive," now, because it views the current incident as "similar" to one which had occurred in 1933, it feels that the corrective actions were not as ef fective as they should have been.
FPL respectfully submits, however, that the view expressed in that letter is incorrect; that the incident in question is a completely isolated instance; that the incident to which the 1984 notice referred was not in fact "similar" to the incident to which the instant Notice refers; and that, although even further measures have been taken as a result of the event to which the instant Notice refers, the corrective actions which began in 1933 have, in fact, been positively implemented. Significant evidence to that effect is provided by the fact that the instant incident is the only one at Turkey Point involving a potential for employee exposure exceeding regulatory limits since those corrective actions were taken. Ll:1 PEOPLE. SERVING PEOPLE NUREG-0040 1.A-1?1
k We believe that appropriate controls were in place such that a substantial potential 1for exposure above the limits of 10 CFR 20 did not exist for the work task on the
' flux mapper drive unit. Rather, the detailed elements of the Turkey Point Health Physics and Maintenance Programs, as they applied to this work task, were fully sufficient .to protect Turkey Point technicians during the performance of this maintenance.
FPL further submits that it was only through an individual's willful disregard for the job requirements that a potential developed for overexposure. The involved
-individual's deliberate disregard for the requirements of the work task were, we believe, strictly a discipline problem, not an indication of weakness in the Health Physics or Maintenance Programs. Consequently, FPL took strong disciplinary ~ ~ ; action against the individual.
We are aware that the NRC's Enforcement Policy (10 CFR Part 2, Appendix,C) ! states that, generally, " licensees are held responsible for the acts of their employees.",(Section V.A.). FPL fully subscribes to that view. _ lt has therefore strongly emphasized and impressed upon its employees the need to comply with radiation protection procedures. When, as in this case, an employee, nevertheless, L willfully f ails to do so, diciplinary action is taken. Section V.A. also states that Licensees "are not ordinarity' cited for violations resulting from matters not within their control, such as equipment failures that were not avoidable by reasonable licensee quality assurance measures. or 3 management controls." FPL submits that the incident which is the subject of the astant Notice was very similar in nature to the example suggested in the section. Reasonable management controls were in place to prevent exposures such as occurred here. . Moreover, what did occur was not the result of a " personnel error" in the conventional sense, but rather as a result of a willful deviation from' well
- understoodf protective procedures. Continued management stress on the importance of compliance with procedural controls and swif t and . appropriate disciplinary action when a willful violation does, nevertheless, occur are the basic defenses against repetition of such willful acts. FPL has fully utilized those defenses. In these circumstances we submit that the Commission should not relate ,
the imposition of a :lvil penalty to the improvement of conduct either by the licensee or by any other person, i lt is not FPL's purpose to avoid responsibility by hiding behind legal distinctions between penalties which are " punitive" and those which are " remedial or i' deterrent," a position already rejected by the Commission 1/ but rather.to urge that the civil penalty sought to be imposed in this case serves neither a " remedial" nor a " deterrent" purpose. 2/ Although FPL has implemented certain additional measures (beyond disciplinary action), as explained in the attachment, they will not, we submit, deter a deliberate violation in the future. The only effective 1/ Atlantic Research Corporation, CLI.80-7,11 NRC 413 (1980). 2] 11 NRC, supra, at 425. L1:1 4 I i
~
NURFA-0940 I.A-1P2 i - -. - .,- - -_. ... - . - - - --. - - -.-. .
remedial and deterrent measure in the circumstances of this case is prompt, publicized and significant disciplinary action - a step which has already been taken by the Company, in short, the proposed penalty does not serve the regulatory purpose set forth in the Commission's own Enforcement Policy (Section V.8) in which it was stated that:
" Civil penalties are designed to emphasize the need for lasting remedial action and to deter future violations."
A detailed discussion of the reasons for our views is provided in the attachment to this letter. Should you or your staff need any additional information on this important issue, please contact us. Very truly yours,
. . Woody Group Vice President-Nuclear Energy ide Attachment cc: Dr. J. Nelson Grace, Regional Administrator, Region !!, USNRC Harold F. Reis, Esquire .
PNS-LI-86-162 Ll:1 NUPEG-09A0 I.A-123
RE: Turkey Point Units 3 & 4 i Docket Nos. 30-250 and 50-251 - Notice of Violation and Proposed imposition of Civil Penalty (EA 86-38)
- 1) INTRODUCTION i Florida Power & l.lght does not concur with findings A and B of EA 86-33. It is true that during the recent incident the I&C technician's willful disregard for I numerous job requirements caused a potential for overexposure. However, it is FPl.'s opinion that the checks and balances contained in the Turkey Point Maintenance and Health Physics (HP) programs are sufficient to protect workers and ensure that personnel exposures are maintained within the Company's Administrative guidelines. The Turkey Point Program provides numerous i independent controls to protect against inadvertent errors. We have determined that in this case the individual's blatant and intentional disregard for the established controls is a disciplinary problem which has been dealt with appropriately, and not a weakness in our program.
The notice of violation stressed similarities between this incident and an unauthorized Reactor Sump entry that occurred on October 14, 1983. Florida Power & Light disagrees that these incidents are similar for the following reasons:
!) The Reactor Sump incident involved an improper entry into the designated storage area for withdrawn thimbles. Plant refueling procedures required that the irradiated portion of thimble tubes be withdrawn from the reactor vessel to the sump area at elevation -4'.
! The'recent incident involved work in the location of the incore detector i drive units. Unauthorized, transient high radiation levels were created at elevation 30'6" by the I&C technician when he withdrew an incore detector in violation of procedures. i 1 2) The reactor sump entry was performed without an approved Radiation Work Permit (RWP) which is required by Technical Specifications. l In the recent incident, a specific RWP requiring Health Physics coverage, was written to allow work on the flux map drive unit. The HPS:3 NUREG-0940 1.A-124
RWP was authorized by the Nuclear Plant Supervisor (NPS) and the Health Physics Shif t Supervisor (HPSS).
- 3) The reactor sump entry was a single occurrence not covered by a Plant Work Order (PWO) or Plant Procedures. No pre-job briefings were conducted with the worker prior to the entry.
In the recent incident the I&C technician was specifically briefed by Health Physics Supervision on job requirements. The job activities for the flux map system- are covered by specific Maintenance Procedures, which included Health Physics precautions and notifications. Additionally, the PWO issued for the job required I&C and QC supervisors to approve and sign of f the PWO before commencing repair.
- 4) The reactor sump incident invo!ved problems with interdepartmental communications. Lack of awareness of plant conditions and radiological responsibilities by the individuals involved also contributed to personnel errors.
The recent incident was caused by the irresponsible actions of one individual when he circumvented established plant controls. The I&C technician entered the containment work area twice. He complied with the RWP during the first entry. He willfully violated the RWP requirements on his second entry.
!!) DISCUSSION OF SPECIFIC FINDINGS IN EA 36-38
GENERAL COMMENT
S For additional background to substantiate FPL compliance with 10 CFR 19.12 and Technical Specification 6.8.1, the following additional information is provided:
- 1) The assigned task to troubleshoot the drive system malfunction was accurately described in PWO #8404. Step 1 of the PWO instructions required I&C and QC supervisory approval and sign off prior to commencing repairs. The I&C technician violated the requirements of the PWO during both entries into Unit 3 containment.
HP5:3 NUREG-0940 I.A-125
- 2) Troubleshooting Procedure 0-G MI- 102.1, as referenced in the instructions of PWO #8404, required compliance with Maintenance Procedure 12407.2. " Flux Detector Drive Mechanism Repair and Detector Replacement". As part of this procedure, the following steps have been proceduralized since 1973 to ensure sulficient measures are in place to maintain personnel exposure ALARA:
Step 4.2 "Af ter the detector has been fully withdrawn to the drive unit, a thorough survey must be performed by Health Physics prior to initiation of maintenance on the
, drive mechanism or detectors."
Step 4.3 "While performing maintenance inside containment, two persons sht!! be present at all times." Step 9.1.2 " Notify Health Physics that the detector is located at the Sataty Limit Switch at the outlet of the Drive Unit, so that the area can be surveyed." The I&C technician deliberately failed to comply with these requirements.
- 3) The I&C technician was qualified to troubleshoot and repair the flux map drive system. Since his original employment in March,1984, he has been assigned to a I&C Field Supervisor who was responsible for the flux map drive systems. The I&C technician performed maintenance on the drive systems at least seven times. His previous work had been satisfactority performed in accordance.wlth plant procedures and RWP requirements.
i HP5:3 l i l NilREG-0940 1.A-126
- 4) .The I&C technician was well qualified in radiological awareness. He had been adequately trained concerning his responsibilities to comply with RWP requirements, postings, and Health Physics instructions (including disciplinary actions for noncompliance). The I&C technician had attended three. qualification classes in radiological training since March,1984 He successfully completed the courses (last course September 20,1985) with grades well above average. The radiological training course is based on INPO/!ndustry Standards. Also, as stated earlier, the technician had performed this work before and was aware of the radiation levels associated with in-core detectors.
- 5) A specific RWP #86-304 was generated to perform work on the flux map drive system. The RWP was approved by the Nuclear Plant Supervisor, Health Physics Supervisor and ALARA Section. The RWP specifically required constant Health Physics coverage for all work evolutions.
- 6) Prior to entry into the RCA, the I&C technician documented his understand ng of the RWP (specifically RWP #86-304) when completing the Form HP 1.1 "RWP Entry Log". By signing this form, the individual acknowledges that he has read and understands i the requirements of the RWP.
- 7) The l&C technician demonstrated his awareness by complying with all the RWP requirements during his first entry into containment. A Health Physics technician inside containment obtained a copy of RWP #86-304 from the Control point and discussed the job requirements with the I&C technician. Radiological surveys were completed by a Health Physics technician during the first entry.
- 8) After the first entry, the Health Physics Shif t Supervisor briefed the I&C technician on the job requirements,if additonal work should be needed. The Health Physics Shif t Supervisor (HPSS) introduced the I&C technician to the Health Physics technician assigned to provide job coverage. A pre-job briefing took place between the I&C technician, the HPSS and the assigned H.P. technician. This HPS:3 neluded the radiation levels associated with the in-core detectors.
NUREG-0940 1.A-l?7
Additionally, both the HP55 and the assigned Health Physics technician instructed the I&C technician to contact them prior to performing additional work.
- 9) Approximately two hours af ter the initial containment entry, the I&C technician withdrew the incore detector without notifying Health Physics. This is in direct violation of MP-12404.1, " Normal Operations of Incore Moveable Detector System."
, 10) The I&C technician reentered Unit #3 containment without notifying the HP55 or his assigned Health Physics technician as required.
- 11) Af ter entering containment, the I&C technician stated that he made an effort to contact Health Physics using the plant page system.
Unable to quickly locate a Health Physics technician inside containment (he stated approximately five minutes), the I&C technician decided to enter the posted and barricaded area without i Health Physics coverage. Af ter the first entry, as a precautionary measure, the Health Physics Shitt Supervisor barricaded and posted the area: "High Radiation Area" " Keep Out"; before the detector was withdrawn. This required the I&C technician to consciously 1 bypass the barricade and posted area. Had he obeyed the postings, this event would have been prevented.
- 12) Prior to each containment entry, the l&C technician was queried by l
the control point Health Physics technician to verify his understanding of the RWP requirements. In both cases, he was instructed to contact Health Physics inside containment. I i
- 13) Upon exiting containment, the control point HP technician found that the I&C technician's dosimeter read 460 mR. The HPSS was notified and an Exposure Investigation Report was initiated. The I&C technician's TLD was immediately pulled for processing.
l HP5:3 lHIREG-0940 f.A-128 l l
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- 14) The I&C technician admitted to numerous errors. During the initial exposure investigation (that evening) and subsequent management critique, the I&C technician acknowledged that he had violated RWP i requirements, radiological barriers and plant procedures. In addition, the I&C technician admitted to the NRC inspector that he had made some mistakes.
- 15) Verbatim compliance with Plant procedures is an established policy for all work at Turkey Point Power Plant. The concept of verbatim compliance is included in the training for all workers at the Nuclear Site. The I&C technician was well informed of his responsibilities I for verbatim compliance with plarit procedures and Radiation Work Permits.
'I
- 16) The assignment by his supervisor was for the I&C technician to investigate the problem and then report back prior to performing any repair. He failed to do so and performed the repair without notifying his supervisor in violation of the PWO and applicable procedures.
, ' As can be seen from the foregoing information, appropriate controls were in place to ensure that a substantial potential for overexposure would not exist for the required job. 1 Turkey Point Plant had previously established a system to minimize the potential for overexposure. This system consists of the following:
- 1. Strics procedural requirements to notify Health Physics prior to 1 performing work on drive units.
- 2. Specific RWP for a!! High Radiation Area work.
- 3. Radiological barriers and postings.
- 4. Requirements to carry survey meter in high radiation area, or health physics coverage required.
~5. Copies of RWP at RCA entrance, Dress Facility and at Containment access.
HPS:3 NUREG-0940 I.A-129 I
- 6. Requirements to review the RWP and sign HP 1.1 Form "RWP Entry Log" at the RCA entrance acknowledging this review.
- 7. Pre-job briefings by Health Physics.
- 8. Plant work order system that details the work scope and supervisory /QC reviews.
- 9. Verbatim Comp!!ance Policy.
- 10. Site specific contract HP Technician Training Program.
- 11. INPO/ Industry Based Radiological Training Program.
In addition to this system of protection, additional controls consist of:
- 1. Twenty-four hour Health Physics control points at containment access.
- 2. Twenty-four hour Health Physics coverage inside containment during outages.
- 3. Health Physics technicians read all personnel dosimeters for entry and exit to Radiation Controlled Areas and containment.
Actions have been taken to ensure that individuals know the importance of verbatim compliance with instructions as follows:
- 1. Plant Manager Policy letters dated January 26,1984, June 3,1985 and April 14,1986.
- 2. Corporate Vice President Policy letter on compliance with RWP's dated June 5,1985.
- 3. General employee training teaches the importance of Procedural and RWP compliance.
- 4. Nuclear Management team meeting at Turkey Point to stress i management directives to plant personnel.
From this information, it can be seen that it was only through the intentional disobedience by the specific individual of many well known requirements that the potential for overexposure existed. This is not an issue of inadequate training because the individual complied with the requirements of the RWP during the first entry and was fami!!ar with the work task. As addressed in the NRC inspection report, the I&C technician failed to follow existing procedures or PWO requirements in at least five cases. i 1 l NUREG-0940 I.A-130
l-I
.A) NRC FINDING A )
10 CFR 19.12 requires that all individuals working in or frequenting any portion of a restricted area shall be instructed h precautions or procedures to minimize their exposure and in the purposes and functions of protective devices employed. ' Contrary to the above, instructions given to a worker who entered the Traversing Incore Probe (TIP) drive area of Unit 3 containment on January
- 8,1986, with a radiation survey instrument with which he was to assess the radiation hazards that may be present did not include methods of detecting instrument faltures and actions to be taken if the instrument was suspected of failure. The individual remained in the TIP drive area for 3 minutes and l was unawate that the instrument was not respondhg properly because of the high radiation levels in the area. -1 FPL RESPONSE .
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l The second paragraph of Finding A of EA 86-34 states that the instructions l l given to the I&C technician who entered the Trip Drive Area (TIP) of Unit 3 containment did not include methods of detecting instrument failure and { l actions to be taken if the instrument was suspected of failure. It notes that i he remained in the TIP drive area for five minutes unaware that the + instrument was not responding properly. The. Implication of this statement I is that the instruction he received about precautions or procedures to ! minimize exposure and for the purposes and functions of protective devices was inadequate to meet the requirements of 10 CPR 19.12. FPL doesn't . contend that the I&C technician's instruction expressly included detailed l methods of detecting failures of the specific instrument, a radiation survey meter, he was using. Nevertheless, he had received other and wholly adequate training and instructions to minimize his exposure and training in f the purpose and function of the protective device employed. This included { training and testing in the following areas: l l \ HPS:3 i I i l NilREG-0940 T.A-131 ;
- - - .. - -,___ _ . ., . , _ ..- ,. _ - _. ~ .. . ~ . __. ,. . - . - _ , _ . _ _ _ . _ _ _ . . , _ _ . . .
a) Technicrl Specification requirements for survey meters in High Radiation Areas. b) Pre-use inspection and operation of survey meter. c) Calculation of staytime. d) Correct sequence for selecting survey instrument ranges when entering an unknown radiation field. e) Interpretation of survey meter readings for all ranges selected. f) Requirement to exit the area when unusual conditions are observed (including the requirement to leave the area and notify HP if significant increases in radiation levels exist from previous entry.). g) Individual responsibilities as stated in FPl.'s Plant Safety Rules. h) Compliance with procedures, RTP requirements, H.P. verbal instructions, barricades and postings. Moreover, the radiation survey meter was issued to the I&C technician to comply with Technical Specification requirements for entering containment which was posted as a High Radiation Area. The meter was not issued for him to assess the radiation hazards associated with the withdrawal of incore detectors. In addition to the normal roving HP technician in the area, a Health Physics technician was specifically assigned to cover the work and assess the radiation hazard, using a high range survey instrument. The I&C technician was instructed by HP on what the radiation levels in the work area were expected to be, that he needed HP coverage, and not to enter the area without it. Accordingly, it is clear that the instructions received by the I&C technician more than adequately covered the precautions and procedures required to minimize exposure as well as the purpose and functions of the protective devices he was using. HP3:3 NUREG-0940 1.A-132
B) NRC FINDING B Technical Specification 6.8.1 requires that procedures x established, implemented, and maintained consistent with Appendix A o. Regulatory Guide 1.33, Revision 2, February 1978. Regulatory Guide 1.33, Appendix A. Revision 2, February 1978, requires procedures for radiation protection, maintenance, and operation of nuclear instrument systems.
- 1. Procedure 190.19, Control .of Maintenance on Nuclear Safety Related and Fire Protection Systems, Paragraph 8.3, requires thorough documentation of disassemble / troubleshooting on plant work orders (PWOs). When all discrepancies and problems have been identified, work is to be stopped and the foreman / supervisor is required to clearly define the problem and corrective actions on the PWO in a step-by-step format.
Contrary to the above, on January 8,1986:
- a. An Instrument and Control (I&C) technician fatted to thoroughly document the disassembly and troubleshooting of the Unit 3 TIP drive on the PWO.
- b. An I&C technician failed to stop work when the discrepancies and problems outlined on the PWO had been identified and performed work outside the scope of the instructions of the PWO.
- c. ,The I&C Foreman failed to clearly define the problem and corrective action on the PWO in a step-by-step format.
- 2. Procedure 12407.2, incore Flux Detector Drive Mechanism and Detector Replacement, requires that health physics perform a thorough survey af ter the detector has been fully withdrawn, that two persons be present at all times while performing maintenance inside containment, and that workers not exceed the exposure limits established by health physics on the radiation work permit.
HPS3 f!!! REG-0940 !.A-133
Contrary to the above, on January 8,1986:
- a. A survey of the Unit 3 TIP drive area was not performed by health physics af ter the TIP was withdrawn from the reactor core.
b.- Two persons were not present during the I&C technician's second containment entry to perform maintenance on the "A" TIP drive.
- c. The I&C technician failed to keep his exposure within limits established by the radiation work permit.
s
- 3. Procedure - 12404.1, Normal Operation of Incore Moveable Detector -
Sy: tem, requires that Nuclear Plant Operations and Health Physics Operations be notified before operating the incore detector. i Contrary to the above, on January 8,1986, Health Physics Operations was not notified before the operation of the incore detector. FPL RESPONSE: Finding B states that " Technical Specification 6.8.1 requires that procedures be established, implemented, and maintained consistent with Appendix A to Regulatory Guide 1.33, Revision 2, February 1978." It then refers to three procedures specified in that Regulatory Guide and enumerates one or more instances of failure to comply with each of those procedures. FPL submits that each instance of such failure occurred (as we show below, in one instance, the I&C technician did comply $vith the procedure) not as a result of a betakdown in the Health Physics or maintenance programs but as a result of the deliberate failure of the l&C technician to comply with the requirements. j l I 1 1 HP3:3 i l l l l MVPEG-0940 1.4-134 l l
Specifically, the work description instructions on PWO #8404 for the repair of Unit #3 flux map detector "A" stated:
- 1) Investigate using O-GMI-102.1 (i.e. procedure for trouble-shooting).
Document all work. FS (Field Supervisor) and QC Notification Required for repair method approval.
- 2) If power entry is required, use attached HP 3.
- 3) Retest per attached Appendix F, AP 0190.28 (Post Maintenance Testing).
Step 4.1.3 from the precautions section of O-GMI-102.1 states:
" Observe proper radiation practices to limit personnel exposure, ALARA.
All work in the radiation control area shall be accomplished in accordance with the requirements of the RWP and the ALARA program." Subsection 6.1, Troubleshooting from O-G MI-102.1 required the I&C Technician to list his trouble-shooting steps and when the problem is identified to proceed to Subsection 6.2. Proper completion of 6.2 fulfills instruction 1 of PWO #8404 On his initialinvestigative entry to obtain data for Subsection 6.1 of O-GMI-102.1 the I&C technician determined that the problem was only loose hold-down nuts on the drive take-up reel. The activated detector tip was still remotely located below the vessel. Without notifying his supervisor, the I&C technician tightened the nuts, and contrary to finding B.I.a of EA 86-38, docurnented this action on Attachment 1 of O-GMI-102.1 for PWO
#8404.
The facts clearly establish that, on his initial investigative entry to obtain data for Subsection 6.1 of 0-GMI-102.1, the I&C Technician determined that the problem was loose hold-down nuts on the drive take-up reel. The activated detector tip was still remotely located below the vessel. Without notif ying his supervisor, the I&C technician tightened the nuts. That is, he HP5:3 l NUREG-0940 I.A-135
made the repair without first makmg the notification and obtaining the repair method approval required by the work description instructions in PWO
#8404. With this factual background the specific procedural violations enumerated in Finding B may be best assessed.
Finding B.I.a states that the I&C technician " failed to thoroughly document the disassembly and troubleshooting of the Unit #3 TIP drive on the PWO." l
' Actually, however, and in contrast to his violation of the other significant procedural requirements, the I&C technician completely documented his 6
action on Attachment 1 of 0-GMI-102.1 for PWO #8404. In fact, that documentation provided important information disclosing his violation of those other requirements which lead to the disciplinary action taken against him. Each of the other specific findings enumerated in Finding B either was an aspect of the I&C technicians unilateral and unauthorized decision to go l forward with the repair despite instructions and procedures which clearly precluded him from doing so or was an unavoidable consequence of that decision. Thus, Finding B.1.b. refers to his " failure to stop work when the discrepancies and problems outlined in the PWO had been identified" and his perfermance of work outside the scope of the instruction. However, as , pointed out above, Trouble Shooting Procedure 0-GMI-102.1, Maintenance Procedure 12407.2 and PWO #8404 all clearly required him to stop work and, as also made clear above, he was fully familiar with this requirement. l Similarly, the failure of the I&C Foreman "to clearly define the problem and. I corrective action on the PWO in a step-by-step format" resulted from the technician's failure to stop work and notify his supervisors of what he had found made it impossible for the !&C foreman to take the next step. Finding B.2.a and b. state that a survey of the Unit #3 TIP drive area was not performed by health physics and that two persons were not present during the I&C technician's second containment entry. Again, however, steps 4.3 and 9.1.2 make it clear that each of these precautions are required, but, again, the unilateral decision to proceed with what he i 1 apparently considered to be a quick repair af ter he was unable to locate a Health Physics technician within containment, made these HP5:3 l ttuRDi-0040 f.A-136
violations inevitable. The failure of the I&C technician to keep his exposure within the limits of the RWP, referred to in Finding B.2.c., was also an obvious consequence of that decision. The failure to notify Health Physics operations before operating the incore detector, referred to in Finding B.3., was, similarly, the inevitable consequence of the I&C technician's decision to go ahead and make the repair despite the explicit instructions to the contrary in PWO #8404 (Procedure 0-GMI-iO2.1). III. CORRECTIVE ACTION As has been emphasized throughout this statement, the individual's deliberate, but irresponsible action was the root cause of the incident. One important corrective measure taken was strong disciplinary action against that individual which was fo!! owed by his resignation. That disciplinary action itself should have a significant deterrent impact upon other employees tempted to ignore radiation protection requirements. In addition, the following actions have been initiated:
- 1) Fo!!owing the incident, Supervision re-emphasized the Company's Policy on verbatim compliance with procedures and Radiation Work Permits and the consequences for failure to comply with the Company's requirements. ,,
/
- 2) Unless High Radiation Control points are established inside the containment, personnel working under RWPs that require Health Physics coverage will not be allowed to enter containment without,HPSS notification and authorization. '
- 3) Additional enhancements have been made to Maintenance procedure 12407.2, "Incore Flux Detector Drive Mechanism Repali and Detector Replacement", to further clarify notifications and job responsibilities.
- 4) The Flux Mapper system power supply is tagged out to the HeaIth e
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Physics Supervisor. .
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c( HP5:3
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NtlREG-0940 I.A-137
- 5) Emphasis has been increased in training on the limitations of radiation survey instruments that are issued and the actions to be taken for unusual conditions. Also, in addition to complying with RWP's and postings, individuals are instructed not to enter areas where the radiation levels are higher than the range of the instrument.
IV. CONCLUSION i FPL respectfully requests the commission to reconsider the determination that Fin 64gs A and B constitute circumstances warranting a severity Level 111 ; viola'tlon with a Civil Penalty. FPL has ~ est'ablished numerous, redundant independent controls to pre !ude inadver tent errors that would lead to unnecessary radiation exposur e. Nevertheless, such controls cannot always prevent a deliberate unilateral decision to ignore those controls from ever occurring. The message of any penalty imposed upon FPL is that if an undesirable incident occurs, penalties will be imposed despite ' the existence of extensive precautions against its occurrence. We submit that the NRC's enforcement policy intends no such message. 1 V. MITIGATION ! l Even if, contrary to the foregoing, the Commission determines that complete l i remission of the penalty is not appropriate, we believe that the five factors referred to in the NRC enforcement policy (10 CFR Part 2, Appendix C Section V.B.) clearly call for mitigation. As the letter transmitting the notice recognizes, FPL reported the event upon its discovery even though it was not required to be reported. Second, with respect to past performance, the letter of transmittal recognizes that the actions which FPL took beginning in 1983 " appeared to be extensive and comprehensive". The instant incident is the only event from which a different inference may be drawn. However, as we show in detail in the previous paragraphs, that inference is not justified. In addition, FPL promptly took further disciplinary and other action to reduce the likelihood of repetition of such an event in the future. We believe the actions taken by FPL since 1983, and the failure to repeat incidents of the type that occurred prior thereto demonstrate that the third factor referred to in section V.B., past performance, also justifies mitigation of the penalty. Finally, FPL had no prior notice of this employee's willful action. Consequently, the fourth and fif th f actors referred to in U5:3 section Y.B. also support mitigation. l l NilREG-0940 I.A-138
#gp* * * %g,'o, UNITED STATES E # g NUCLEAR REGULATORY COMMISSION 5 8 WASe41NGTON. O. C. 20EM
/ OCT 141986 Docket Nos. 50-250, 50-251 License Nos. DPR-31 DPR-41 EA 86-38
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3 Florida Power and Light Company ATTN: Mr. C. O. Woody Group Vice President Nuclear Energy Department P. O. Box 14000 Juno Beach, FL 33408 Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTY: EA 86-38 (REFERENCE REPORT NOS. 50-250/86-04 and 50-251/86-04) This refers to your letter of May 28, 1986 in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by our letter of April 28, 1986. Our letter concerned violations found during the inspection conducted by Region 11 personnel on January 15-16, 1986 at Turkey Point Units 3 and 4 of activities authorized by NRC License Nos. DPR-31 and DPR-41. The violations were discussed during an Enforcement' Conference conducted in the Region II Office in Atlanta, Georgia on January 31, 1986. In your response, you stated that you did not agree with Violations A and B and you requested reconsideration of the determination that Violations A and B involved circumstances warranting categorization as a Severity Level III problem with a civil penalty. After careful review of your response, we have concluded for the reasons presented in the enclosed Order and Appendix that the violations occurred as stated in the Notice of Violation. and Proposed Imposition of Civil Penalty, that the violations were correctly categorized as a Severity Level III problem, and that a sufficient basis exists for mitigating the proposed $50,000 civil penalty by 50 percent. Accordingly, we tiereby serve the enclosed Order on Florida Power and Light Ccopany imposing a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000). In accordance with Section 2.790 of tne NRC's " Rules of Practice," Part 2. Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC's Public Document Room. CERTIFIED MAIL RETURN RECEIPT REQUESTED i NUREG-0940 I.A-139
Florida Power and Light Company The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely,
.- -- - //
J s M. Tay , Director nspection a d Enforcement
Enclosure:
Order Imposing civil Monetary Penalty with Appendix cc w/ enc 1: C. M. Wethy, Vice President Turkey Point Nuclear Plant C. J. Baker, Plant Manager Turkey Point Nuclear Plant L. W. Bladow, Plant QA Superintendent J. Arias, Jr., Regulatory and Compliance Supervisor l l 1 l NUREG-0940 1.A-140
UNITED STATES NUCLEAR REGULATORY CO M ISSION In the Matter of FLORIDA POWER AND LIGHT COMPANY Docket Nos. 50-250 and 50-251 (Turkey Point, Units 3 and 4) License Nos. DPR-31 anc DPR-41 EA 86-38 ORDER IMPOSING CIVIL MONETARY PENALTY I Florida Power and Light Company (the licensee) is the holder of Operating License Nos. DPR-31 and DPR-41 (the licenses) issued by the Nuclear Regulatory Comission (the Comission/NRC) on July 19, 1972 and April 10, 1973, respectively. The licenses authorize the licensee to operate the Turkey Point Units 3 and 4 in accordance with conditions specified therein. II A safety inspection of the licensee's activities under the licenses was conducted by the NRC from January 15-16, 1986. As a result of this inspection, it appeared that the licensee had not conducted its activities in full compliance with NRC requirements. A Notice of Violai. ton and Proposed Imposition of Civil Penalty (NOV) was served upon the licensee by letter dated April 28, 1986. The NOV stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the NOV on May 28, 1986. NUREG-0940 f.A-lal
i i l III After consideration of the licensee's response and the statements of facts, explanations, and arguments for mitigation or remission of the proposed civil penalty contained therein, as set forth in the Appendix to this Order, the Director, Office of. Inspection and Enforcement, has determined that the violations identified in the Notice of Violation and Proposed Imposition of Civil Penalty were properly classified at Severity Level III but that the
$50,000 civil penalty should be mitigated by 50 percent based on the licensee's extensive corrective actions.
IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 USC 2282, PL 96-295, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: The licensee pay a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000) within thirty days of the date of this Order by check, draft, or money order payable to the Treasurer of the United States and mailed to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. V The licensee may, within thirty days of the date of the Order, request a hearing. A request for a hearing shall be addressed to the Director, Office of NUREG-0940 f.A-142
Inspection and Enforcement at the above address. A copy of the hearing request shall also be sent to the Assistant General Counsel for Enforcement, U.S. Nuclear Regulatury Consnission, Washington. 0.C. 20555. If a hearing is requested, the Commission will issue an Order designating the time and place of the hearing. Upon failure of the licensee to request a hearing within thirty days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made by that tine, the matter may be referred to the Attorney General for collection, in the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee violated NRC requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty; and (b) whether on the basis of such violations this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION d J
.W s M. Tay1 , Director fice of in ection and Enforcement Dated at Bethesda, Maryland thisgNay of October 1986 NUREG-0940 I.A-143
.. _ .. .. .- . -.- - -- -_ -- ..~
APPENDIX STAFF ASSESSMENT OF LICENSEE RESPONSE i' On April 28, 1986, a Notice of Violation and Proposed Imposition of Civil Penalty (NOV) was issued for .several violations of NRC mquirements. Florida Power and Light Company's response to the NOV was provided in a letter dated May 28, 1986. In its response, the licensee denies the violations. In addition. l the licensee provides reasons as to why, if the Comission determines that the r violations did occur, the penalty should be mitigated. Provided below are:
. (1) a restatement of each violation (2) .a sumary of the licensee's coments l on each violation, (3) the NRC's response to each of the licensee's cosments, i
and (4) the hAC's conclusion. A. Violation A I-10 CFR 19.12 requires' that all individuals working in or frequenting any portion of a restricted area shall be instructed in precautions or pro- ! cedures to minimize their exposure and in the purposes and functions of , protective devices employed. i i
- Contrary to the above Instructions given to a worker who entered the i Traversing Incore Probe (TIP) drive area of Unit 3 containment on January 8, 1986 with a radiation survey instrument with which he was to assess the radiation hazards that may be present did not include methods of detecting instrument failures and actions to be taken if the instrument was suspected of failure. The individual remained in the TIP drive area for 5 minutes and was unaware that the instrument was not responding properly because !
- of the high radiation levels in the area. i Licensee Coments Regarding Violation -A I- The second paragraph of Violation A of EA 86-38 states that the instructions given to the I&C technician who entered the TIP drive area of Unit 3
, containment did not include methods of detecting instrument failure and j actions to be taken if the instrument was suspected of failure. It notes ! ! that he remained in the TIP drive area for f.ive minutes unaware that the , instrument was not responding properly. The implication of this statement ' { is that the instructions he received about precautions or procedures to j minimize exposure and for the purposes and functions of protective devices l were inadequate to meet the requirements of 10 CFR 19.12. FPL does not ' i contend that the I&C technician's instructions expressly included detailed i ! methods of detecting failures of the specific radiation survey meter he was ' i using. Rather, the licensee contends that he had received other and wholly adequate training and instructions to minimize his exposure and training
- in the purpose and function of the protective device employed. This included training and testing in the following areas
- (a) Technical Specification requirements for survey meters in high 4
radiation areas. (b) Pre-use inspection and operation of survey meter. 4 (c) Calculation of staytime. a i i [ NUREG-0940 f.A-144 _ . . ~ . , . . - - _ . ~ _ . _ _ , _ _ _ _ - - . _ - . , . . , , . . - . _ . _ _ . . . . - _ - _ _ . . - , - = - _ . _ . . _ . . . . . _ . _ . _ _ - - -
4 Appendix (d) Correct sequence for selecting survey instrument ranges when entering an unknown radiation field. (e) Interpretation of survey meter readings for all ranges selected. ,
- (f) Requirement to exit the area when unusual conditions are observed '
(including the requirement to leave the area and notify HP if i
.significant increases in radiation levels exist from previous
- entry).
- (g) Individual responsibilities as stated in FPL's Plant Safety Rules.
(h) Compliance with procedures, RWP requirements. HP verbal instructions,
- - barricades and postings.
The licensee claims that the !&C technician was well qualified in radiological awarer.ess in that he had been adequately trained concerning his responsibilities to comply with RWP requirements, postings, and health physics instructions. }' The !&C technician had attended three qualification classes in radiological training since March 1984. He successfully completed the courses (last. . . course September 20,1985) with grades well above average. The radiological ;
' training course is based on INP0/ Industry Standards. Also, the technician l had performed this work before and was aware of the radiation levels associated with in-core detectors.
I The licensee also' contends that the radiation survey meter was issued to the j I&C technician to comply with Technical Specification (TS) requirements for 1 entering containment which was posted as a high radiation area. The meter 3 was not issued for him to assess the radiation hazards associated with the i withdrawal of incore detectors. In addition to the normal roving HP j technician in the area, another HP technician was specifically assigned
- to cover the work and assess the radiation hazard, using a high range survey instrument. After the first entry, the Health Physics shift super-visor (HPSS) briefed the I&C technician on the job requirements if additional work was needed. The HPSS introduced the I&C technician to the HP technician assigned to provide job coverage. A pre-job briefing took place between the !&C technician, the HPSS, and the assigned HP technician. This included 4
the radiation levels associated with the in-core detectors. Accordingly, it is clear that the instructions received by the !&C technician more than l adequately covered the precautions and procedures required to minimize i exposure as well as the purpose and functions of the protective devices l he was using. NRC Response j
- Workers entering a high radiation area should have a general knowledge of
- the radiation levels expected in the area and specific actions to take if significant changes in radiological condicions occur. When interviewed by the inspector, the I&C technician stated that he was not aware of the higher i radiation levels associaten with the TIP drive work. Radiation survey
] instruments are principally issued for workers to detect changes in work
- area radiation levels. It is the NRC's position that training on the use of l the instrument provided in accordance with TS requirements also must include
!. methods of detecting instrument failure. As indicated in the licensee's ! response, specific training on detecting instrument failure was not included -
- in the technician's training. The ifcensee's training also did not address the actions individuals are to take if an instrument is suspected of not s i l NUPE'G-0940 1.A-145 1
-- _._-._ - _ _ _ . . _ _ _ _ _ ~~._. _ _ _ _
+
Appendix _ functioning properly. As a result, the l&C technician failea to recognize-that the instrument malfunctioned when the radiation levels exceeded the upper limits of the instrument. Additionally, during an interview with the subject I&C technician, the technician stated that although he had performed
- - this task several times in the past, he was not aware that the radiation levels would be so high.. The IAC technician also stated that he was introduced to the Health Physics technician who was to provide job l
coverage, but that a pre-job briefing did not take place. B.- Violation '8: 1 Technical Specification 6.8.1 requires that procedures be established, f implemented, and maintained consistent with Appendix A of Regulatory Guide 1.33. Revision 2. February 1978. Regulatory Guide 1.33, Appendix A. Revision 2. February 1978, requires 1
- procedures for radiation protection, maintenance, and operation of nuclear instrument systems.
l 1.. Procedure 190.19. Control of Maintenance on Nuclear Safety Related 1 and Fire Protection Systems, Paragraph 8.3, requires thorough documentation of disassembly / troubleshooting on plant work orders
- _ (PW0s). When all discrepancies and problems have been identified, work is to be stopped and the foreman / supervisor is required to clearly define the problem and corrective actions on the PWO in a l step-by-step forinat.
l Contrary to the above, on January 8,1986: , a. An Instrument and Control (!&C) technical failed to thoroughly document the disassembly and troubleshooting of the Unit 3 TIP p orive on the PWO.
- b. An !&C technician failed to stop work when the discrepancies and i problems outlined on the PWO had been identified and perforined
{ work outside the scope of the instructions of the PWO. ! c. The I R Foreman failed to clearly define the problem and corrective action on the PWO in a step-by-step format. I
- 2. Procedure 12407.2, Incore Flux Detector Drive Mechanism and Detector Replacement, requires that health physics perforin a thorough survey
' after the detector has been fully withdrawn, that two persons be present at all times while performing maintenance inside containment, and that workers not exceed the exposure limits established by health physics on the radiation work permit. l Contrary to the above, on January 8, 1986:
- a. A survey of the Unit 3 TIP drive area was not performed by health physics after the TIP was withdrawn from the reactor core.
l b. Two persons were not present during the !&C technician's second
- containment entry to perform maintenance on the "A" TIP drive.
I i ! NilPEG-0940 I.A-146 l
-----,,an--w e ,-v ,w---.---n_ mm.,-._ ,,.m-, _- -- ,--..ww._-w__n_.
i Appendix 4
- c. The I&C technician failed to keep his exposure within limits established by the radiation work permit.
- 3. Procedure 12404.1, Normal Operation of Incore Moveable Detector System, requires that Nuclear Plant Operations and Health Physics Operations be notifiec before the operation of the incore detector.
Contrary to the above, on January 8,1986. Health Physics 9perations was t not notified before the operation of the incore detector. Licensee General Cosuents Regarding Violation 8 Violation 8 states that " Technical Specification G.8.1 requires that 4 procedures be established, implemented, and maintained consistent with Appendix A to Regulatory Guide 1.33, Revision 2. February 1978." It then 1 refers to three procedures specified in that Regulatory Guide and , enumerates one or more instances of failure to comply with each of those i procedures. FPL submits that each instance of such failure occurred (in one instance the I&C technician did comply with the procedure), not as a ! result of a breakdown in the health physics or maintenance programs but as a result of the deliberate failure of the I&C technician to comply with the requirements. NRC Response i As acknowledged in the licensee's response, licensees are held responsible I for the acts of its employees. They also are responsible for the safety of employees. Although Flurida Power and Light stated that the violations were the result of deliberate acts of the I&C technician, the NRC believes that at least two other individuals had the opportunity to take action which could have led to the exercise of adequate radiological controls.
- Specifically, a second IAC technician was in the control room and participated in the movement of the TIPS. This technician failed to
.i ensure that HP Operations was notified prior to the operation of the TIPS as required by Procedure 12404.1. In addition, the Senior Nuclear Watch
- Engineer was aware that the TIPS were being moved and took no action to deterinine if proper notifications had been mace.
Licensee Comments Regarding Violation 8.1.a Violation 8.1.a states that the !&C technician " failed to thoroughly ] document the disassembly and troubleshooting of the Unit 3 TIP drive on the PWO." Actually, however, and in contrast to his violation of the other significant procedural requirements, the !&C technician completely documented his action on Attachment 1 of 0-GMI-102.1 for PWO #8404. In i fact, that documentation provided important information disclosing his , violation of those other requirements which lead to the disciplinary action taken against him. NRC Resoonse i The !&C technician failed to complete Attachment 2 of procedure 0-GM-102.1 ! outlining the statement of repairs he had made on the TIP drive. I 1 i
- j. NUREG-0940 I.A-147 n,w- -,,,-,--.m.nm -- , - - -
Appendix , Licensee Comments Regarding Violation B.2 Violation 8.2.a. and b. state that a survey of the Unit #3 TIP drive area was not performed by health physics and that two persons were not present during the I&C technician's second containment entry. Again, however, steps . 4.3 and 9.1.2 make it clear that each of these precautions are required, . but again, the unilateral decision by the I&C technician to proceed with ' what he apparently considered to be a quick repair after he was unable to ' locate a Health Physics technician within containment, made these violations inevitable. The failure of the I&C technician to keep his exposure within i the limits of the RWP, referred to in Finding B.2.c., was also an obvious , consequence of that decision. NRC Response Although Florida Power and Light stated that these violations were the result of the deliberate acts of the I&C technician, the NRC believes that at least two other individuals had the opportunity to take action which could have led to the exercise of adequate radiological controls. Specifically, a second I&C technician was in the control room and participated in the movement of the TIPS. His responsibility was to withdraw the TIP so that it could be re-zeroed by the I&C technician present in containment. This technician failed to ensure that HP Operations was notified prior to the operation of the TIPS as required by Procedure 12404.1. In addition, the Senior Nuclear Watch Engineer was aware that the TIPS were being moved and took no action to determine if proper notifications had been made. Moreover, 1 the I&C supervisor who assigned the two technicians, one of whom was to withdraw the TIP, should have taken overt action to ensure that proper identifications were made prior to beginning work. It should also be noted that the second I&C technician failed to notify HP that the TIP drive would be operated. Licensee Consnents Regarding Violation B.3 The failure to notify Health Physics Operations before operating the incore detector, referred to in Violation B.3., was, similarly, the i inevitable consequence of the I&C technician's decision to go ahead and make the repair despite the explicit instructions to the contrary in PWO #8404 (Procedure 0-GM1-102.1). NRC Response At the time of the inspection, the inspector learned that a second I&C technician was present in the control room. His responsibility was to withdraw the TIP so that it could be re-zeroed by the I&C technician present in containment. The I&C supervisor who assigned the two i technicians, one of whom was to withdraw the TIP, shsuld have taken l overt action to ensure that proper identifications were made prior to beginning work. It should also be noted that the second !&C technician failed to notify HP that the TIP drive would be operated. NtlREG-0940 f.A-148
- - - -. . ~ . . - - - . . _ - . - . -. .- . - - - . - - .
i [ Appendix ! C. Licensee Additional Arguments for Mitigation { Licensee Coments The licensee contends that the five mitigating factors addressed in 10 CFR : 1 Part 2, Appendix C call for mitigation of the civil penalty. The licensee states (1) the event was reported upon its discovery even though it was i not required to be reported, (2) the event was dissimilar to the October 14, 2 1983 event and corrective actions for that problem were effective, (3) prompt corrective action was taken, and (4) the licensee had no prior notice of the employee's willful action. NRC Resoonse , 2 I Regarding mitigation or remission of the civil penalty, the mitigation and escalation factors addressed in the " General Statement of Policy and , Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1985) were considered in the staff's deterutnation of the proposed civil penalty. , The NRC considered increasing the base civil penalty amount because of the i similarity of this most recent event to the 1983 incident and to incidents { against which the NRC previous 1p has cautioned all licensees to take preventive measures (e.g., Infomation notice 82-51 " Overexposure in i Reactor Cavities," December 1982). However, because FP&L reported the
! event upon its discovery, even though it was not required to be reported,
! and has apparently taken extensive corrective actions, the NRC decided not :
- j. to escalate the base civil penalty. Further, the NRC does not consider i the fact that the licensee had no prior notice of the employee's willful action to be an appropriate basis for mitigating the Civil penalty.
!' This incident and the October 14, 1983 incident are similar because both i ) involved failure to adhere to procedures in high radiation areas. Adherence I to procedures forms a basic framework for providing effective, consistent j radiological controls for work in high radiation areas. Short of providing r i direct, continuous health physics coverage for each and every task, these i procedures serve as the formal mechanism for initiating necessary comuni- { cations between various plant workers and the health physics support group. i This comunication results in appropriate radiological support for maintenance ^ and surveillance activities. 8ypassing these proceoures and thus failing to comply with the radiological precautions in them seriously weakens the j health physics control program established to protect the workers. It is i the licensee's responsibility to ensure that these procedures are adhered tu. i However, in view of the licensee's extensive corrective actions which included ! re-instructing the entire plant staff of the need to follow radiation control i procedures; taking disciplinary action against the involved individual and { his supervisor; tagging out the flux mapper system power supply to the Health j Physics Supervisor; and prohibiting individuals working under a radiation g work permit requiring health physics coverage to enter containment without ? notifying the health physict shift supervisor and obtaining his authorization. l we have determined that 50 percent mitigation of the penalty is appropriate. T .f i i i i 1 NUREG-0940 I.A-149 l ,
Appendix NRC Conclusion The NRC has determined that the violations occurred as stated in the Notice of Violation and Proposed Imposition of Civil Penalty, that the violations were correctly categorized as a Severity Level III problem, and that the licensee has provided a sufficient basis for a 50 percent reduction in the proposed
$50,000 civil penalty based on the licensee's extensive corrective action.
Accordingly, a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000) is imposed. f NUREG-0980 1.A-150
fLOH80 A PCW F A & L:Gw r Cotte ANv NOVEMBER 13 1986 L-86-466 Mr. James M. Taylor, Director Of fice of Inspection and Enforcement U. S. Nuclear Regulatory Commission Washington, D. C. 20555 Dear Mr. Taylor Re: Turkey Point Units 3 and 4 Docket Nos. 50-250 and 50-251 Order imposino Civil Penalty (EA 86-38) We appreciate your review and reconsideration of the proposed civil penalty associated with EA 86-38. While we regret that your review did not conclude that total mitigation was warranted, our intent and effort are directed toward assuring that appropriate corrective actions are in place and working. Accordingly, attached is FPL Check No. 56770 to sottsfy the imposed monetary penalty in full. Also provided for information are several comments and clarifications regarding the NRC Staff's review of our response to the original Notice of Violation. These comments are provided in the attochment to this letter. Should you or your staf f have any questions on this information, please contact us. Very truly yours,
. g#
C . w# I.Group ce President Nuclear Energy COW /RC/gp A ttachments RG3/006/l P[nPLE sF fWING P(OPLE NtJREG-0940 f.A-151 k
Re: Turkey Point Units 3 and 4 Docket Nos. 50-250 and 50-251 Order imoosina Civil Penolty EA 86-38) ATTACHMENT The following comments and clarificotions concern the NRC's response to FPL's original response (L-86-215) to the Notice of Violation. Vielselen A l NRC Response:
"When interviewed by the inspector, the I&C technicion stated that he was not aware of the higher radiation levels ossociated with the TIP work."
Also, i "The I&C technician also stated that he was introduced to the Health Physics technicim who was to provide job coverage, but that a pre-job briefing did not take place." FPL Comment: FPL has a statement, propored and signed by the HP technician, stating that a pre-job briefing did take place. The statement includes explicit details concerning potential dose rates, contamination levels, oirborne radioactivity, and resultant protective clothing, and respiratory protection criterio. Violation S.2 and 8.3 NRC Response:
"...the assigned l&C supervisor who assigned the two technicions, one of whom was to withdraw the TIP, should have taken overt action to ensure that proper identifications were mode prior to beginning work."
FPL Comment: The l&C supervisor did not assign the second I&C technician. The scope of the job, os identified on the PWO, was to troubleshoot only. After troubleshooting, the l&C technician should have notified OC and his supervision. Unknown to the I&C supervisor, the original I&C technician requested help from a second I&C techniclon to withdraw the detector. 4 I 4 I RG3/006/2 , I l NIIREG-0940 1.A-15? _ _ . - . . - = - - _ . . - - _ - - . - - - , _ - - - . . - _ - -
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\...../ 0CT 231986 Docket No. 50-302 License No. OPR-72 EA 86-37 Florida Power Corporation ATTN: Mr. Walter S. Wilgus Vice President Nuclear Operations P. O. Box 14042, M.A.C. C-2-M St. fetersburg, FL 33733 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION ANO PROPOSED IMPOSITION OF CIVIL PENALTY AND NOTICE OF DEVIATION (NRC INSPECTION REPORT N05. 50-302/85 01 AND 50-302/85-22; NRC INVESTIGATION REPORT N0. 2-85-004) This refers to the inspections and investigation conducted during the period January 14 1985 through December 11, 1985. As a result of these inspections andinvestIgation,severalviolationsintheadministrationoflicensed operator training and requalification training and in the documentation of this training were identified. The results of requalification examinations admin-istered to Crystal River licensed operators by the NRC on March 5,1985, were consistent with the inspection findings to the extent that they indicated licensed operator requalification training had been ineffective and unsatisfac-tory. Over 70 percent of the individuals administered the examination failed. The results of the inspections and investigation were discussed on January 28, 1986, during an Enforcement Conference held in the NRC Region !! Office with you and members of your staf f. The nature and number of deficiencies identified by the NRC Indicate inadequate management control of, and attention to, the area of licensed operator training and retraining. This lack of management control and attention was evidenced by deficiencies in the conduct and documentation of training and testing, the failure to implement coaulitments to the Commission, inaccuracies in the documentation of trainimg on license applications, and the failure to adequately evaluate individual tralnees' performance prior to licensing. The inadequate management attention was further evidenced by Florida Power Corporation (FPC) training supervision's apparent lack of awareness of applicable requirements and commitments as contained in Title 10 of the Code of Federal Regulations NUREG0737,theFinalSafetyAnalysisReport(FSAR),letterstotheCommissIon, and FPC procedures. Additionally, there appears to have been a widespread misconception that the conduct and documentation of reactor operator (RO) and senior reactor operator (SRO) training were not quality-related activities, requiring attention to detail. CERT!FIE0 MAIL RETURN RECEIPT REQUESTED NUREG-On40 I A-153 I
Florida Power Corporation 2 OCT 23 566 Violation A in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty addresses the reduction in scope and subsequent failure to implement the Licensed Operator Requalification Program. Numerous procedural revisions within the Training Department led to the omission of requalification training commitments, and the conduct of a requalification program unlike that contained in Amendments 35 and 42 of the FSAR which had been approved by the NRC. The reductions in program scope were never submitted to the NRC for approval as required. Of particular concern was an NRC requirement, as a condition of acceptance of the original requalification program, that licensed operators achieve a passing grade of 80 percent on requalification lecture examinations or be provided with remedial training and re-examined. This requirement was procedurally deleted and licensed personnel were allowed to fail multiple lecture examinations on safety-related material with no corrective action or retest. The ' negative impact of this failure to resolve training deficiencies as they were identified became more evident when 70 percent of the individuals taking the NRC requalification examinations in March 1985 failed. Other examples of the failure to implement the approved requalification training program are also included in the Notice of Violation. License renewal applications submitted during this period continued to certify that all requalification training had been successfully completed with no deficiencies listed. 1 Additionally, Violation 8 addresses procedural deficiencies including failure to establish and implement adequate training procedures. FPC had made several hundred commitments in the area of training. Despite a computerized commitment tracking system. FPC failed to establish and implement adequate controls over the revisions of Training Department procedures and programs. Numerous procedural revisions resulted in the omission of many commitments to the NRC. In' addition, commitments made to resolve previously cited training violations were negated by subsequent licensee actions. Violation C addresses the failure to maintain adequate training records and to detect record deficiencies during QA training audits. To emphasize the need for FPC to maintain adequate management control over the training and retraining of licensed operators, and to assure that operator training is conducted according to commitments in the FSAR and approved programs, I have been authorized, af ter consultation with the Director, Of fice of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Eighty Thousand Oollars (580,000) for the violations described in_the enclosed Notice. In accordance with the " General Statement of Policy and-Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations have been categorized as a Severity Level Il problem. The base civil penalty for a Severity level 11 violation or problem is Eighty Thousand Dollars (580,000). The escalation and mitigationfactorsintheEnforcementPolicywereconsidered,andnoadjustment of the base civil penalty amount has been deemed appropriate. 1 As a result of the inspections and investigation, the staff also determined that a number of R0 and SR0 license and license renewal applications submitted between 1982 and 1984 contained inaccurate information. The NRC requires extraordinary care be taken to assure information provided in R0 and SRO license applications MIPEr. 0n40 f.A-154
Florida Power Corporation 3 OCT 23 586 is complete and accurate. FPC did not vigorously implement a program to accurately document the training given R0 and SRO candidates, adequately verify the information prior to its submittal to the NRC, or provide for checking that training it had told the NRC would be completed by a specific date had in fact been completed by that date. You are expected to take all actions necessary to ensure that in the future all communications with the NRC are complete and accurate in all significant respects. The inspection findings also indicate the failure to implement commitments made regarding training requirements derived from NUREG 0737. This matter is discussed in the enclosed Notice of Deviation. You are required to respond to the enclosed Notices and you should follow the instructions specified therein when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, TitleJ0, Code of Federal Regulations, a copy of this letter and the enclosure will 5e placed in the NRC's Public Document Room. The responses directed by this letter and accompanying Notice are not sutject to the clearance procedures of the Office of Management and tiudget as required by the Paperwork Reduction Act of 1980, PL 96-511. Should you have any questions concerning this letter, we will be glad to discuss them with you. Sincerely, f.t . ,
};,. L J. Nelson Grace Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Notice of Deviation cc w/encis:
P. F. McKee, Nuclear Plant Manager R. Widdell, Manager Nuclear Operations Licensing and Fuel Management NtlPEG-0940 f.A-155
NOTICE OF VIOLATION MU PROPOSED IMPOSITI F 0F CIVIL PENALTY Florida Power Corporation Docket No. 50-302 Crystal River Unit 3 License No. DPR-72 EA 86-37 Based on the results of an investigation conducted by the NRC Office of Investigations (01 Report No. 2-85-004) at the Crystal River Nuclear Generating Plant from January 25, 1985 through December 11, 1985, and inspections conducted January 14-18, 1985, and April 29 through May 1,1985, violations of NRC require-ments were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Section 234 Regulatory Commission of the Atomic proposes Energy Act toas of 1954, impose a civil amended, penalty') ("Act pursuant
, 42 U.S.C. 2282, to PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
A. 10 CFR 50.54(1-1) requires that within three months after issuance of an operating license, the licensee shall have in effect an operator requalifi-cation program which shall, as a minimum, meet the requirements of Appendix A of 10 CFR Part 55. Furthermore, the licensee shall not, except as specifically authorized by the Commission, make a change in an approved requalification program by which the scope, time allotted for the program, or frequency in ! conducting different parts of the program is decreased. Technical Specification 6.4.1 requires that a retraining and replacement training program for the facility staff shall be maintained under the direction of the Nuclear Plant Manager and shall meet or exceed the requirements and recommendations of Section 5.5 of ANSI N18.1-1971 and Appendix A of 10 CFR Part 55. i Contrary to the above, through numerous training procedure revisions and the annual FSAR update in 1984, the scope of the requalification training program, as approved by the NRC under FSAP Amendments Nos. 35 and 42, and contained in Section 12 of the Crystal River FSAR, was significantly reduced without prior Commission approval. Specifically, the following requirements were deleted from the NRC-approved requalification program l without prior Commission approval during the period from January 1982 until January 1985:
- 1. Achievement of an 80 percent pass grade on lecture examinations or attendance at remedial training. (Procedure revisions reduced the required passing score to 70 percent and required no remedial training.)
- 2. Instructional sessions and emergency drills conducted by Shift Supervisors for all shift members to ensure that the information contained in abnormal and emergency procedures is covered annually.
I NUREG-0940 I.A-156
Notice of Violation 2
- 3. A minimum of 40 hours of requalification lecture attendance for each licensed operator and backup operator annually.
- 4. Walkthroughs of procedures with a Shift Supervisor for individuals
, not completing quarterly procedure reviews by the assigned due date.
- 5. Use of the results of the annual requalification examination to determine topics to be emphasized during the following requalification period.
4 6. Review of a licensed operator's entire training file by the operations manager prior to license renewal to evaluate the level of understanding.
- 8. Technical Specification 6.4.1 requires that a retraining and replacement training program for the facility staff shall be maintained under the direction of the Nuclear Plant Manager and shall meet or exceed the require-ments and recommendations of Section 5.5 of ANSI N18.1-1971 and Appendix A of 10 CFR Part 55.
" 10 CFR, Part 50, Appendix B, Criterion V, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished
, in accordance with these instructions, procedures, or drawings.
Contrary to the above, adequate training department procedures were ' not established, implemented, and maintained to ensure satisfactory requalification training and continued operator competency. , Specifically the requalification program was inadequate in that there was:
- 1. Failure to establish or implement procedures during the period January 1982 to January 1985, to control the administration, grading, and review of written tests, oral boards, and walkthrough examinations including failure to develop Training Department Procedure (TOP) 106, Examination Preparation and Evaluation, as was required by TOP-102, Conduct of Training.
- 2. Failuretoimp5mentFPCTrainingDepartmentProcedureTDP-203, Licensed Operator Requalification Training Program, Revision 1, Section 5.9.2 and Operations Section Implementation Manual OSIM 4, l
Revision 40, Interface Policies and Practices, requiring semiannual evaluations of all licensed operators and senior operators. Self-evaluations were done by backup licensees without review by the Operations Superintendent or were not performed at all as , required by the above procedures during the period January 1982 to January 1985. l NUREG-0940 I.A-157
Notice of Violation 3
- 3. Failure to implement FPC Training Department Procedure TOP-105, lesson Plan Development, Revision 4, requiring the use of approved lesson plans in conducting requalification training lectures. On January 14 and 15, 1985, three requalification lectures were conducted without using approved lesson plans.
- 4. Failure to implement procedures TDP-203 Licensed Operator RequalificationTrainingProgram, Revision 1,Section1and TDP-107, Training Methods and Evaluations, Revision 0 Section 5.4.2, requiring semiannual evaluations of instructors who teach licensed operator training courses for most of the instructors who conducted training in 1983 and 1984.
C. 10 CFR 50.54(1-1) requires that within three months after issuance cf an operating license, the licensee shall have in effect an operator requalification program which shall, as a minimum, meet the requirements of Appendix A of 10 CFR Part 55. Furthermore, the licensee shall not, except as specifically authorized by the Commission, make a change in an approved requalification program by which the scope, time allotted for the program, or frequency in conducting different parts of the program is decreased. 10 CFR Part 55, Appendix A, Item 5.b, allows records of requalification tri.ining to be a reproduced copy or microfilm if such copies or microfilm are duly authenticated by authorized personnel and the microfilm is capable of producing a clear and legible copy. Technical Specification 6.10.2 requires that records of training and qualification for current members of staff be retained for the duration of the operating license. Contrary to the above, the licensee failed to maintain adequate, legible, and retrievable records of licensed operator training and retraining and failed to detect and correct numerous training and training record deficiencies during QA training audits. The NRC review of the training ! records of licensed operators and instructors for the period January 1982 to January 1985, identified multiple examples of incomplete documentation, missing or not retrievable entries, numerous discrepancies and errors, and difficult to re.trieve or very poor microfilm copies of illegible quality. The specific record discrepancies were numerous, but examples of the types of problems encountered included: l 1. Missing original hard copy training files which were apparently lost
- 2. Ungraded examinations and records of oral boards and walkthroughs
- 3. Unsigned examinations HUREG-0940 1.A-158 i
r I- Notice of Violation 4 [ t
- 4. Unsubstantiated written examination grade changes
- 5. Incomplete on-shift time sign-offs by backup licensees
- 6. Incomplete quarterly procedure review sign-offs !
- 7. Missing documentation for instructor qualifications training l i
; 8. Missing documentation for three months control room experience prior to writing for NRC SRO license
- 9. Microfilm training records stamped poor copy with sections illegible
! 10.' Missing SRO license training records
- 11. Missing records of engineer training i j
Collectively,lement problem (Supp I).these violations have been categorized as a Severity 1.evel II ' i (Civil Penalty - $80,000 assessed equally among the violations.) i i Pursuant to the provisions of 10 CFR 2.201, Florida Power Corporation is hereby i required to submit to the Of rector, Office of Inspection and Enforcement, U.S. ! Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional i ! i ! Administrator,is the date of th Notice a written statement or explanation including for eachU.S. Nucl ' violation: (1) adelssion or denial of the violation, (2) the reasons for the j violation if admitted, (3) the corrective steps that have been taken and the : l results achieved, (4) the corrective steps which will be taken to avoid further ! violations, and (5) the date when full compliance will be achieved. If an
- adequate reply is not received within the time specified in this Notice, the t Director Office of Inspection and Enforcement, may issue an order to show cause I
' why the license should not be modified, suspended, or revoked or why such other i action as may be proper should not be taken. Consideration may be given to ' ] extending the response time for good cause shown. Under the authority of 1 Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time asJrovided for the response required above under t 10 CFR 2.201, Florida Power Corporation may pay the civil penalty by letter i addressed to the Director, Office of Inspection and Enforcement, with a check, j draft, or money order payable to the Treasurer of the United States in the ,
; cumulative amount of Eighty Thousand Dollars ($80,000) or may protest imposition '
- of the civil penalty in whole or in part by a written answer addressed to the :
Director, Office of Inspection and Enforcement. Should Florida Power Corporation fail to answer within the time specified, the Director, Office of Inspection and ! Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Florida Power Corporation elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1)denythe i violations Ifsted in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the l l ! I ) NUREG-0940 1.A-159 ,i
.-.-~---n----,--- __-~~---.~,-nn-_.-- -,_
Notice of Violation 5 penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.8 of 10 CFR Part 2. Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Florida Power Corporation s attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties. Upon failure to pay any civil penalties due which have been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY C0W415510N h y .k.'ll(.5M, f J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this 43 day of October 1986 NUREG-0940 I.A-160
NOTICE OF O(VIATION Florida Power Corporation Docket No. 50-302 Crystal River Unit 3 License No. OPR-72 EA 86-37 l The following deviations were identified during inspections conducted on January 14-1s,1985 and Aprf129 through May 1,1985. The itcensee in a submittal dated December 15, 1900 committed to the implementation of NUREG 0737, Items 1.A.2.3 and I.C.5. ; ! Contrary to the above, the licensee failed to adequately implement certain of
- these items as follows
l A. Itee I. A.2.3 of NUAEG 0737 requires that instructors who teach systems, integrated plant operations, transients, and the simulator to licensed personnel demonstrate SR0 qualifications by completion of an NRC examina-tion and be enrolled in appropriate requalification programs. At least three instructors at Crystal River have taught these courses to licensed individuals during the latter half of 1981 and during 1982 prior to completion of an SRO level examination or without attending license requalification training.
- 8. Ites !.C.5 of NUREG 0737 requires that operating experience originating
! both within and outside the organization be continually provided to operators and that it be incorporated into plant operating procedures and I training / retraining programs. The Itcensee's letter of December 15, 1980, states that this information is provided to operators and other personnel l and will be incorporated into training and retraining programs. During l the N4C inspection in January 1985, it was found that the licensee had, l prior to that time, made attendance at operational experience training l lectures voluntary for licensed operators and senior operators. l Please provide, in writing within 30 days of the date of this Notice, a description of corrective actions regarding these deviations, actions taken to avoid further deviations, and the dates when these actions were or will be completed FOR THE NUCLEAR REGULATORY Co m !$$!0N hy $l . 1 ., l J. Nelson Grace l Regional Administrator Dated at Atlanta, Georgia i this 43 day of October 1966 l l ! NUREG-0!MO f.A-161
weiter S.Wileue v.c e, .e ai uweer coeree.ons November 21, 1986 3F1186-13 Mr. James M. Taylor. Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, DC 20555
Subject:
Crystal River Unit 3 Docket No. 50-302 Operating License No. OPR-72 Proposed imposition of Civil Penalty Notice of Violation Notice of Deviation NRC Inspection Reports 85-01 and 85 22 Enforcement Action 86-31 i Dear Siri in accordance with 10 CFR 2.205 and in response to the subject Notice of Violation dated October 23, 1986, Florida Power Corporation (FPC) hereby
- forwards a check in the amount of eighty thousand dollars (check number 874565) payable to the Treasurer of the United States.
FPC regrets the three violations specified in the subject Notice occurred. The attached is submitted as our response to the Notice of Violation and Deviation in accordance with 10 CFR 2.201. The reasons for the occurrences were numerous and overlapping but generally fall into five significant categories.
- 1. Insufficient FPC commttoer.t control.
- 2. Insufficient administrative controls.
- 3. Ineffective communications and interfaces between FPC and NRC and among various FPC organtrations, such as training, operations, licensing, and quality assurance.
4 Intensitivity to and poor appitcation of the practices and philosophies of quality assurance as it pertained to operator training. i 3001 Thirty fowth Street South
- P O to:14042.St Pereaves.Flories 33133 $13 444 $208 4
4 NilRf'n-0940 1.A-162
November 21. 1986 3F 1186-13 Page 2
- 5. Insufficient audit program effectiveness as it pertained to operator training.
These " root-causes" have been discussed and amplified upon in numerous meetings with the NRC Region !! personnel. Likewise, the corrective actions taken to remedy the deficiencies identified in the Notice (to the maximum extent practicable), as well as the corrective action steps taken to prevent recurrence, have been extensively reviewed and discussed with NRC Region !! personnel. FpC management has taken strong and immediate steps to identify and correct
'noted deficiencies and has acted to preclude a repeat of such a situation.
The steps have included: a complete revision of our training procedures. ! addition of training personnel; re-organization of the Training Department with the Manager Nuclear Operations Training reporting directly to the Vice. President. Nuclear Operations; and numerous other corrective and preventive
' actions. We are confident that the enceptional effort and financial resources expended to correct the identified weaknesses are indicative of FPC's desire ta significantly improve our performance. The results of our efforts have been substantiated by internal FPC audits, external consultant audits, and NRC inspections (most recently 50-302/86-22). FPC recognizes '.
that continued management vigilance and resources need to be focused on this critical area, and we will continue our strong support of the training activity. Sincerely, q a N W. 5. W11 Vice 9te ent Nuclear rations l I ERC/feb l Attachment l TRA86 0195 ! me Dr. J. Nelson Grace i Regional Administrator, Region !! ! U.S. Nuclear Regulatory Commission ! 101 Marietta Street N.W., Suite 2900 Atlanta, GA 30323 t l t e NilREG 0940 f.A 163
FLORIDA POWER CORPORATIO"
RESPONSE
lEtt INSPECTION REPORTS 85-01 AM 85-22 VIOLATION A 10 CFR 50.54(1-1) requires that within three months after issuance of an operating Itcense, the licensee shall have in effect an operator requalification program which shall, as a minimum, meet the requirements of Appendix A of 10 CFR Part 55. Furttermore, the licensee shall not, except as specifically authorized by the Commission, make a change in an approved requalification program by which the scope, time allotted for the program, or frequency in conducting different parts of the program is decreased. Technical Specification 6.4.1 requires that a retraining and replacement training program for the facility staff shall be maintained under the direction of the Nuclear Plant Manager and shall meet or exceed the requirements and recommendations of Section 5.5 of ANSI N18.1-1971 and Appendix A of 10 CFR Part 55. - Contrary to the above, thruugh numerous training procedure revisions and the annual FSAR update in 1984, the scope of the requalification training
- program, as approved by the NRC under FSAR Amendments Nos. 35 and 42, and contained in Section 12 of the Crystal River FSAR. was significantly reduced without prior Commission approval. Specifically, the following requirements were deleted from the NRC-approved requalification program without prior Commission approval during the period from January 1982 until January 1985.
i
- 1. Achievement of an 80 percent pass grade on lecture examinations or attendance at remedial training. (Procedure revisions reduced the j required passing score to 70 percent and required no remedial training.)
! 2. Instructional sessions and emergency drills conducted by Shift Supervisors for all shift members to ensure that the information contained in abnormal and emergency procedures is covered annually.
- 3. A minimum of 40 hours of requalification lecture attendance for each licensed operator and backup operator annually.
4 Walkthroughs of proceduaes with a Shif t Supervisor for individuals not completing quarterly procedure reviews by the assigned due date.
- 5. Use of the results of the annual requalification examination to determine topics to be emphasized during the following requalification period.
- 6. Review of a licensed operator's entire training file by the operations manager prior to license renewal to evaluate the level of understanding.
1 1 4 NUREG-094(1 1.A-164 ,
1 :, , s. RESPONSE A ,
- 1. Florida Power Corporation's Position Florida Power Corporation (FPC) agrees with the stated violation . in' that the scope of the requalification training program was reduced ,
without NRC approval. -
- 2. Cause ^ ^' '
The causes of the violation are: a) insufficient FPC commitment control; b) insufficient administrative control over program changes; and c) unfamiliarity with the requirements of 10 CFR 50.54(1-1); ,
- 3. Corrective Action y The entire FPC docket and correspondence file as it pertained to , - /
nuclear training was reviewed to ensure our comitment control system - ' correctly identified FPC's nuclear training commitments. , , The Licensed Operator Requalification Training Program = as described in Final Safety Analysis Report (FSAR) Chapter 12 Appendix C was reassembled from the previously approved description and subsequent' commitments. It was submitted to the NRC on March 15, 1985. Training Department Procedure TOP-203, " Licensed Operator Requalifi-cation Training Program", was revised and issued to reflect the revised -f program scope described in the newly reassembled and expanded FSAR ; Chapter 12, Appendix C. 4 Action to Prevent Recurrence s FPC revised the Training Department procedure controlling training program changes. All revisions now require a comitment review and a 10 CFR 50.54(1-1) review prior to revising the Licensed Operator , Requalification Training Program. FPC developed a new Nuclear Operations Department procedure (N00-11) which controls (along with other administrative procedures) all program changes requiring 10 CFR 50.59 and 50.54 reviews and, where applicable, NRC approval prior to implementation. Personnel responsible for review and approval of the licensed operator ' requalification program have been made aware of the requirements of 10 CFR 50.54(1-1).
- 5. Date of Full Compliance The actions stated above have been implemented. .
2 b NUREG-0940 1.A-165
1 VIOLATION S t Technical Specification 6.4.1 requires that a retraining and replacement training program for the facility staff shall be maintained: under the direction of the Nuclear Plant Manager and shall . meet or exceed the requirements . and recommendations - of Section 5.5 of ANSI .N18.1-1971 and Appendix A of 10 CFR Part 55. 4 ~ 10 CFR Part 50, Appendix B, Criterion V, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or i drawings of a type , appropriate to the circumstances and . shall be
' accomplished in accordance with these instructions, procedures, or drawings. .
Contrary to the above, adequate training department procedures were not i established, implemented, and maintained to ensure satisfactory
- requalification training and continued operator competency. Specifically, the requalification program was inadequate in that there was:
} 1. Failure to. establish or implemen't procedures during the period January , 4 1982 to January 1985 to control the administration, grading, and review ' i of written tests, oral boards, and walkthrough examinations, including l [' failure to develop Training Department Procedure (TOP) 106,
. Examination Preparation and Evaluation, as was required by TDP-102, Conduct of Training.
I
- 2. Failure to' implement. FPC Training Department Procedure TDP-203, Licensed Operator Requalification Training Program, Revision 1, Section - .
l 5.9.2 and Operations Section implemetation Manual OSIM .4, Revision 40, 5 Interface Policies and Practices, requiring semiannual evaluations of all licensed operators and senior operators. Self-evaluations were done by backup licenses without review by the Operations Superintendent > or were not perfomed at all as required by the above procedures during
. the period January 1982 to January 1985. ; . 3. Failure to implement FPC Training Department Procedure TDP-105, lesson Plan Development, Revision 4 requiring the use of approved lesson plans in conducting requalification training lectures. On January 14
! and 15, 1985, three requalification lectures were conducted without using approved lesson plans. l j 4 Failure to implement procedures TDP-203, Licensed Operator Requalification Training Program,- Revision 1, Section 1 and TDP-107, l Training Methods and Evaluations, Revision 0, Section 5.4.2, requiring ' ! samtannual evaluations of instructors who teach licensed operator , I training courses for most of the instructors who conducted training in i 1983 and 1984. RESPONSE S
- 1. Florida Power Corporation's Position FPC agrees with the stated violation in that adequate procedures were not established, implemented, and maintained to ensure satisfactory 3
NUREG-0940 1.A-166 l l
requalification training and continued operator competency. FPC does note that the violation is for failure to implement procedures and not because our operators were incompetent. The details on example 4 have been previously discussed. There was no FPC requirement to conduct instructor evaluations until Policy Statement 84-01 was issued September 14, 1984, and then it was only required annually.
- 2. Cause The causes for this violation were a lack of sufficient administrative control to ensure procedural requirements were met and poor application of the requirements of 10 CFR 50, Appendix B, as they apply to training activities, particularly the requirement to establish and implement procedures which control quality activities (Criterion V).
- 3. C_orrective Action The entire ~ Training Department Procedure Manual was rewri tten to establish sufficient administrative controls on procedural requirements. Checklists and attachments were developed to document, the perfomance of procedure steps.
TDP-106, Examination, Preparation, Administration and Grading, was issued and staff training on its requirements was conducted. Awareness of quality assurance requirements and their interrelattenship with training . activities was increased through more staff training and internal memoranda. 4 Action to Prevent Recurrence The Training Department' procedure process was significantly strengthened in the areas of review and approval. At least two levels of FPC management must approve all administrative procedures. Note: In Item 4 of the January 20, 1986 letter on i.icensed Operator Requalification Training Program - Summary of Corrective Actions, FPC stated that three levels of FPC management reviewed all administrative procedures. Due to reorganiza-ti on , there are now two levels of management. However, the highest level of management was and continues to be the Vice President, Nuclear Operations. A new computerized Nuclear Operations Training Information System (NOTIS) has been developed and implemented. This system will track completion of all procedure requirements, including instructor evaluations, semi-annual operator perfomance ev al ua tions , e tc . It also generates exception (eports identifying overdue requirements. NUREG-0940 I.A-167
Training Department personnel are required to participate in Training Department procedure indoctrination to assure a better understanding of procedural requirements. 5.- Date of Full Compliance The actions stated above have been implemented. VIOL 4 TION C 10 CFR 50.54(1-1). requires that within three months after issuance of an operating license,. the licensee shall have in effect an operator requalification program which shall, as a minimum, meet the requirements of Appendix A of 10 CFR Part 55. Furthermore, the licensee shall not, except as specifically authorized by the Commission, make a change in an approved requalification program by which the scope, time allotted for the program, or frequency in conducting different parts of the program is decreased. 10 CFR Part 55, Appendix A, Item 5.b, allows records of requalification training to be a reproduced copy or microfilm if such copies or microfilm are duly authenticated by authorized personnel and the microfilm is capable of producing a clear and legible copy. Technical Specification 6.10.2 requires that records of training and qualification for current members of staff tie retained for the duration of the operating license. Contrary to the above. the licensee failed to maintain adequate, legible, and retrievable records of licensed operator training and retraining and failed to detect and correct numerous training and training record deficiencies during QA training audits. The NRC review of the training records of licensed operators and instructors for the period January 1982 to January 1985; identified mul tiple examples of incomplete documen tation ,
- missing or not retrievable entries, numerous discrepancies and errors, and difficult to retrieve or very poor microfilm copies of illegible quality.
The specific record discrepancies were numerous, but examples of the types of problems encountered included:
- 1. Missing original hard copy training files which were apparently lost
- 2. Ungraded examinations and records of oral boards and walkthroughs
!. 3. Unsigned examinations
- 4. Unsubstantiated written exantination grade changes
- 5. Incomplete on-shift time sign-offs by backup licensees
- 6. Incomplete quarterly procedure review sign-offs
- 7. Missing documentation for instructor qualifications training I
til! PEG-09d6 I.A-168
- 8. Missing documentation for three months control room experience prior to writing for NRC SRO license
- 9. Microfilm training records stamped poor copy with sections illegible
- 10. Missing SRO license training records a
- 11. Missing records of engineer training RESP 0llSE C
- 1. Florida Power Corporation's Position FPC agrees with the stated violation in that adequate, legible, and retrievable records of licensed operator training and retraining were not maintained in some cases, and numerous training and training record deficiencies were not detected during 0A audits.
- 2. Cause The poor records situation was caused in part by the emphasis placed on the result of final examinations as opposed to those individual, training elements which comprise the complete training curricula. In addition. Training Department personnel were not sufficiently cognizant of the fact that training activities are quality related and, as such, did not recognize the need to pay meticulous attention to the accuracy and completeness of licensed operator training records.
i There were insufficient administrative controls in place to ensure required training was properly documented upon completion. In cases where changes to training records needed to be made, guidance had not been provided to the appropriate personnel on how to make such changes. There was no backup system to alert management that appropriate training document? ion had not been received when the. due date had passed. Training audits were ineffective because the personnel conducting the audits a) were not sufficiently experienced in the comprehensive requirements for licensed operator training, and b) made use of audit plans which resulted in superficial review.
-3. Corrective Action Ungraded exams for the 1984 hot license class were immediately graded and filed as quality records. Other exam deficiencies were reviewed and corrected or annotated with appropriate resolution.
In the case of missing or incomplete records, other valid sources of documentation, such as attendance sheets, shift logs, computer printouts, etc., were used to complete inadequate records to the extent possible. I
)
l NUREG-0940 I.A-169
Hard copy working files were established at the training center for each hot license candidate and licensed operator so records could be audited and retrieved on a daily basis. In numerous cases where the records were incomplete, it was assumed by FPC the training was not done or not done in the manner prescribed by procedure; therefore, additional training was conducted. A review team conducted a 2-mentn review of all licensed operator training and retrainin) policies, practices, procedures, and records. The review team cpnsisted of 5 full time members and 3 part time persons with backgrounds in training,
. operations, licensing, regulatory compliance, and quality assurance. A total of 45 major deficiencies were written and responded to wi th corrective action taken in all cases. The report produced by this review team was transmitted to the NRC on October 15, 1985 (3F1085-10).
4 Action to Prevent Recurrence Training program procedures have been significantly improved. They now include specific documentation requirements and checklists to ensure all program requirements are identified and recorded when complete. A new computerized Nuclear Operations Training Infonnation System (NOTIS) has been implemented to track completion of programmatic
- requi rements. It will generate " exception" reports when documentation has not been received by the time the training activity is scheduled to be complete. New administrative controls have been established to track the transmittal and receipt of the quality records documenting required training.
A new Nuclear Training Controls Supervisor position has been established and filled to direct the record management effort and ensure compliance with documentation requirements. A training department procedure has been developed and implemented to address tracking and resolution of deficiencies in training activities as they are identified. In order to enhance the effectiveness of future audits, revisions have been made to the audit planning criteria and scope statements for audits of personnel training and qualifications to incorporate the following elements:
- a. Provide more explicit cri teria for conduct of audits of replacement and requalification training of licensed operators,
- b. Provide more explici t cri teria for audits of personnel qualifications versus job requirements.
- c. Require that an individual holding or having held an SRO license be a member of the audit team.
- 5. Date of Full Compliance The actions stated above have been implemented.
i NUREG-09a0 I.A-170
4 FLORIDA POWER CORPORATION RESPONSE TO IWTICE OF DEVIATION FA 86-37 DEVIATION A Item I.A.2.3 of NUREG 0737 requires that instructors who teach systems, integrated plant operations, transients, and the simulators to licensed 9ersonnel demonstrate SR0 qualifications by completion of an NRC examination and be enrolled in appropriate requalification programs. At least three instructors at Crys tal River have taught these courses to licensed individuals during the latter half of 1981 and during 1982 prior to completion of an SR0 level examination or wi thout attending license requalification training.
RESPONSE
- 1. Corrective Action A detailed review of instructor qualification records was conducted.
Two of the three instructors who are referenced in the deviation are no, longer FPC employees. The third instructor referred to received an SRO license in 1978, he subsequently left FPC, returned in 1982, and ragained his SR0 in August 1983. All other instructors were either SRO licensed or certified when they conducted training. All licensed instructors took and passed an NRC-administered requalification examination in 1985. All certified instructors were enrolled in accelerated requalification training in 1985 and tested by FPC to ensure technical competency. All new instructors were excluded from teaching licensed operator training classes until they completed SRO training and were either certified or licensed wi th the exception of one instance where an R0-licensed instructor was granted Guest Lecturer status and used to teach electrical distribution because he had a special expertise needed for the class.
- 2. Action to Prevent Recurrence FPC has revised initial instructor qualification training requirements and administrative procedures to ensure compliance with the regulatory requirements.
FPC has revised its instructor requalification training commitments as stated in FPC's letter dated July 28, 1986 to the NRC (3F0786-14). NUREG-0940 I.A-171
FPC is agressively expanding the size of its operations instructor staff by nearly 100% from 8 to 15 licensed and non-licensed operator instructors. This expansion will help ensure appropriately qualified manpower is available to teach the heavy class load of requisite courses.
- 3. Date of Full Compliance The actions stated above have been implemented. Authoriz3 tion has beer, granted to increase staff size from 8 to 15 instructors, and the filling of new positions is in progress. Assuming minimal turnover, the staff should reach 15 instructors by July 1987.
DEVIATION 8 Item I.C.5 of NUREG-0737 requires that operating experience originating both within and outside the organization be continually provided to operators and that it be incorporated into plant operating procedures and training / retraining programs. The licensee's letter of December 15, 1980 states that this information is provided to operators and other personnel and will be incorporated into training and retraining programs. During the NRC inspection in January 1985, it was found that the licensee had, prior to that time, made attendance at operational experience training lectures' voluntary for licensed operators and senior operators.
RESPONSE
Discussion NRC's statement that " . . . the licensee had, prior to that time, made attendance at operational experience training lectures voluntary . . ." is not correct. FPC management has always required attendance at requalification training lectures which address operational experience and industry feedback. Some licensed personnel did not attend these required subject lectures for a variety of reasons, such as illness, conflicting work schedules, needs for shift personnel to be at the plant when training was scheduled at the I training center, etc. This " lack of attendance" problem was further aggravated by the Training Department's inability to quickly and easily identify who was delinquent in attendance, and, therefore, no remedial or l " makeup" sessions were conducted.
- 1. Corrective Action All outstanding oparational information feedback packages were reviewed for training impact. Those that had not been previously incorporated were factored into existing lesson plans, or new lesson plans were developed for special training.
l l NUREG-0940 I.A-172
- 2. Action to Prevent Recurrence As recommended by NRC Inspection Report 85-01, administrative procedures have been revised to formalize the informatica review, dissemination, and incorporation process.
FPC has expanded the requalification training classroom time available for lectures by 50% per training week (from 3 to 4-1/2 days) in order to move a significant portion of the operational feedback training burden from on-shift to the Training Department. However, required reading and critical time-sensitive training will still be conducted on-shift. To track required attendance at lectures, FPC has developed an extensive, computerized system called NOTIS (Nuclear Operations Training Information System) which identifies persons who are required to attend training, documents attendance based on input from attendance records, and generates exception reports identifying personnel who missed required training. This system also tracks oparational feedback and industry information items which have training impact in order to ensure required training activities are completed on schedule.
- 3. Date of Full Compliance The actions stated above have been implemented.
NUREG-0940 I.A-173 _. . .\
[ ***
- " 7.
umTED STATES
- NUCLEAR REGULATORY COMMISSION o
usamoTON, D. C. 205% %; v...../ SEP1: L Docket No. 50-320 License No. DPR-73 EA 86-146 General Public Utilities Nuclear Corporation ' ATTN: Mr. P. R. Clark, President 100 Interpace Parkway Parsippany, New Jersey 07054 Gentlemen:
Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (INVESTIGATION REPORT NOS. H-83-002 and I-84-029) This refers to investigations conducted March 25 - August.10,1983 and , November 1,1984 to September 5,1985 by the hRC's Office of Investigations I (01). In February 1983, the hRC received allegations involving weaknesses in ! l procedural and management control of activities conducted at Three Mile Island, Unit 2 (TMI-2) involving the refurbishment work associated with the Reactor ( Building Polar Crane. After an initial 0! investigation of the allegations, the Office of Inspection and Enforcement (IE) issued a Notice of Violation (NOV) on February 3, 1984. You responded to this h0V on February 28, 1984 and by letter dated April 18, 1984 from Richard DeYoung to P. R. Clark, the action was resobed. However, by letters cated October 5 and October 8,1964, GPU Nuclear notified the staff that acottional *c.difications were made to -ae Peactor Building Polar Crane withuut :.repe en.;1 cering .wiew ana at .. e r. tc i ,, r . S ese .:cci f.u ..;t.; involved the acditio1 of i hand release r.echanisr: which directly affectec the ability of the main hoist brakes to properly function. 01 was subsequently asked to investigate this issue as well. A Report of Investigation was issued on Septeraber 23, 1985 and the report was made public shortly thereafter. We have consiaered your submittals on January 15 and February i8,1986 of reports prepared by Kennedy P. Richardson ana Edwin Stier regarding the results of the investigation. The information provided in these reports was considered in ceveloping this proposed enforcement action. Based on our review of the original procedural violations and of the hand release mechanism incident, the addition of the hand release mechanism appears to be dnother more serious example of the original Violations in which modifications were made to the Reactor Building Polar Crane without proper engineering review and documentation. This violation directly affected the ability of the main hoist brakes to properly function. In addition, GPU Nuclear and Bechtel Northern Corporation (BNoC) personnel were aware of the requirements to comply with GPU Nuclear's approved procedures and the fact that BNoC was not complying with CERTIFIED MAIL RETURN RTEETPT RE0 VESTED MUREG-0940 1.A-174
GPU Nuclear Corporation tnem with regard to refurbishment of the polar crane. Therefore, the violation was apparently willful. In accordance with the General Statement of Policy and Procedure for NRC Enforcement Actions,10 CFR Part 2, Appendix C (1986), the violation has been categorized as a Seterity Level III violation. To emphasize the need for you to properly control the activities of your contractors performing modifications, I have been authorized, after consultation with the Comission, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Forty Thousand Dollars ($40,000) for the violation described in the enclosed Notice. The base civil penalty for a Severity Level III violation at the time it occurred was $40,000. We examined the escalation and mitigation factors allowed by the Enforcemert Policy and none were considered appropriate. In addition to the above violation, we noted that in response to questions in a July 18, 1983 letter from the NRC staff regarding any modifications to the crane that were not "in-like kind," the Site Director. TMI-2, stated in a letter dated August 16,1983, "The polar crane's two main hoist brakes were replaced in kind." Page 8 of an attachment to that letter identified a list of items as " replacement-in-kind" parts on the polar crane, including the main hoist brakes. The statements were not accurate because the main hoist brakes were not replaced "in-kind." The new brakes included a hand release mechanism not on the original brakes which added an additional function to the brakes (ability to lower a load in case of a power failure) and was identified by the vendor as complicating maintenance (Westinghouse Leaflet Po. 3710-2). If the staff had known that the brakes had not been replaced "in-kind" it would have requested additional information to ensure that the modification had been performed in accordance with procedures and had received appropriate design, engineering, and quality assurance reviews. Cn Septeua e , 19c;J , tre WC Depq r rogran Cirector, 'NO, ad$ we further fornal questions to the licensee specifically recuiring, accrg other things, that "you should review the modifications for the polar crane and certify to NRC that modifications involving unlike kind components have been eveluated and reviewed in accordance with applicable administrative procedures." GPLh's responses, dated Octcber 11 and 25,1983, failed to inform the NRC that the main hoist braxes of the polar crane had not been replaced in-kina. 01 statea in its report (I-84-029) that "No evidence was oeveloped to indicate that Licensee Management knowingly intended to deceive the NRC when, in written dnd Verbal Comunications, they described the main hoist brakes as replaced
'in-kind'." We have concluded that at the time he signed the letter, the TMI-2 Site Director was not aware that the brakes had not been replaced in-kind.
Therefore, we do not believe that the statements were knowingly or intentionally made and have decided not to cite for a material false statement. However, in view of the intense attention that was paid to this issue at the time the submittal was made, the repeated questioning by the NRC on whether there were any additional unlike-kind replacements, and the ability to identify the addition of the hand release mechanism from drawings and discussions with the many personnel on-site who knew of its existence, we believe additional NUREG-0940 I.A-175
l 6PU Muclear Corporation attention should have been devoted to ensuring the accuracy of these submittals and expect that future submittals will be complete and accurate in all significant respects. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. In responding to the Notice you may incorporate by reference previous submittals as appropriate. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure ccepliance with NRC ngulatory requirements. i l In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, ; Title 10 Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Motice are not subject to the clearance procedures of the Office of Management and Budget as required l by the Paperwork Reduction Act of 1980, PL.96-511. I Sincerely, y - /- m6Nt. T r ffice of Inspection and Enforcement
Enclosure:
Notice of Violation and
<rgosed Irrgett uon of Civil Penalties NUREG-0940 1.A-176
NOTICE OF VIOLATION AND PROPOSED IMPOSITIDT0F CIVIL PENALTY GPU Nuclear Corporation Docket No. 50-320 Three Mile Island Unit 2 License No. OPR-73 EA 86-146 From March 25 - August 10, 1983 the NRC's Office of Investigations (01) conducted an investigation into allegations dealing with procedural and management controls related to refurbishment of the polar crane raised by former Three Mile Island, Unit 2 (TMI-2) Site Operations Department Personnel. An interim report was issued by OI on September 1,1983. The OI findings confirmea many of the allegations of procedural control violations and lack of adequate management attention toward Contractor activities. A Notice of Violation was issued to GPU Nuclear-for these violations on February 3,1984. In letters dated October 5 and 8,1984, GPU Nuclear notified the NRC that another modification had been made to the Reactor Building Polar Crane without proper engineering review and documentation. From November 1, 1984 to September 5,1985, another investigation was conducted regarding the installation of a hand release mechanism for the main hoist brakes. This investigation resulted in an 01 Report dated September 23, 1985 which confirmed that certain GPU Nuclear procedures were violated and that those violations were in fact willful. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985) the Nuclear Regulatory Consission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended ("Act"), 42 USC 2282, PL 96-295, and 10 CFR 2.205, for the particular violation set forth below: Technical Specification, Section 6.8.1 9 in effect for activities at T.M -4 s e i n 3 Liu ,.eriod up .; cetaser K,1983 requir.c wr; ter, p cceaures to be established, in.plemented and maintained covering ;ECOVERf M00E dctivities, including those activities which coulo increase the likelihood of failures in systems important to nuclear safety. Acministrative Procedure AP 1021, " Engineering Change Memorandum (ECM)," states in paragraph 4.0 that "The ECM is the traveler by which proposed plant tie-in, betterment and modification packages are assembled, reviewed, and coordinated with GPU's site organizations for their effects on the existing plant systems, components, and structures." Administrative Procedure AP 1043, " Work Authorization Procedure" establishes a means by which proposed changes to TMI-2 are initiated, reviewed, and approved in accordance with plant Technical Specifications. It requires a Work Permit to be issued as the document to authorize initiation of-work proposed by an ECM and to track work through completion, turnover, test and final records retention. Contrary to the above, the licensee did not fully implement the requirements of this Technical Specification for clean up activities at TMI-2 and in particular for those activities associated with refurbishment of the Reactor Building Polar Crane as evidenced by the fact that sometime prior NtlREG-0940 I.A-177
4 Notice of Violation to' November,1983 a modification was made to the main hoist brakes of the polar crane without using the required GPU Nuclear-approved ECM or Work Permit to add a hand release mechanism not present on the original brakes. This hand release mechanism also added an additional ~ function to the main hoist brakes. This is a Severity Level III violation. (Supplement I). (Civil Per.alty - $40,000) Pursuant to the provisions of 10 CFR 2.201, GPU Nuclear Corporation is hereby , . required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Comission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region I, within-30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted. (3) the corrective steps that-have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieveo. This response may incorporate by reference previous submittals of GPU Nuclear as appropriate. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, . may issue an order to show cause why the license should not be modified, j- suspended, or revoked or why such other action as may be proper should not be i taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR i 2.201, GPU huclear Corporation may pay the civil penalty by letter addressed to the Directer, Office of :rspectier and Enforcerent eith a check, draft, or l monej urder payaole tc tne Treasurer of the LMteo no;es ir ud cunu!ative amount of Forty Thousar.d Dollars (540,000) cr may protest imposition of the l civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should GPU Nuclear Corporation fail to answer within the tine specified, the Director Office cf Inspection and Enforcement, will issue an orcer imposing the civil peralty in the amount proposed above. Should GPU Nuclear Corporation elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violation listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may* request remission or mitigation of the penalty. In requesting mitigation of the proposed' penalty, the five factors addressed in Section V.B of 10 CFR Part 2 Appendix C (1985) should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately [ from the statement.or explanation in reply pursuant to 10 CFR 2.201 but may l incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing ! page and paragraph numbers) to avoid repetition. GPU Nuclear Corporation's ! attention is directed to the other provisions of 10 CFR 2.205, regarding the l procedure for imposing a civil penalty. I l NUPEG-0940 1.A-178 l
Notice of Violation Lpon failure to pay any civil penalty due which has been subsequentl'y cetermined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISS!ON
/
W lf s M. Tay1 Director
,jdffice of Inspection and Enforcement Dated at ethesda, Maryland thisa9 ay of September 1986 NUREG-0940 1.A-179
U GPU Nucleer Corporation Nuclear o
- emarao Middletown, Pennsylvania 17057 0191 717 944 7621 TELEX 84 2386 Writer's Direct Dial Nurnber:
l (717) 948-8461 4410-86-L-0176 Document ID Oll6P l ' October 29, 1986 l Office of Inspection and Enforcement Attn: James M. Taylor - Director US Nuclear Regulatory Commission Washington, DC 20555
Dear Mr. Taylor:
Three Mlle Island Nuclear Station Unit 2 (TMI-2) Operating License No. DPR-73 Docket No. 50-320 Response to Notice of Violation and Proposed Imposition of Civil Penalties I This responds to your letter of September 29, 1986, which forwarded a Notice of Violation and Proposed Imposition of Civil Penalty. Your action is based on the findings of an investigation by the NRC Office of Investigations which concluded that applicable GPU Nuclear procedures were violated during the installation of hand release mechanisms on the polar crane main holst brakes. I In addition, you stated that in reaching your conclusion, you considered the reports prepared by Kennedy P. Richardson, submitted on January 15, 1986, and Edwin H. Stelr, submitted on February 28, 1986. GPU Nuclear agrees that the Violation did occur and will forward payment of the proposed fine of $40,000 under separate cover. The attachment to this letter provides the GPU Nuclear response to the Notice of Violation. Sincerely,1 - a_ . l l P. Clark President PRC/FRS/JJB/vlmv ! cc: Regional Administrator. Office of I&E - Dr. T. E. Murley Director, TMI-2 Cleanup Project Directorate, Dr. W. D. Travers GPU Nuclear Corporation is a subsidlary of the General Public Utilities Corporation l NUREG-0940 I.A-180
l NRC NOTICE OF VIOLATION Technical Specification Section 6.8.1.g In effect for activities at TMI-2 during the period up to October 31, 1983, required written procedures to be estab11shed, laplemented and maintained covering RECOVERY MODE activities, including those activities which could increase the likelihood of failures in systems important to nuclear safety. Administrative Procedure AP 1021, " Engineering Change Memorandum (ECM)," states in paragraph 4.0 that the "The ECM is the traveler by which proposed plant tie-in, betterment and, modification packages are assembled, reviewed and coordinated with GPU 's site organizations for their effects on the existing plant systems, components, and structures." Administrative Procedure AP 1043, " Work Authorization Procedure," establishes a means by which proposed changes to TMI-2 are initiated, reviewed, and approved in accordance with plant Technical Specifications. It requires a Work Permit to be issued as the document to authorize initiation of work proposed by an ECM and to track work through completion, turnover, test and final records retention. Contrary to the above, the licensee did not fully implement the requirements of this Technical Specification for clean up activities at TMI-2 in particular for those activities associated with refurbishment of the Reactor Building Polar Crane as evidenced by the fact that sometime prior to November, 1983 a modification was made to the main hoist brakes of the polar crane without using the required GPU Nuclear-approved ECM or Work Permit to add a hand release mechanism not present on the original brakes. This hand release mechanism also added an additional function to the main hoist brakes. GPU NUCLEAR RESPONSE GPU Nuclear acknowledges that the events cited above did occur. GPU Nuclear letters 4410-84-L-0IS7 dated October 5, 1984 and 4410-84-L-0169 dated October 8, 1984 originally reported the improper installation of the hand release mechanism on the main hoist brakes of the polar crane. These letters, as supplemented by GPU Nuclear letters 4410-84-L-0177 dated October 12, 1984; 4410-84-L-0181 dated October 18, 1984; 4410-84-L-0220 dated December' 14, 1984; 4410-84-L-0224 dated December 19, 1984; and 4410-85-L-0016 dated January 8, 1985, described the causes of the violation and the corrective actions taken to avoid siellar occurrences. The adequacy of this investigation was 1 documented in the January 9,1985 NRC letter, 8.J. Snyder to F.R. Standerfer, which concluded that the GPU Nuclear investigation into the matter of the
- installation of the hand release mechanism was complete and adequate and that i the crane had been demonstrated to be operable and safe to use for load conditions. Although some open items remained as a result of the NRC January 9, 1985 letter, none related to the addition of the hand release mechanism nor, as stated in the January 9, 1985 letter, adversely affected the ability of the crane to operate in a safe manner. Therefore, it can be concluded that
! full compliance was achieved on January 9, 1985. i l 190 REG-0940 1.A-181
An additional issue which warrants comment by GPU Nuclear is the assertion that the violation was "apparently willful." Our inquiry into this matter does not support your conclusion. In particular, the TMI-2 Report prepared by Edwin H. Stelr found a number of procedural deficiencies associated with the installation of the brake releases, but concluded "The evidence does not show that anyone recognized that the installation of brake releases on the polar crane constituted modifications under either GPU Nuclear or Bechtel procedures untti after August 1984." GPU Nuclear continuss to support this conclusion and remains steadfast in the view that violation of the applicable procedures was not willful. The record demonstrates GPU Nuclear has consistently attempted to ensure that its approved procedures be followed at TMI-2 and has responded promptly to evidence of any deficiencies in procedural compliance. However, debate on this issue serves no useful purpose at this late date and GPU Nuclear does not intend to pursue it further. } i l l I NitREG-0940 1.A-182 l
l l ATTACHMENT 4410-86-L-0176 October- 29, 1986 l l I METROPOLITAN EDISON COMPANY JERSEY CENTRAL POWER AND LIGHT COMPANY PENNSYLVANIA ELECTRIC COMPANY GENERAL PUBLIC UTILITIES NUCLEAR CORPORATION Three Mlle Island Nuclear Station, Unit 2 (TMI-2) Operating License No. DPR-73 Docket No. 50-320 Notice of Violation This letter is submitted in response to the Nuclear Regulatory Commission's letter of September 29, 1986, which forwarded a Notice of Violation and Propo,ed Imposition _of Civil Penalty concerning polar crane modifications. All statements contained in this response have been reviewed and all such statements made and matters set forth therein are true and correct to the best of my knowledge, information, and belief. M-P . Clark P esident Signed and sworn before me this 29th day of October, 1986. ( n-
f Notarp/ Public stio07 me smP. n0rAsv Pseue LANOO90f R87 TOWNSHIP. DAUPNIN COUNIT SY 00356s8104 EIPIREs AUS. 21.1999 Esmher Pesesylvesis Asseelaties of Roerten NilREG-0940 I.A-183
#"% UNITED STATES y< ; NUCLEAR REGULATORY COMMISSION
$?
D ,, f REGION IV ett RYAN PLAZA ORIVE. SUITE 1000
% ARUNGTON. TEXAS 70011 APR 28 386 Docket No. 50-298 License No. DPR-46 EA 86-44 Nebraska Public Power District ATTN: Larry G. Kunci Vice-President Nuclear P. O. Box 499 Columbus, Nebraska 68601
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NO. 50-298/85-23) This refers to the inspection conducted on July 29 through August 2, and August 12-16, 1985 at the Cooper Nuclear Station, Brownville, Nebraska. During this inspection, NRC inspectors identified violations of NRC requirements pertaining to your security program. An enforcement conference to discuss these matters was held on December 17, 1985 s.t the Region IV offices in Arlington, Texas. The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties indicate a lack of management effectiveness in the oversight and control of the Cooper Nuclear Station security program. The l NRC is particularly concerned about the violation involving the degraded vital I area barrier. It appears that this condition existed for at least three months prior to its discovery by the NRC inspectors, and that NPPD management was aware of the degradation yet failed to take corrective action. Specifically, general concerns about this particular vital area barrier were identified to NPPD management during a previous NRC inspection (Inspection Report No. 50-298/85-10) l conducted in March 1985 and the specific degraded barrier was identified during a vital area barrier survey performed by a contractor in April 1985, i l To emphasize the need for improved management attention to the oversight and I control of the NPPD security program, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Fifty Thousand Dollars ($50,000) for the violations described in the enclosed Notice. In accordance with the "Ceneral Statement of Policy and Procedure for l NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1985), violations I.A and i CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0040 T.A-184
Nebraska Public Power District I.B described in the enclosed Notice have been categorized in the aggregate as a Severity Level III probles. The base value of a civil penalty for a Severity Level III violation or problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. Other violations which are of lesser significance and which were identified during the same inspection are also described in the attached Notice. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. Please make reference to those actions and schedules which you have reported to us previously or intend to implement to increase the effectiveness of your management controls over the security program. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforce- , ment action is necessary to ensure compliance with NRC regulatory requirements. The material enclosed herewith contains Safeguards Information as defined by 10 CFR Part 73.21 and its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, the material will m be placed in the Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely,
,3 --
V h Cl$ On-Robert D. Martin Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalties NUREG-0940 I.A-185
. Nebraska Public Power District
" ""$hk$' hbst""*"
- ~ ' -
NLS8600184 May 28,1986 Mr. James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555
Dear Mr. Taylor:
Subject:
Notice of Violation and Proposed imposition of Civil
- Penalties; NRC Inspection Report No. 50-298/85-23 This letter is written in response to the NRC letter dated April 28, 1986 Transmitting Notice of Violation and Proposed Imposition of Civil Penalty as a result of Inspection Report No. 50-298/85-23. Therein it indicated that seven of our activities were in violation of NRC requirements sad that two of these violations were being assessed a civil penalty. Attached are statements of the violations and our responses in accordance with the referenced letter and 10CFR2.201. Attachment 1 addresses the violations assessed a $50,000 civil penalty and Attachment 2 addresses the remaining violations.
We have reviewed the April 28, 1986, letter and have concluded that additional clarification is warranted regarding one of the violations accessed a civil penalty and that mitigation is requested pursuant to 10CFR2.205. The District is denying the other alleged violation assessed a civil penalty for reasons described in Attachment 1. For these reasons, payment of the prope=ed civil penalty is not enclosed. If you have any questions regarding this response, please contact me. In accordance with the provision of 10CFR Part 73.21, we request that the attached report be treated as proprietary information and withheld from public disclosure. Sincerely, L. G. unc1 Vice-President Nuclear Power Group GRS:cbl28/6 Attachment ec: Regional Administrator - Region IV U.S. Nuclear Regulatory Commission NllREG-0940 I.A-186
Mr. James M. Taylor Page 2 May 28,1986 STATE OF NEBRASKA)
)ss PLATTE COUNTY )
L. G. Kuncl, being first duly sworn, deposes and says that he is an authorised representative of the Nebraska Public Power District, a public corporation and political subdivision of the State of Nebraska; that he is duly authorized to submit this information on behalf of Nebraska Public Power District; and that the statements contained herein are true to the best of his know and belle . L/ G. KunclN Subscribed in my presence and sworn to before me this d day of Mam , 1986. O OmalM. mmgm NOTARY / PyBLIC magyg RMb%tM I NUREG-0940 I.A-187
/ 'g UeNTED STATES ! NUCLEAR REGULATORY COGAMISSION 3 suAspeessGTOed. D. C. 30505 \ %,t....
OCT 101986 Docket No. 50-298 License No. OPR 46 EA 86-44 Nebraska Public Power District ATTN: L. G. Kunc1, Vice President Nuclear Power Group P. O. Box 499 Columbus, Nebraska 68601-0499 Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTY This refers to your letter of May 28, 1986 submitted in response to the Notice of Violation and Proposed Imposition of Civil Penalties sent to you by letter dated April 28, 1986. The Notice of Violation described violations found during the physical security inspection conducted at your Cooper Nuclear Station on July 29 - August 2 and August 12-16, 1985. After careful consideration of your response in which you denied Violation I.B. and for the reasons given in the Appendix to the enclosed Order Imposing Civil Monetary Penalty, we have concluded that Violation I.B should be withdrawn. We have also given careful consideration to your request for mitigation and have concluded for the reasons given in the Appendix that mitigation of the civil penalty for Violation I.A is not warranted. Accordingly, we hereby serve the enclosed Order.on Nebraska Public Power District imposing a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000). The effeci.iveness of your corrective actions will be reviewed during subsequent inspecticos. The NRC has also reviewed your responses to the five violations not assessed civil penalties and finds them responsive to the concerns raised in the Notice of Violation. Some of the corrective actions have already been implemented and reviewed by the NRC inspectors during subsequent inspections. The remaining corrective actions will be reviewed during future inspections to ensure that full compliance has been achieved. The enclosed Appendix contains Safeguards Information as defined by 10 CFR Part 73.21 and its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, the material, with the exception of the transmittal letter and the Order will not-be placed in the Public Document Room. Sincerely, f mu f a M. Taylor, ector 0 ice of Insoect on and Enforcement CERTIFIED MAIL , RETURN RECEIPT REQUESTED NilP.EG-0940 1.A-188
UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 50-298 NEBRASKA PU8LIC POWER DISTRICT ) License No. DPR-46 P. O. Box 499 ) EA 86-44 Columbus, Nebraska 68601-0499 ORDER INPOSING CIVIL MONETARY PENALTY I Nebraska Public Power District (licensee) is the holder of License No. DPR-46 issued by the Nuclear Regulatory Commission (NRC). License No. OPR-46 authorizes , the generation of power using nuclear material and is due to expire on June 4, 2008. II An inspection of the licensee's activities under its license was conducted on
- July 29 - August 2 and August 12-16, 1985. As a result of the inspection, it appeared that the licensee had not conducted its activities in full compliance with NRC requirements. The results of the inspection were discussed with licensee representatives during an enforcement conference held in the Region IV office in Arlington, Texas on December 17, 1985. A written Notice of Violation 4
1 and Proposed Imposition of Civil Penalties was served upon the licensee by letter dated April 28, 1986. This Notice stated the nature of the violations, requirements of the NRC that the licensee had violated, and the amount of civil penalties proposed. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalties by letter dated May 28, 1986. NUREG-0940 I.A-189
Upon consideration of the licensee's response and the statements of fact, explanation, and arguments for remission or mitigation of the proposed civil penalties contained therein, as set forth in the Appendix to this Order, the Director, Office of Inspection and Enforcement has determined that Violation 1.B and the associated $25,000 proposed penalty should be withdrawn. However, the NRC concludes that Violation !.A occurred as stated and the licensee's request , for mitigation of the associated civil penalty is not warranted. Accordingly, a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000) should be imposed. l !!! In view of the foregoing and pursuant to Section 234 of the Atomic Eneroy Act of 1954, as amended (42 U.S.C. 2282, P.L. 96-295) and 10 CFR 2.205, IT IS i HEREBY ORDERED THAT: i The licensee pay a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000) within thirty days of the date of this Order, by check, 1 l draft, or money order, payable to the Treasurer of the United States, and mailed to the Director, Office of Inspection and Enforcement, USNRC, l Washington, D.C. 20555. I IV i The licensee may, within thirty days of the date of this Order, request a hearing. A request for hearing shall be addressed to the Director, Office of l NUREG-0980 I.A-190 i 1
<-v*- - . - - , -,n -_ , ,.-.,.,__ -. __ _ _ , _ _ . _ , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3 Inspection and Enfbrcement. U.S. Nuclear Regulatory Comission. Washington, D.C. 20555. A copy of any request for hearing shall also be sent to the Assistant General Counsel for Enforcement Office of the General Counsel, at the same address. If a hearing is requested, the Commission will issue an Order designating the time and place of hearing. Upon failure of the licensee to request a hearing within thirty days of the date of this Order, the pEovisions of this Order shall be effective without further proceedirigs, and if payment
- has not been made by that time, the matter may be referred to the Attorney
+
General for collection. ) V In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: 1 i (a) whether the licensee violated NRC requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty. I referenced in Section II above, and (b) whether, on the basis of such violations, this Order should be i i i sustained. t l FOR THE NUCLEAR REGULATORY COPWIS$10N
/S a
h,,_ r es M. Taylor rector fice of Inspection and Enforcement Dated aA 8ethesda, Maryland, the/d*tlay of October 1986. 1 . i i NUREG-0940 I.A-191
. . . . . _ _ _ _ _ _ _ _ _ . _ . _ _ _ _ _ . . _ _ _ . . _ _ _ _ _ _ _ . ~ . _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ . . _ .
GENERAL OFFICE Nebraska Public Power District ' ""JEso"~E74'f0*!st""*" NLS8600331 October 27, 1986 Mr. James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclea: Regulatory Commission Washington, DC 20555
Dear Mr. Taylor:
Subject:
Order Imposing Civil Monetary Penalty Re: 1) Letter from J. M. Taylor to L. G. Kuncl, dated October 10,1986, " Order Imposing Civil Monetary Penalty" l 1
- 2) Letter from R. D. Martin to L. G. Kuncl, dated April 28,1986, " Notice of Violation and Proposed Imposition of Civil Penalties" (NRC Inspection Report No. 50-298l85-23)
This letter is written in response to the Order Imposing Civil Monetary Penalty served to the District in the NRC letter dated October 10, 1986, Reference 1. Therein you indicated that one violation (Violation I.B) was withdrawn after consideration of our response to the violations found during a physical security inspection conducted at Cooper Nuclear Station, Reference 2. You also indicated that mitigation of the civil penalty for Violation I. A was not warranted and that payment of a penalty of
$25,000 was ordered.
Nebraska Public Power District appreciates the consideration given our response of May 28, 1986. A hearing is not requested and payment of the civil penalty is enclosed. If you have any questions regarding this response, please contact me. Since ely, ( . L. G. Ktnel , Vice-President i Nuclear Power Group LGK/grs:km23/2(6B) l Enclosure cc: Regional Adminiatrator - Region IV U.S. Nuclear Regulatory Commisalon NtlREG-0940 I.A-197 l
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Docket No. 50-278 License No. OPR-56 EA 86-59 Philadelphia Electric Company ATTN: Mr. S. Daltrof f Vice President Electric Production 2301 Market Street Philadelphia, PennsyTwania 19101. Gentlemen: <
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Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC Inspection Report No. 50-278/86-09) This refers to an NRC special inspection conducted on March 18-21, 1986 of activities authorized by NRC Operating License No. OPR-56 at the Peach.. Bottom Atomic Power Station, Unit 3. The circumstances associated with the withdrawal of a controi rod during reactor startup in a sequence different from that - - specified in the control rod program were reviewed. The incident, which . resuTted in violations of the station's Technical Specifications, was identi- -c fied by members of your staf f and promptly reported to the NRC. The details - " are provided in Inspection Report (50-278/86-09) sent to you by letter dated March 25,. 1986. On March 27, 1986,. an enforcement conference was conducted with Mr. V. Boyer and you and members of your staffs to discuss the Antident, the related violations, their causes, and your corrective actions.
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These violations are described in the enclosed' Notice of Viciation and Proposed Imposition of Civil Penalties and resulted from numerous personnel ' errors by several licensed personnel, including the-Shift Supervisor and Shift Superin- ' tendent, both of whom are licensed senior rea: tor operators. The violations occurred when automatic systems were inoperable or bypassed and the compensa-tory measures required by Technical Specifications were> not properly implemented. The incident was initiated when the licensed reactor operator performing the startup withdrew the wrong. control rod from the core. The Rod Worth Minimizer (RWM), designed to detect such an occurrence, was inoperable at-the time. As required by the Peach Bottom Technical Specifications, a~second - licensed operator had been assigned to independently verify the correct red selection and withdrawal sequence; however, he did not identify this error. In
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addition,, am opportunity occurred to identify and. correct the error when the procedural step was reached to. withdraw the control rod which had been already mistakenly pulled' but neither of the reactor opoeators identified the prior error. . CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 T.A-193
Philadelphia Electric Company 2 Subsequently, when the Rod Sequence Controi System (RSCS) prevented further , red withdrawals because the missedired had not yet been withdrawn, the Shif t Supervisor and Shif t Superintendent, both of whom were supposed to be oversee-ing and managing the startup activities, apparently assumed the missed rod was in the full-out position, and they physically performed the manipulation to' bypass the RSCS position for that rod to the full-out position. The RSCS was bypassed without assuring that the control rod was in its correct positioni Although alternate means of verifying control rod position were available, such as the plant process computer printout and the full core display showing control rod position, these means apparently were not used. These facts-indicate a failure on the part of your supervisory staff to properly oversee reactor operations in the control room. These personnel errors by four licensed individuals indicate that a pattern of inattention to detail, failure to adhere to procedural requirements, and a generally e:omplacent attitude of staff toward performance of their duties continues to exist at Peach Bottom. On June 21, 1985, an enforcement conference was conducted.with you and members of your staff to discuss the apparent inattentiveness of a licensed operator while at the centrols of the reactor. Further, on June 18, 1984, a 530,000 civil penalty was issued for violations of the station's Technical Specifications involving control room persennel errors including two instances when heatup rates were exceeded, and one instance
-when the reactor vessel was pressurized above linits. In addition, two civil penalties, in the re5pective amounts of 5100,000 and 540,000, were issued in 1983 for four violations of containment integrity that resulted from the -
failure of non-licensed indi'viduals to follow procedures. The-latest incident demonstrates that the actions taken to correct this pattern have not been effective. We view such problems as being indicative of a lack-of management involvement ~1n and attention to station activities to assure that the station personnel' respect, understand the need for, and adhere to your policies and procedures for the safe operation of the facility. To emphasize the need for increased management involvement and attention in station activities to assure improved personnel performance, I have been authorized, af ter consultation with the Director, Of fice of Inspection and Enforcement, to issue the enclosed No. ice of Violation and Proposed In' position of Civil Penalty in the amount of $200,000 for the two violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), the violations have been categorized as two Severity Level III problems. Although the base civil penalty for each Severity Level III problem is $50,000, the civil penalty for each problem has been increased by 100% because: (1) in each case, an opportunity existed for a licensed individual to detect and correct the rod pull error, but the error was not recognized, and (2) the enforcement history at Peach Bottom regarding your staff's adherence to procedures has been poor. The errors by the licensed individuals are being considered to determine whether any further corrective actions are appropriate. MUREG-0940 I.A-194
3 , ei . r Philadelpnia Electric Company 3 You are required to respond to this letter and should follow the instructions. specified in _the enclosed Notice when preparing your response. In your response you should document the specific actions taken and any additional = ' actions you plan to prevent recurrence. Af ter reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further:NRC enforcement action is necessary to ensure compliance with NRC regulatory require.nents. In accordance with Section 2.790 of the NRC's " Rules o'f Practice," Part 2, Title 10. Code of Federal Regulations, a copy of this; letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of-Management and . Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
, _ Sincerely, A? W Thomas E. Hurley Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1:* R. S. Fleischmann, Manager (Receives All 2.790 Inforiation) John S. Kemper, Vice President, Engineering and Research s Troy B. Conner, Jr. , Esquire W. H. Hirst, Director, Joint Ceneration Projects. Department,- Atlantic Electric Eugene J. Bradley. Esquire,; Assistant General _ Counsel (Without Report) Raymond L. Hovis, Esquire Thomas Magette,, Power Plant Siting, Nuclear Evaluations (Without Report) W. M. Alden, Engineer in Charge, Licensing Section Public Doce=ent Room (POR) local Public Document Room (LPOR), . Nuclear Safety Information Center (NSIC)
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NRC Resider.t Inspector
. Commonwealth of Pennsylvania to
[ NUREG-0940 I.A-195
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Philadelphia Electric Company- Docket No. 50-278 Peach Bottom, Unit 3 License No. OPR-56 EA 86-59 During an NRC inspection' conducted on March 18-21, 1986, in response to an incident identified by the licensee and reported to the NRC, two violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to section 234 of the Atomic Energy Act of 1954, as amended ("Act"), 42 U.S.C. 2282, PL 96-265, and 10 CFR 2.205. The particular violations and the associated civil penalties are set forth below. 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 Regulatory Guide 1.33 states in part that the activity 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, Revision 3, "Startup Rod Withdrawal Sequence Instructions." Step 13 of GP-2 requires the reactor operator to withdraw control rod 02-23. 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 been withdrawn. B. Technical Specification Limiting Condition for Operation 3.3.8.3.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 program. Contrary to the above, at 1:28 a.m. on March 18, 1986, .shile the reactor was in the startup mode below 25% 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 licensed operator also incorrectly documented that rod 02-23 had been withdrawn. This is a Severity Level III problem (Supplement I). (Civil Penalty - $100,000, assessed equally among the violations). i NUREG-0940 I.A-196 l L
2 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 shall be bypassed unless the control rods are moved in sequence to their correct position and the actual rod position is known.
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 Shif t Superintendent when in fact the rod was full-in.
- 8. 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 - 5100,000, assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Philadelphia Electric Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, USNRC Region I, 631 Park Avenue, King of Prussia, Pennsylvania 19406, within 30 days of the date of this Notice, a written statement of explanation in reply, including for each alleged violation, (1) admission or denial of the alleged violation, (2) the reasons for the violation, if admitted, (3) corrective steps that have been taken and the results achieved (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. Consi tration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR
-2.201, Philadelphia Electric Company may pay the civil penalty in the amount of Two Hundred Thousand Dollars (S200,000) or may protest imposition of the civil penalty in whole or in part by a written answer. Should Philadelphia Electric Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an Order imposing the civil penalty in the amount proposed above. Should Philadelphia Electric Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice, in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed.
NUREG-0040 T.A-197
3 In addition to protesting the-civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation
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of the proposed penalty, the five f actors contained in Section V.B of 10 CFR
-part 2, Appendix C, should be. addressed. Any written answer in accordance with-10 CFR 2.205 should be set forth> separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate by specific reference (e.g., citing page and paragraph numbers) to avoid repeti_ tion. The attention of Philadelphia Electric Company is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
Upon failure to pay any civil penalty due, which has been subsequently determined in accordance with the applicable provisions of.10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION
& 9 Thomas E. Murley Regional Administrator Dated at King of Prussia, Pennsylvania, this f " day of June 1986.
i l , NUREG-0940 1.A-198 i
PHILADELPHIA ELECTRIC COMPANY 2301 MARKET STREET P.O. BOX 8699 PHILADELPHIA. PA.19101 smetoe t. oatino,, mm emp veca paassosser 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. I NUREG-0940 I.A-199
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Mr. James M. Taylor July 23, 1986 Page 2
. Restatement of Violations:
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 Regulatory Guide 1.33 states in part that the activity of " Hot Standby to Minimum Load (nuclear Startup)" requires procedures. Technical Specification 6.8.1 is implemented by the Peach Botton General Procedure GP-2, Appendix 1, Revision 3, "Startup Rod Withdrawal Sequence
- Instructions." Step 13 of GP-2 requires the reactor operator to withdraw control rod 02-23.
l l Contrary to the above, at 1:28 a.m. on March 18, 1986 while at step 13 of GP-2, Appendix 1, the reactor j operator withdrew control rod 10-23 rather than rod ' 02-23 and incorrectly documented that rod 02-23 had been withdrawn. 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 i licensed operator shall verify that the operator at the reactor console is following the control rod program.
o Contrary to the above, at 1:28 a.m. on March 18, 1986, I while the reactor was in the startup mode below 25%~ 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 licensed operator also incorrectly documented that rod 02-23 had been withdrawn. This is a Severity Level III problem (Supplement I). (Civil Penalty - $100,000 assessed equally among the violations). II A. Technical Specification Limiting Condition for i 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 shall be bypassed unless the control rods are moved in sequence to their correct postion and the actual rod position is known. NUREG-0940 1.A-200
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 a Proposed Imposition of Civil Penalties l , 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 General Electric (GE) Company have reviewed this event and determined that the current Unit 3 reload analysis Rod Drop Accident (RDA) results bound this event. The l NUREG-0940 1.A-201
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
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condition such that RDA consequences would not have exceeded the design criteria. 1 Corrective Actions Taken and Results Achieved: I 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 8:42 AM control rod insertion was begun to return the 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 within a few minutes. The Plant Manager and the Superintendent-Nuclear Generation, who were in Philadelphia at the corporate headquarters, were immediately dispatched to the plant to investigate the matter. NUREG-0940 I.A-202 s - _ _ - - - - -
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-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 4- 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 ' 7 prevent recurrence. Corrective Actions Taken to Prevent Recurrence: To prevent recurrence, the folloEing actions have been developed and implemented:
- 1. A' letter was issued on March 18, 1986 from the Operations Superintendent to all licensed personnel 4
outlining the event and describing interim requirements for verification of proper rod positioning.
- 2. A procedural control has been implemented to use the i
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 i two maps will then be verified to be identical before I proceeding to the next rod group. i 3. Six procedures involving RWM and RSCS have been revised and PORC approved to enhance the procedural 4 requirements. Included in these revisions is the RSCS bypass procedure which has been revised to require a . Shift Supervision signature for proper verification of t rod position prior to bypassing the RSCS input for any j rod.
- 4. On March 24, 1986 the Plant Manager issued a letter to Shift Supervision to ensure that best efforts are made i
to place the RWM in service prior to commencing reactor startup. In accordance with this direction, i the procedure for manual bypass of the RWM has been i revised to require the permission of the Plant i l NUREG-0940 I.A-203
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t Mr. James M.. Taylor July 23, 1986 i: Page 6 Manager, Operations Superintendent, or Operations 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 is.being followed.
t
- 6. Plant staff management meetings have been held with all Operations Personnel to discuss the event and individual responsibilities.
- 7. The four individuals responsible for this event were disciplined. Disciplinary measures involved three suspensions and one written reprimand.
Further, Philadelphia Electric has begun the process of implementing the Human Performance Evaluation System (HPES) at both Peach Bottom and Limerick. The HPES has been developed through a pilot program by the Institute of Nuclear Power Operations (INPO) and several nuclear utilities. HPES's objective is to-identify and correct situations that cause human errors. The success of this program is dependent on operating,
- maintenance and, testing personnel reporting actual or potential situations that can cause human errors do that they can be 1 corrected before someone else is put into the same situation.
I Date When Full Compliance was Achieved: i Full' compliance with the Technical Specifications which were violated during this event was achieved on March 18, 1986 when Unit 3 was manually scrammed at 0855 hours. i l' Licensee's Answer Pursuant to 10 CFR Section 2.205 and Request I for Mitigation of Amount of Proposed Civil Penalties 1 Concerning the imposition of civil penalties as discussed in the referenced letter, Philadelphia Electric Company believes that the additional increase of 100% for each of the two ' penalties is excessive, unwarranted and fail.s to properly balance l the factors enumerated in Appendix C to Par', 2 in determining the . appropriate penalty level. Accordingly, Philadelphia Electric l -Company requests that consideration be given to reducing the , proposed penalty of $200,000 to the base penalty of $100,000. Your letter of June 9, 1986 additionally stated, "We view such problems as being indicative of a lack'of management , involvement in and attention to station activities to assure that i l i NUREG-0940 1.A-204 l l l . , -. - . - _ . . . - - - - - . - - - . - , . - - - - . . - . , _ _ . . . ~ . _ . , . - . - - . - - . - . . . . . . _ . . ..- _ .. - .-
T 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 4 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 4
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 exce'eded, and one instance when the reactor vessel was I pressurized above limits. Indeed, the 1984 Civil Penalty associated with the violation was mitigated from S40,000 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 I concerning the apparent inattentiveness of a licensed operator l 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 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 j Achieved.
- We can not agree that increased emphasis is required j to improve management involvement in order-to assure personnel i 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, j although not always implemented, are directed toward betterment i ! NUREG-0940 I.A-205 t w-- -ow< --wr-.n-i, --er... em -w * --.-----,-------,-.------,-v---, =--,-. - --.-,---+---.-,-.-.-w---- . . - .
Mr. James M. Taylor. July 23, 1986 Page 8 1 of operations. .Ne encourage this and view such proposals as
- indications of.a healthy attitude, an attitude not expected of a o 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 i 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 i to which the Plant Manager reports. l I This appointment was made with the direction that i close attention be paid to the activities at Peach Bottom with I the aim of strengthening those weaknesses which had been l identified by INPO and the NRC. The Superintendent - Nuclear i Generation has been meeting frequently with the power plant staff to develop programs to eliminate these weaknesses. He reviews i 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 d by the recent NRC evaluation team during a two-week inspection of Peach Bottom. Note that the planning of this action pre-dates
- the March 18 incident.
In further support of the requested mitigation of the proposed penalties and as directed by the referenced letter, the i five factors contained in Section V.B of. Appendix C to Part 2 are addressed below.
- 1. Prompt Identification and Reporting (reduction of up
- to 50% of the base civil penalty may be given when a I
Licensee identifies the violation and promptly reports the violation to NRC). l
- The Unit 3 reactor was operated with control rod 02-23 l out-of-sequence for a relatively short period of time.
l 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). i Further, the unit was promptly shutdown. After ! discovery of the error, Philadelphia Electric Company I is convinced that prompt and appropriate actions both ! relating to the reporting to the Commission and the j recovery of the plant to a safe status were taken by management and shift personnel. Philadelphia Electric NUREG-0940 I.A-206
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 cf 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).
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 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 NUREG-0940 I.A-207
Mr. James M. Taylor July 23, 1986 : Page 10 of a Licensee audit, or specific NRC or industry notification, and had failed to take effective preventive steps). 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 failure to consider prior notices of similAr events.
- 5. Multiple Occurrences (an increase of as much as 50% 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 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 truly yours, if /
, [, f ((/ Lj
/
cc: Dr. T. E. Murley, Administrator, Region I, USNRC Mr. T. P. Johnson, Resident Site Inspector 4 l NUREG-0940 f.A-208 __ ____ - . . . _ _ _ . _ . _ . _ _ _ _ . ~ . . _ ___ _._ __ _ _ _. _ . _
1 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 thereof; and that the statements and matters set forth therein are true and correct to the best of his knowledge, information and belief. bt j l' Subscribed and sworn to before me this)7# ay of f , lfN Y WO/ A Notary Public MELANIC R. CAMPANELtA feseen MNc. PwWsNo. PMa#pYa Co. Sly Committeen (spres Fetfuey !!,1990 NUREG-0940 I.A-209
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t USIITED STATES I \ NUCLEAR REGULATORY COMMISSION waemmevou,o c.seems { I S
\..... DEC 121986 i
Docket No. 50-278 License No. DPR-56
! EA 86-59 Philadelphia Electric Company 4
ATTN: J. S. Kemper Senior Vice President
. 2301 Market Street ]
Philadelphia, Pennsylvania 19101 1 1 Gentlemen: This refers to your letter dated July 23, 1986 in response to the Notice of Violation and Proposed luposition of Civil Penalties (Notice) sent to you with our letter dated June 9,1986. Our letter and Notice described violations associated with an event reported to the NRC by members of your staff. The i violations, which involved numerous personnel errors by control room staff, were categorized in the aggregate as two Severity Level III problems, and the base civil penalty amount for each problem was increased by 100 percent because i of your recent poor enforcement history in the area of procedural adherence.
, in your response to the Notice, you acknowledge the occurrence of the viola-tions as stated, but you request that the proposed civil penalties be mitigated from $200,000 to $100,000 because you believe escalation of the civil penalties was excessive and unwarranted. After careful consideration of your response, i we have concluded, for the reasons given in the enclosed Order Imposing Civil Monetary Penalties and Appendix, that a sufficient basis for mitigation of the ; proposed penalties was not provided in your response. Accordinoly we hereby serve the enclosed Order on Philadelphia Electric Company imposing, civil penalties in the amount of Two Hundred Thousand Dollars ($200,000).
! We also note that in your response you disagree with the NRC contention that j these personnel errors by four licensed individuals indicate a continuation of j a pattern of inattention to detail, failure to adhere to procedural requirements. and a generally complacent attitude of staff toward performance of their duties
- ~
at Peach Bottom. Apparently you attribute these problems to the failings of certain individuals against whom administrative disciplinary actions have been
- taken by Philadelphia Electric Company. Further, you disagree that an increased emphasis on management involvement is needed to ensure improved personnel per-l formance, stating that " management and supervisors continually express the need i to follow procedures and pay close attention when conducting operations." These
! actions by management and supervisors have not been effective in preventing l' recurrence of personnel errors, as evidenced by this most recent event. It is not sufficient for management to hire qualified personnel and provide them with !. adequate training and procedures for performing their duties; management also must provide appropriate oversight of personnel to assure they perform their duties properly.
CERTIFIED MAIL RtIURN RtctIPT REQUESTED NUREG-0940 I.A-210
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i Philadelphia Electric Company Your enforcement history since January 1983 involves three previous civil penalties for violations of technical specification requirements, two civil penalties for violations of radiation protection requirements, and a total of , i' twelve enforcement conferences. Many of these enforcement conferences involved violations resulting from personnel errors. Therefore, it is clear that a
- pattern of inattention to detail, failure to adhere to procedural requirements, i and a generally complacent attitude of the staff has existed at Peach Bottom i resulting from insufficient oversight of personnel. These types of deficiencies cannot be overcome solely by minor disciplinary actions of an administrative nature; rather, management must be sufficiently involved to correct the pattern.
In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. t ! The response directed by the accompanying Order is not subject to the j clearance procedures of the Office of Management and Budget as required by the l Paperwork Reduction Act of 1980, PL 96-511. I Sincerely,
) -
=_
1 i s M. Taylo [ rector 4 ffice of Ins ction and Enforcement i i
Enclosure:
Order leposing Civil tienetary Penalties and Appendix
. cc w/ enc 1:
4 R. S. Fleischmann, Manager, Peach Bottom Atomic Power Station
; John S. Kemper, Vice President Engineering and Research Troy B. Conner, Jr., Esquire W. H. Hirst, Director, Joint Generation Projects Department, Atlantic Electric G. Leitch, Superintendent Nuclear Generation Division 4 Eugene J. Bradley, Esquire. Assistant General Counsel (Without Report) j Raymond L. Hovis Esquire i Thomas Magette, Power Plant Siting, Nuclear Evaluations (Without Report)
W. M. Alden. Engineer in Charce, Licensino Section 1 ! PublicDocumentRoom(PDR)(LPDR) Local Public Document Room Nuclear Safety Information Center (NSIC) NRC Resident inspector Comonwealth of Pennsylvania ) h i
! NUREG-0940 1.A-211 I
UNITED STATES NUCLEAR REGULATORY COMISSION In the Matter of Docket No. 50-278 License No. DPR-56 Philadelphia Electric Company EA 86-59 (Peach Bottom Atomic Power Station, Unit 3) ) ORDER IMPOSING CIVIL MONETARY PENALTIES I Philadelphia Electric Company, Philadelphia, Pennsylvania 19101 (licensee), is the holder of License No. DPR-56 issued by the Nuclear Regulatory Commission (Commission /NRC). This license authorizes the licensee to operate the Peach
. Bottom Atomic Power Station Unit 3. Delta, Pennsylvania in accordance with the conditions specified therein.
II During March 18 - 21, 1986, an NRC inspection was conducted at Peach Bottom to review the circumstances associated with an event that occurred at Unit 3 involving the withdrawal of a control rod during reactor startup in a sequence different from that specified in the control rod program. As a result of the inspection, it was found that the licensee has not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalties was served upon the licensee by letter dated June 9, 1986. The Notice states the nature of the violations, the provisions of the Commission's requirmnents (nat the licensee has violated, and the amount of civil penalties proposed for the violations. l l= l l l l NUREG-0940 I.A-212
2 An answer dated July 23, 1986 to the Notice of Violation and Proposed Imposition of Civil Penalties was received from the licensee. III After consideration of the statements of fact, explanation, and argument for mitigation of the proposed civil penalties contained in your response and as set forth in the Appendix to this Order, the Director Office of Inspection and Enforcement, has determined that the penalties proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalties should be imposed. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act - of 1954, as amended (42 U.S.C. 2282, PL 96-295), and 10 CFR 2.205. -IT IS HEREBY ORDERED THAT: The licensee pay civil penalties in the amount of Two Hundred Thousand Dollars ($200,000) within thirty days of the date of this Order, by check, draft..or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Inspection and Enforcement, U.S. Nuclear Reaulatory Commission, Washinoton, D.C. 20555. MlREG-0940 I.A-213
3 V The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission Washington, D.C. 20555. A copy of the hearino request also shall be sent to the Assistant General Counsel for Enforcement, Office of General Counsel, U.S. Nuclear Regulatory Commission. Washington, D.C. 20555. If a hearing is requested, the Commission will issue an Order designating the time and place of hearing. If the licensee fails to request a hearing within thirty days of the date of this 1 Order, the provisions of this Order shall be effective without further proceedinos and, if payment has not been made by that time, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee violated NRC requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties and (b) whether, on the basis of such violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMISSION
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J ms M. Taylor rector fice of Inspe ion and Enforcement Dated at Bethesda, Maryland thisgNay of December 1986 NUREG-0940 I.A-214
l l 1 APPENDIX , EVALUATION AND CONCLUSION l In Philadelphia Electric Company's July 23, 1986 response to the Notice of Violation and Proposed Imposition of Civil Penalties (Notice) dated June 9,1986, the licensee acknowledges the occurrence of the violations stated in the Notice but requests mitigation of the civil penalty amount from $200,000 to $100,000. Provided below are (1) a restatement of the violations, (2) a summary of , the licensee's response including their reasons for re and (3) the NRC evaluation of the licensee's response. questing mitigation, Restatement of Violations 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 Regulatory Guide 1.33 states in part that the activity of " Hot Standby to Minimum Load (nuclear startup)" requires procedures. Technical Specifications 6.8.1 is implemented by the Peach Bottom General Procedure GP-2 Appendix 1. Revisica 3. "Startup Rod Withdrawal Sequence Instructions. " Step 13 of GP-2 requires the reactor operator to withdraw control rod 02-23. 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 been withdrawn.
- 8. Technical Specification Limiting Condition for Operation 3.3.B.3.b requires that whenever the reactor is in the startup or run mode below 255 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 program.
Contrary to the above, at 1:28 a.m. on March 18, 1986, while the reactor was in the startup mode below 25% 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 licensed operator also incorrectly documented that rod 02-23 had been withdrawn. This is a Severity Level !!! problem (Supplement I). (Civil Penalty - $100,000, assessedequallyamongtheviolations). a NilREG-0940 I.A-215
8 i Appendix II.A. Technical Specification Limiting Condition for Operation 3.3.8.3.a and 3.3.A.2.d require that whenever the reactor is in the startup or run mode below 215 rated power, the Rod Sequence Control System (RSCS) , shall be operable, and no position switches shall be bypassed unless ' the control rods are moved. in sequence to their correct position and the actual rod position is known. I 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 1 the startup mode below 215 rated power, a rod block occurred. The RSCS position switch for rod 02-23 was bypassed to the full-out post-a tion by the Shift Supervisor and Shift Superintendent when in fact the rod was full-in. B. Technical Specification Surveillance Requirement 4.3.A.2.d requires I 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, assessedequallyamongtheviolations). 4~ Summary of Licensee's Response
< The licensee acknowledges the occurrence of the violations as stated in the
. Notice of Violation and Proposed Imposition of Civil Penalties, but requests , that the proposed penalties in the cumulative amount of $200,000 be reduced to the base civil penalty amount of $100,000. The licensee states that the increase of the base civil penalty amount in this case is excessive, unwarranted, a j and does not properly consider the mitigation and escalation factors set forth ! in the " General Statement of Policy and Procedures for NRC Enforcement Actions."
- 10 CFR Part 2 Appendix C.
4 The licensee contends that the NRC basis for escalating the amount of the 4 proposed civil penalties, namely, the licensee's history of personnel errors involving failures to adhere to procedures and not paying attention to detail, ! is insufficient. Also, the licensee argues that two of the civil penalties i' issued to Peach Bottom in the past three years were mitigated based on the licensee's corrective actions. Further, the licensee maintains that the NRC, in considering its request for mitigation, should consider the prompt managerial actions in identifying and reporting the event, as well as the comprehensive corrective actions taken subsequent to the event. i i I I i j NUREG-0940 I.A-216
l ) l
- ~ Appendix '
l NRC Evaluation , The NRC staff carefully reconsidered the mitigation and escalation factors - j identified in the Enforcement Policy. In evaluating the licensee's request :
- for mitigation of the civil penalties based on prompt identification and
i t reporting, the NRC staff considered, amono other things, the length of time ' 4 the violations existed prior to discovery, the opportunity available to discover the violations, and the promptness and completeness of any required {. reports. In this case, numerous opportunities had existed for four licensed ' operators to identify and correct the problem had they been more attentive to the details of their duties, including adherence to safety procedures. Since i these errors were not promptly identified by personnel who have a sionificant t
- role in the safe operation of the plant, mitication of the civil penalties !
, based on this factor is not appropriate. ! i The NRC staff also recognizes the corrective actions taken by the licensee < l subsequent to the event, including disciplinary actions, restructuring and ! reassioning certain nuclear station management, and reviewing the incident i with station operations personnel. While the NRC staff acknowledges the need for these actions, the NRC staff does not view them as sufficiently extensive , to warrant mitigation, since the licensee focused narrowly on the failure of , certain individuals through minor disciplinary actions of an administrative , i nature rather than on the broad management responsibility in overseeing personnel performance. The licensee has taken the position that no additional emphasis i is needed to improve menacement oversight and contends that a pattern of inattention to detail or failure to adhere to procedural requirements does I not exist at Peach Bottom. The NRC staff disagrees with the licensee's assess- '
- ment, particularly in licht of the licensee's enforcement history. Improved ,
. management involvement and oversight is needed at the Peach Bottom facility to ' ! preclude the recurrence of significant personnel errors in the future. Since j the licensee failed to undertake vigorous and extensive corrective actions in
- this recard, mitigation is inappropriate.
1 The licensee contends that its past performance did not warrant escalation of ' I the civil penalty. To the contrary, the enforcement history in the area of ! personnel performance has been poor. Therefore, escalation of the civil penal-j ties by 100 percent is appropriate and warranted in this case. As described in the NRC letter dated June 29, 1986 transmitting the Notice of Violation and
- Proposed Imposition of Civil Penalties, three previous civil penalties issued for violations of technical specifications involved violations that resulted from personnel errors. Althouoh the licensee is correct in stating that one J of these previous civil penalties, as well as a civil penalty issued on !
May 30, 1985 for violation of radiation protection requirements, were partially > ! miticated based on the licensee's corrective actions, the NRC staff considers ! it appropriate to escalate the current civil penalty because those previous ' corrective actions were not fully effective in precluding recurrence of such i personnel errors. In addition, the NRC staff evaluated the licensee's claim l 4 that the enforcement conference conducted on June 29, 1986 involved an issue i of " fitness for duty" rather than the inattentiveness of a licensed operator.
- The NRC staff believes this example also demonstrates an attitude of inattention i j to duties in the control room for which corrective actions were not effective r
, and further reinforces the necessity for effective management involvement in ' } the area of personnel performance of their duties. I I I ( I ! i, i NUREG-0940 I.A-217 i i ~
Appendix NRC Conclusion The violations occurred as originally stated. The NRC staff concludes that the licensee's corrective actions were not sufficiently extensive nor was the identification of the problem sufficiently prompt to warrant mitigation of the proposed penalties. Rather, the staff concludes that it is appropriate to escalate the base civil penalties based on the licensee's prior poor perfonnance in the area of adherence to procedures. Given the number of licensed operators, including two supervisors involved, a significant civil penalty is warranted. Accordingly, the civil penalties in the amount of Two Hundred Thousand Dollars ($200,000) should be imposed. l l NUREG-0940 I.A-218 l
,##**4,,g ussfac sTATao 8')# a NUCLEAR REGULATORY COMMISSION
{ j naescos y
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OCT 151986 Docket No. 50-344 License No. NPF-1 EA 86-113 Portland General Electric Company 121 S.W. Salmon Street Portland, Oregon 97204 Attention: Mr. Bart D. Withers Vice President - Nuclear Gentlemen:
Subject:
NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05. 50-344/86-10, 50-344/86-24, AND 50-344/86-32) This refers to the routine inspection conducted during the period March 18 - April 28, 1986 and to two special inspections conducted May'13 - June 12, 1986 and August 4 - 14, 1986 of activities authorized by NRC License NPF-1 for the Trojan Nuclear Power Plant. Two violations of NRC requirements were identified by NRC inspectors during the inspections and the results of these inspections were sent to you by letters dated May 16, July 1, and August 20, 1986, respectively. The violations involved the inoperability of the Residual Heat Removal (RHR) system and an unacceptable quality control inspection conducted during the installation of a pressurizer safety valve. Enforcement conferences were held with you and members of your staff on July 9,1986 at your offices in Portland, Oregon and on September 5, 1986 at our offices in Walnut Creek, California, to discuss the violations, the root causes of these violations, your corrective actions, and the NRC enforcement policy. Violation I in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involves the inoperability of one of the emergency core cooling system (ECCS) subsystems. On March 31, 1986, the flow path for RHR system cold leg injection to two of the four reactor coolant system loops was isolated for one hour and ten minutes in violation of technical specification requirements. This violation appears to be the result of an incomplete under-standing of the safety system design bases by your plant staff, a topic previously discussed with you in a March 27, 1986 enforcement conference involving the control room emergency ventilation system. Although we recognize that your actions to correct the underlying causes of the violations involving control room emergency ventilation system were in progress at the time that the circumstances described in Violation I occurred, this is another example of a violation that we consider significant. This violation , emphasizes the importance for you to expedite the programs already initiated to establish design basis documents with accurate system descriptions and to CERTIFIED MAIL RTUITHtTTPT REQUESTED NUREG-0940 1.A-?19
. .-- .-. - ~ - - - - - .- - --. . . - - . - - -
Portland General Electric Company 2 O CI 17,1980 - e f assure that your plant' staff' understands system design bases to prevent the recurrence of similar types of violations. ) Violation II in the enclosed Notice involves an instance of an incomplete inspection by a contract quality control (QC) inspector. On May 13, 1986, an NRC inspector observed that a QC inspector failed to properly witness the ; torquing of the bolts on the inlet flange for a pressurizer safety valve as
- prescribed by the established procedures. Although the QC inspector was in .
i the work area, the QC inspector was not actually witnessing the bolt torquing i process. However, apparently because of carelessness and a lack of attention . 1 to detail, the QC inspector signed the inspection record to indicate that the f witnessing of the bolt torquing had taken place. Upon learning of this
, problem, plant personnel took prompt and extensive corrective actions ;
l consisting of the immediate suspension of the QC inspector and subsequent
- investigation, reinspections and evaluations of the individual's work. As discussed in the July 9, 1986 enforcement conference, Portland General ;
4 Electric Company management should continue to be alert to conditions that l contributed to this violation, including supervision of employees,
- adherence ;
to established procedures, and training of personnel. i To emphasize the importance of ensuring that plant personnel understand the j design basis operation of-systems and that quality control personnel conscien- 3 tiously perform their duties, I have been authorized, after consultation with ! + the Director, Office of Inspection and Enforcement to issue the enclosed Notice ! of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty ! Thousand Dollars ($50,000) for the' violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC i Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), each of the violations described in the Notice have been classified as a Severity l l Level III. The base value of a civil penalty for a Severity Level III violation , 3 L is $50,000. The escalation and mitigation factors of the Enforcement Policy were j considered and no adjustment to the base civil penalty has been deemed appropriate
- for Violation I.' W 1e the civil penalty could have been mitigated based on your i j prompt and extensive corrective actions for the indepth system review performed, ;
i there were also grounds for escalation of the civil penalty based on this l violation being another example of the failure to maintain systems in an l j operable status because of a lack of understanding the system's design bases, i The base civil penalty was fully mitigated for Violation 11 because of your ) prompt and extensive corrective actions and your prior past performance given ' j no similar types of violations have been previously identified. , ! You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your ' response, you should document the specific actions taken and any additional actions you plan to prevent recurrence.' After reviewing your response to this i Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. 1 i' 4 I ] l NUREG-0940 1.A-220 i l
_.s ~M
.+ .
Portland General Electric Company 3 OCT.'<51920 o-In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the. enclosure will be placed in the NRC's Public Document Room. The responses directed by this Notice, are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. nce ely,
.1',r ( \
John B. Martin Regional Administrator
Enclosure:
Notice of Violation ,_. cc w/ enclosure: W. S. Orser, PGE J. W. Durham, Esq. , W. Dixon, DOE e, r. P'llPEri-0940 1.A-221 _= =
-- - ~ _ .- -.~ - - -. -- - .- .
w d NOTICE OF VIOLATION
, AND
! . PROPOSED IMPOSITION OF CIVIL PENALTY Portland General Electric Company Docket No. 50-344 (Trojan Nuclear Power Plant) License No. NPF-1 EA 86-113 During NRC routine and special inspections conducted during the period of
- March 18 - August 14, 1986, violations of NRC requirements were identified.
, The violations involved operability of the residual heat removal system and
- the quality control inspection of a pressurizer safety valve. In accordance i
with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The violations and associated civil penalty are set forth below: I. Violation Assessed a Civil Penalty Technical Specification Limiting Condition for Operation (LCO) 3.5.2 requires in Modes 1, 2, and 3 that two independent emergency core cooling l i system (ECCS) subsystems be operable with each subsystem comprised in part of a residual heat removal (RHR) pump and an operable flow path. l Technical Specification LCO 3.0.3 requires that when a Limiting Condition for Operation and/or associated action requirements cannot be satisfied, the reactor be placed in at least hot standby within one hour. The operability for the RHR system flow path for a loss of coolant accident is represented in the Trojan Updated Final Safety Analysis Report (FSAR), Section 6.3 which shows that RHR flow will be injected into all four cold legs of the reactor coolant system. , I Contrary to the above, on March 31, 1986 while in Mode 1 for one hour and l ten minutes, portions of two ECCS subsystems (the RHR system) were inoperable l- when valve MD-8809A was closed. With valve MD-8809A closed, the flow path ^ for both trains of RHR cold leg injection was such that RHR flow to only l two of the four reactor coolant system cold legs would have been achieved. l This is a Severity Level III violation (Supplement I). l (Civil Penalty - $50,000). !' II. Violation Not Assessed a Civil Penalty 10 CFR 50, Appendix B, Criterion V, as implemented by the Trojan Nuclear Plant Nuclear Quality Assurance Program, Section 5.0, requires in part that j j activities affecting quality be prescribed by and accomplished in accordance
- with documented procedures.
i f I NUREG-0940 f.A-222
c
## wen,% '
usetto STATES 8 e i j ' NUCLEAR REOULATORY anosoas y COMMISSION
\,..../ ~ m ea:b = % ,
Docket No. 50-312 D 2 21986 EA 86-94 Sacramento Municipal utility District , ATTN: William K. Latham, Acting General Manager P. O. Box 15830 Sacramento, California 95813 Gentlemen: SU8 JECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (INSPECTION REPORT N05. 50-312/86-06, 50-312/86-07) This refers to both routine and special NRC inspections conducted at Rancho Seco by members of the NRC staff during the period of December 26, 1985 - April 11, 1986 of activities authorized by NRC License No. DPR-54. The findings of these inspections werL transmitted to you on March 28 and May 14, 1986. An Enforcement Conference.was also held at the Region V office on May 16, 1986 with you and other members of your staff. Based on the results of these inspections and as discussed during the enforcement conference,.it appears that some of your licensed activities were not conducted in full' compliance with NRC requirements. Violation A as discussed in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice) relates to your failure to maintain the cooldown rate within the limits prescribed by the technical; specification while recovering from the December 26, 1985 loss of DC power to the integrated control system (ICS) event. Theovercoolingeventinvolvedadecreasein : primary coolant system temperature from 566 F to 386*F in approximately 26 minutes. Although the Incident Investigation Team (IIT) (see NUREG-1195, February 1986) concluded that the event did not appear to h.ve seriously threatened the integrity of the reactor vessel, the NRC is~ concerned because of the number of overcooling incidents in your operating history. The NRC considers this type of event significant because each time that it occurs, the potential exists for additional operator errors and equipment failures that may exacerbate the event and seriously threaten reactor integrity. Violation 8 involves a significant failure tc take actions to correct known design deficiencies and to establish appropriate procedures for-a loss of DC power to the ICS event. As a result of a number of precursor events, plant modifications should have been completed to lessen the consequences of such an event. For example, it is apparent that had the Emergency Feedwater Initiation and Control System been installed, the overcooling event of December 26, 1985 would have been much less severe and probably would not have exceeded the Technical Specification limit. Furthermore, the absence of approved plant procedures for a loss of DC power to the ICS event and a lack CERTIFIED MAIL
- RETUFRETTPT REQUESTED NUREG-0940 I.A-223
Sacramento Municipal , Utility District 1 of procedures for recovering from such an event directly contributed to the overcooling transient. You should have been aware of the potential for a loss of DC power to the ICS event because of a similar occurrence at Rancho Seco on January 5,1979, your response on February 20, 1980 to IE Bulletin 79-27, " Loss of Non-Class IE Instrumentation and Control Power System Bus During Operation," similar events at other facilities, and NUREG-0667 dated May 1980 which you received that documented the need for procedures related to ICS failures. Despite these occurrences, actions to ensure improvements in reliability of the ICS and the development of procedures to efficiently mitigate a loss of ICS power were not taken. Violation C involves the failure to have procedures governing the control of certain safety-related valves. No procedures existed for securing the high pressure injection system following safety features actuation or for the manual emergency operation of the auxiliary feedwater system control valve (FV 20527). In addition, even though Velan instruction manual (VEL-PS-3) recommended lubrication of the stem threads and other working components be performed frequently and at least every six months, lubrication for the auxiliary feedwater , system valve FWS-063 had never been performed during the operational life of j the plant. As a result, the valve would not close during the December 26, 1985 event. Violation D in the enclosed Notice involves the failure to adequately implement three different procedures during the December 26, 1985 event. Even though Emergency Procedure E.05 stated that the auxiliary feedwater pump shall be stopped when the Once-Through-Steam-Generator level reached 95%, plant personnel did not comply with this requirement. Also, certain personnel were not evacuated from the auxiliary building even though their evacuation was required by procedure, and adequate air samples were not taken to properly assess the ; magnitude of the radioactive material release. Violation E involves the_ failure to adequately implement procedures covering the Emergency Plan. Some of the required counties were not provided updated information on the plant's status after they were initially notified of an Unusual Event; the counties that were notified of the Unusual Event were not provided with all of the required information; and the actual alarm setpoint for the auxiliary building stack monitor did not match the setpoint stated in the applicable procedure. While these deficiencies did not jeopardize public l health and safety, they do indicate weaknesses in your emergency preparedness 4 program. The December 26 overcooling event wu the culmination of a period of regulatory performance problems by Rancho Seco which were caused, in part, by inattention to detail to assure the safe operation of the facility. To emphasize to Sacramento' Municipal Utility District management the need for greater attention to detail regarding adherence to technical specification requirements, correction of design deficiencies, establishment of adequate procedures for handling potential plant transients, and following applicable emergency procedures after a transient has occurred, I have been authorized by the Director, Office i of Inspection and Enforcement after consultation with the Commission, to issue NUREG-0940 I.A-224 l l
Sacramento Municipal Utility District the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Three Hundred Seventy-Five Thousand Dollars ($375,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), Violations A-E have been categorized as five Severity Level III violations and/or problems. The base value of a civil penalty for each Severity Level III violation or problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered. No adjustment to the base civil penalty for the first violation was deemed appropriate. The base civil penalty amount for Violation 8 has been increased by 100 percent because of your prior notice of the potential for a loss of DC power to the ICS event and the duration of your failure to take effective preventive steps. The base civil penalties for Violations C - E have each been escalated by 50% because multiple examples of each of the violations were identified. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. inc rely, John B. Martin Regional Administrator
Enclosure:
Notice of Violation cc w/ enclosure: L. G. Schwieger, SMUD G. A. Coward, SMUD State of CA ! NUREG-0940 1.A-225 l t
l NOTICE OF VIOLATION AND i' PROPOSED IMPOSITION OF CIVIL PENALTIES i Sacramento Municipal Utility District. Docket No. 50-312 Rancho Seco Nuclear Generating Station- License No. DPR-54 EA 86-94 < ! During NRC inspections conducted during the period December 26, 1985 - April 11, ,. 1986, violations involving your failures.(1) to maintain the plant within l technical specification cooldown limits, (2).to correct known deficiencies, (3) to establish appropriate procedures, and (4) to adequately follow existing procedures were identified as a result of a loss of integrated control system (ICS) DC power event on December 26, 1985. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, ; Appendix C (1986), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 1 ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The violations and associated civil penalties are set forth below:
- A. Technical Specification 3.1.2.4 states that the reactor coolant system l cooldown rates shall be' limited in accordance with Figure 3.1.2-2.
Figure 3.1.2-2 states that for reactor coolant temperatures greater than 270*F, the maximum allowable cooldown rate is 100*F/ hour. Contrary to the-above, on December 26, 1985, the reactor coolant system temperature was decreased by 180*F in 26 minutes (566'F to 386*F). This is a Severity Level III violation (Supplement I) (Civil Penalty - $50,000) i 8. 10 CFR Part 50, Appendix B, Criterion XVI requires that in the case of significant conditions adverse to quality, measures must assure that the cause of the condition is determined and corrective action taken to
. preclude repetition.
> Contrary to the above, as of December 26, 1985, a significant condition adverse to quality, specifically, the potential for a loss of DC power to the integrated control' system transient existed, yet the cause of the condition was not determined, nor was adequate corrective action taken. The licensee failed to correct identified design deficiencies or to develop !- procedures which could have significantly lessened the severity of the December 26, 1985 event. This is a Severity Level III violation (Supplement I) i (Civil Penalty - $100,000) C. Rancho Seco Technical Specification 6.8.1.a states that the applicable procedures recommended in Appendix A of Regulatory Guide 1.33 (November, 1972) shallibe implemented. l 1. Section C of Appendix A, Regulatory Guide 1.33, recommends procedures I for startup, operation, and shutdown of safety-related PWR systems including instructions for changing modes of operation. NUREG-0940 I.A-226
Notice of Violation Contrary to the above, no written procedures existed as of December 26, 1985 for securing the safety-related high pressure injection system following safety features actuation or for the manual emergency operation of the safety-related auxiliary feedwater system control valve FV 20527.
- 2. Section I of Appendix A, Regulatory Guide 1.33, recommends procedures for maintenance that can affect-the performance of safety-related equipment. It also recommends preventive maintenance schedules be developed to specify lubrication schedules and inspection of equipment.
Contrary to the above, as of December 26, 1985, no written procedures existed that required inspection, maintenance, or lubrication schedules for the auxiliary feedwater system valve FWS-063. Collectively, the above violat' ions have been categorized as a Severity Level III problem (Supplement I). (Civil Penalty - $75,000 assessed equally among the violations.) D. Rancho Seco Technical Specifications 6.8.1.a states that the applicable procedures recommended in Appendix A of Regulatory Guide 1.33 (November, 1972) shall be established and implemented.
- 1. Emergency Procedure (EP) E.05, " Excessive Heat Transfer", Step 3.1, which is recommended by Regulatory Guide 1.33, Appendix A, Section F, requires that Auxiliary Feedwater Pump (AFW) P-318 be stopped if Once-Through-Steam Generator (OTSG) level increases to 95% in the operating range. Furthermore, Rule 3 of the same procedure states "If excessive primary to secondary heat transfer exists, then stop AFW flow to the steam generator (s) being overcooled."
Contrary.to the above, EP E.05 was not adequately implemented on December 26, 1985 in that AFW Pump P-318 was not stopped when the level.in "A" OTSG reached 95%. Also, even though excessive primary to secondary heat transfer existed, AFW flow was not stopped to the steam generators being overcooled.
- 2. Annunciator Response Alarm Procedure H2PSA-7, Revision 14, Window 12 as recommended by Regulatory Guide 1.33, Appendix A, Section F.27, requires in Step 2 that personnel be evacuated from the area being 2
monitored for high gas activity upon receipt of a high alarm on Auxiliary Building Stack Gaseous Activity. Monitor R150028. Contrary to the above, Procedure H2PSA-7 was not adequately implemented in that upon the receipt of an alarm from Auxiliary Building Stack High Gaseous Activity Monitor R150028 at approximately 5:05 a.m on December 26, 1985 indicating high activity in the auxiliary building, personnel were not evacuated from the auxiliary building as required. . NUREG-0940 I.A-227
l Notice of Violation 3. Procedure AP 305-28, Revisicn 1, dated May 25, 1985, "MPC Determination at Site Boundary From Radioactive Releases," which is recommended by Regulatory Guide 1.33, Appendix A, Section F.27, states in Paragraph 3.0 that a 10 CFR 50.72 evaluation is required if an unplanned, uncontrolled or accidental release of radioactive material occurs. It also states that part of the input for that report shall be derived from sampling the plant stack for noble gases, tritium, particulates and iodine. Contrary to the above, Procedure AP 305-28 was not adequately implemented in that with the occurrence of an unplanned, uncontrolled accidental release of radioactive material on December 26, 1985, an adequate evaluation was not performed to support 10 CFR 50.72 reporting requirements. Noble gas, tritium, particulate and iodine samples were l not taken from.the auxiliary building stack monitor and results that ' should have been derived from that sampling were not used as input for the 10 CFR 50.72 report. ; Collectively, the above violations have been categorized as a Severity Level III problem (Suppleeent I). (Cumulative Civil Penalty - $75,000 assessed equally among the violations.) E. Rancho Seco Technical Specifications 6.8.1.e requires that written procedures shall be implemented and maintained covering Emergency Plan implementation.
- 1. Procedure AP 502, Step 5.1.3, " Notification of Unusual Event,"
requires the Emergency Coordinator to direct that the emergency alarm be sounded for ten seconds and announce, or have announced, the appropriate messages described in Step 5.1.3 over the public address system whenever an Unusual Event has occurred. ; I Contrary to the above, on December 26, 1985, Procedure AP 502 1 was not adequately implemented in that an Unusual Event occurred and the Emergency Coordinator did not ensure that the emergency alarm sounded nor did he announce or have announced the messages described in Step 5.1.3.
- 2. Procedure AP 506, Step 5.1.2, " Notification / Communication",
requires the Emergency Coordinator to direct the Communicator to initiate Attachment 7.2. , " Emergency Notification Call-List," and to provide state and county emergency response organizations with an initial notification of the Unusual Event and certain information concerning the event as identified by Attachment 7.1, Form A. Contrary'to the above, on December 26, 1985, Procedure AP 506 was not adequately implemented in that initial notification to state and county offsite authorities of the Unusual Event did not NUREG-0940 I.A-228
Notice of Violation include all the information specified on Attachment 7.1,' Form A. Specifically, the following Form A information items were not provided: (2) that the event was an actual emergency, (5) the offsite radiological release status, (6) consideration of public protective actions, (7) the status of Emergency Operations Facility activation, (8) the wind direction and speed (9) the downwind sectors affected and (10) the initiating conditions Tab Number used to classify the event.
- 3. Procedure AP 506, Step 5.1.4, " Notification / Communication" requires the Emergency Coordinator to complete a follow-up Notification Form (Attachment 7.4) which requires that follow-up information be sent to state and county emergency response organizations at least hourly during an emergency.
' Contrary to the above, on December 25, 1985, Procedure AP 506 was not adequately implemented in that the Notification Form (Attachment 7.4) was not completed. Follow-up notifications after the declaratinn of an Unusual Event were' hot made to the appropriate offsite authorities of Amador, San Joaquin, and Sacramento counties until termination of the event.
- 4. Procedure AP 501, Attachment 7.2, Tab 4 " Recognition and Classification of Emergencies," Revision 4, dated August 23, 1985, lists an " Emergency Action Level". alarm setpoint for Auxiliary Building Stack Monitor R15002B at 20,000 counts per minute (cpm).
Contrary to the above, as of December 26, 1985, Procedure AP 501 was not adequately maintained in that the Auxiliary Building Stack Monitor R150028 setpoint was changed to 60,000 cpm on July 21, 1984, and the setpoint as listed in Attachment 7.2, Tab 4 still stated that the setpoint was 20,000 cpm. Collectively, the above violations have been categorized as a Severity Level III problem (Supplement VIII). (Cumulative Civil Penalty - $75,000 assessed equally among the violations.) Pursuant to the provisions of 10 CFR 2.201, Sacramento Municipal Utility District is hereby required to submit to the Director, Office of Inspection and Enforcement, U. S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, Region V, within 30 days of the date of this Notice a written statement or explanation, including: (1) admission or denial of the alleged violations, (2) the reasons for the violations if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Irispection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of section 182 of the Act, 42 U.S.C. 2232, this response shall be 4 submitted under oath or affirmation. NUREG-0940 1.A-229
Notice of Violation Within the same time as provided for the response required above under 10 CFR 2.201, Sacramento Municipal Utility District may pay the civil penalties by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the amount of Three Hundred Seventy-Five Thousand Dollars ($375,000) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforement. Should Sacramento Municipal Utility District fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should Sacramento Municipal Utility District elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil l penalties in whole or in part, such answer may request remission or mitigation j of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Sacramento Municipal Utility District's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties. Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to section 234c of the Act, 42 U.S.C. 2282. F : NUCLEAR REGULATORY COWilSSION I fa 6 fohtfB. Martin Regional Administrator Dat t Walnut Creek, California thi ay of October 1986. 1 l 1 l l 1 I
)
NUREG-0940 I.A-230
$SMUD SACRAMENTO MUNICIPAL UTIUTY DISTRICT C P. o, Box 15830 Sacramento CA 95852-1830.(916) 452-3211 AN ELECTRIC SYSTEM SERVING THE HEART OF CAUFORNIA JEW 86-728 November 20, 1986 US NUCLEAR REGULATORY COMMISSION MR. JAMES M. TAYI4R DIRECTOR OFFICE OF INSPECTION AND ENFORCEMENT 7920 NORFOLK AVE PHILLIPS BUILDING BETHESDA MD 20014 MR. JOHN B. MARTIN ADMINISTRATOR REGION V OFFICE OF INSPECTION AND ENFORCEMENT 1450 MARIA LANE SUITE 210 WALNUT CREEK CA 94596 Response to Notice of Violation and Proposed Imposition of Civil Penalty (NRC Inspection Reports Nos. 50-312/86-06, 50-312/86-07).
By letter dated October 22, 1986, the Sacramento Municipal Utility District was transmitted a Notice of Violation and Proposed Imposition of Civil Penalties concerning the December 26, 1985 overcooling transient at Rancho Seco. In accordance with 10 CFR 2.201, Attachments 1 through 5 comprise our response to the Notice of Violation and Proposed Imposition of Civil Penalty. This letter acknowledges the violation cited and describes our intended corrective actions for each specific item listed in your Notice. These responses and the corrective actions committed to in the Action Plan for Performance Improvement sent to you on July 3, 1986 constitute significant corrective action to prevent recurrence of the violations cited. The Plan has additional details and schedule for items to be completed prior and subsequent to plant startup. Attached is a check in the amount of $375,000.00 for payment of the Civil Penalty. Subscribed and sworn to
%*/ /
before me this .JC day of November, 1986.
/ t t er st.;o I u
, c;w J .E. WARD '
Notary Public
~ DEPUTY GENERAL MANAGER, NUCLEAR _ _ My commi_ssion expires:
OFFICIAL SEAL } 3 'D 3 ,/ i "' i SUSAN L FINN
.: tsci.xt p*)2pc . CAUTCRN'A .
) , S'.CMMEN?Q COUNTY \
j Lfy timri ex>res hiAY 15, 1937 . t .M RANCHO SECO NUCLEAR GENERATING STATION C 14440 Twin Cities Road, Herald, CA 95638 9799;(209) 333 2935 NilREG-0940 1.A-?31
AffACHIGNT 1 DISTRICT RESPONSE TO NBC INSPECTION 86-06 & 86-07 NOTICE OF VIOLhTION NRC Violation A Technical . Specification 3.1.2.4 states that the reactor coolant system cooldown rates shall be limited in accordance with Figure 3.1.2-2. Figure 3.1.2-2 states that for reactor coolant temperatures greater than 270 degrees-F, the maximum allowable cooldown rate is 100 degrees-F per hour. Contrary to the above, on December.26, 1985, the reactor coolant system temperature was decreased by 180 degrees-F in 26 minutes (566 degrees-F to 386 degrees-F). 4 District Response to Violation A
- 1) Admission or denial of the alleged violation.
The Pistrict acknowledges and admits that this item occurred as stated. 1 i 2). Reasons for the violation The fundamental cause of the violation was the loss of power to the Integrated Control System (ICS) and the subsequent plant response cooled the reactor coolant afstem at a rate greater than normal.. This design feature ensured the dissipation of decay heat, however, caused the plant to exceed the assumed cooldown rate for normal cooldowns of 100 degrees-F per hour. 1 l 4 A-1 NUREG-0940 I.A-232
A
- 3) Corrective actions which have been taken and results achieved.
The response.to Violations B, C and D provide specific actions which will minimize the likelihood of recurrence and minimize the consequences of both a loss of ICs power event and the inappropriate plant response to the loss of ICS control. These specific actions include the installation of an Emergency Fsedwater Initiation and Control System (EFIC); the development of a loss of ICS power casualty procedure, and; the development of procedures for manual emergency operation of the safety-related Auxiliary Feedwater System control valve FV-20527, and similarly configured valves.
- 4) Corrective. steps which will be taken to avoid further violations.
Plant operating procedures, casualty procedures and emergency operating procedures which relate to plant cooldowns will be revised prior to restart to reflect the current Babcock and Wilcox (B&W) interpretation of 100 degrees-F per hour cooldown. In addition, plant operators will be trained on the revised procedures prior to restart. It should be noted that B&W is performing preliminary analysis for cooldown rates which are less restrictive than those currently in place in the Rancho Seco Technical Specifications. This effort will require the submittal of a proposed amendment with its attendant technical justifications and significant hasards evaluations. This effort to provide a more workable definition of the cooldown l'imits is being pursued independent of the Restart Program. A comprehensive itemisation of the detailed technical specification requirements, with the procedures which implement them, will be developed prior to restart. l I A-2 NUPEG-0940 I.A-233
- 5) Data full compliance will be achieved, t
The casualty procedures for loss of ICS have been ! developed and implemented. The installation of the EFIC System, the revision of l l the Operating, Casualty and Emergency procedures, and
~ training of personnel which include the B&W interpretation of 100 degrees-F per hour, will be completed prior to restart.
l l l l l l \ l l l l l l I A-3 l NUREG-0940 I.A-234
l l l ATTACHMENT 2 l l DISTRICT RESPONSE TO NRC INSPECTION 86-06 & 86-07 NOTICE OF VIOIATION NRC Violation B , 10 CFR Part 50, Appendix B, Criterion XVI requires that in the case of significant conditions adverse to quality, n'easures must assure that the cause of the condition is determined and corrective action taken to preclude repetition. Contrary to the above, as of December 26, 1985, a significant condition adverse to quality, specifically, the potential for a loss of DC power to the Integrated Control System transient existed, yet the cause of the condition was not determined, nor was adequate corrective action taken. The licensee failed to correct identified design deficiencies or to develop procedures which could have significantly lessened the severity of the December 26, 1985 event. District Response to Violation B
- 1) Admission or denial of the alleged violation.
The District acknowledges and admits that this item occurred as stated. B-1 1 ! NllP.EG-0940 I.A-235 l
- 2) Reasons for the violation i
During the first years of Rancho Seco operation, the Integrated ' Control' System (ICS) caused several relatively minor transients as a result of having been provided with only a single power source. A redundant power supply configuration was installed (or both the ICS and Non-Nuclear Instrumentation (NNI) which resolved the concern at that time. With the ICS/NNI related transients which occurred. at Rancho Seco and similar plants during the 1978 through 1980 period, it was recognized that certain equipment should be controlled by safety grade systems independent of ICS/NNI. The District's approach was to combine its i resources with other utilities facing similar requirements and to develop and install an appropriate safety grade auxiliary feedwater control system. At
- Rancho Seco, this system is called the Emergency
! Feedwater Initiation and Control (EFIC) System. A number of factors delayed the installation of EFIC which meant that the interim upgrades, to. comply with post-TMI commitments, remained in service beyond their originally expected dates. A contributing factor waas the failure to recognize the need for compensatory event related procedures, to mitigate the consequences of a loss of ICS event prior to the availability of the yet to be installed independent controls. This directly led to the magnitude of the December 26, 1985 overcooling event.
! 3) Corrective actions which have been taken and results achieved. In order to rosolve tho loss of ICS power impact on the plant, the District will install the EFIC system prior to restart. In addition, subsequent to the December 26 event, the District embarked on a comprehensive program to systematically assess all aspects of facility operation. This program is described in the Action Plan for Performance Improvement already submitted to the NRC.- This new approach not only focuses on providing improved controls and improved ICS/NNI reliability, but recognizes that equipment failures can and will likely , occur. Therefore, it provides procedures, training, and where appropriate, equipment to ensure the prompt i mitigation of a wide range of possible transient i events. This includes procedures which address i recovery from transient conditions and transition to the normal controlling systems and equipment. B-2 l l NUREG-0940 I.A-236
- 4) Corrective steps which will be taken to avoid further violations.
Training is being provided to the operators on these new proceduros and procedure revisions, as well as proper use of the new equipment and controls. As a final validation of these improvements, a " Loss of ICS/NNI Test" will be performed during restart to )
. demonstrate the effectiveness of the entire plant facility, procedures, operator-training triad in mitigating such events.
- 5) Date full compliance wil3 be achieved.
The District will be in full compliance with respect to the violation cited upon installation of EFIC, the successful performance of the " Loss of ICS/NNI Test," and the completion of the Action Plan items scheduled for restart. B-3 l NUREG-0940 1.A-237 l
ATT N 3 DISTRICT RESPONSE TO NRC INSPECTION 86-06 & 86-07 NOTICE OF VIOIATION NRC Violation C.1 l Rancho Seco Technical Specifications 6.8.1.a states that the applicable procedures recommended in Appendix A of Regulatory Guide 1.33 (November, 1972) shall be implemented.
- 1) Section C of Appendix A, Regulatory Guide 1.33, recommends procedures for startup, operation, and !
shutdown of safety-related PNR systems including instructions for changing modes of operation. !
\
Contrary to the above, no written procedures existed as of December 26, 1985 for securing the safety-related high pressure injection system following skfety features r actuation or for the manual emergency operation of the safety-related auxiliary feedwater systems control valve FV-20527. I District Response to Violation C.1 i
- 1) Admission or denial of the alleged violation.
The District acknowledges and admits that this item occurred as stated. f 2) Reasons for the violation During the District's investigation into the root causes of the December 26, 1983 event, the lack of a specific procedure to the return to normal l configuration and lineup, following termination of SFAS, was found to be the root cause of the damage to l the Makeup Pump. This was the determination of the
- lessons learned report. In a similar manner, the lack of procedures and training on manual operation of the Auxiliary Feedwater Control Valves directly caused the valves to be damaged.
l l c.1-1 NUREG-0940 I.A-238
- 3) Corrective actions which have been taken and results achieved.
Procedures specific to the reconfiguration of systems (mode changes) during or immediately following i transients have been provided for the Righ Pressure , Injection (HPI) System. Training, including simulator l usage, has been provided to the operating" crews. l The use of the manual positioning devices on the l Auxiliary Feedwater Control Valves is addressed in new procedures, and enhanced by improved position indicators, and operator training. The need to rely on manual operation has been significantly reduced by incorporation of these valves into EFIC,' and the provision of class 1 control air to each valve.
- 4) Corrective steps which will be taken to avoid further violations.
Revised Emergency Operating procedures, which involve ! the need for mode changes or recovery actions, will be in place prior to restart.
- 5) Data full compliance will be achieved. I The District is now in full compliance with the requirement cited.
4 i I i l C.1-2 i NUREG-0940 I.A-739
d NRC Violation C.2
- 2) Section I of Appendix . A, Regulatory Guide 1.33, recommends procedures for maintenance that can affact L
the performance of safety-related equipment. It also recommends preventive maintenance schedules be developed to specify lubrication schedules and
- inspection of equipment.
l Contrary to the above, as of December 26, 1985, no written procedures existed that required inspection, I maintenance, or lubrication schedules for the Auxiliary l, Feedwater System valve FWS-063. I District Response to Violation C.2
- 1) Admission or denial of the alleged violation.
The District acknowledges and admits that this item i occurred as stated.
- 2) Reasons for the violation During plant construction and initial operation, maintenance procedures were in place, or developed as the specific need was' identified,~to meet the j requirements of Regulatory Guide 1.33 as committed to in Technical Specifications. The preventive maintenance program focused on Technical Specification related commitments, active class 1 equipment, and active balance-of-plant equipment important to reliability. In recent years the preventive maintenance (PM) requirements became better defined, the program was computerized and expanded to include l additional equipment. Much of the maintenance effort was a balance between " corrective" and " preventive" maintenance. For example, during each refueling outage i several hundred valves would be overhauled, although their selection was typically subjectively done by a maintenance engineer, rather than by a programmatic j process which ensured a uniform level of attention.
The Auxiliary Feedwater System Valve FWS-063 is Class 1, with respect to its pressure boundary; however, it is a maintenance valve that is normally locked opened and is not required to function during design events; therefore, it was not incorporated into the original PM program. C.2-1 NilREG-0940 1.A-240
\
- 3) Corrective actions which have been taken and results
)' achieved. During 1985,'the District took a number of actions to upgrade the level of maintenance support of Rancho Seco which were directed at improving its reliability, performance, and safety. Significant among these was the budgeting, hiring and commitment of personnel and , resources directly into the plant PM program. These resources, for the most part, were in place prior to the December 26 event. Their initial efforts were to develop and implement a comprehensive PM program with the necessary procedures and process to ensure that plant equipment is receiving the necessary attention to ensure its safe and reliable operation.. The District is confident that this program would have soon provided the programmatic PM for FWS-063. i Following the December. 26 event, lack of lubrication was identified as the root cause. of the inoperability of manual valve FWS-063. ~ The other manual valves in the Auxiliary Feedwater System were determined to be functional. To determine if a lack of scheduled PM lubrication of other manual valves is a generic problem, inspection, testing and PM have been scheduled for those valves which could be used to isolate-active systems or components within the plant. A-comprehensive valve preventive maintenance program is ' + being implemented.
- 4) Corrective steps which will be taken to avoid.further violations.
4 The results of valve maintenance, inspections, testing and operations will be documented to verify the operational readiness of plant valves. The overall valve program is an integral part of the Restart Program and is intended to demonstrate the material condition of the plant and its readiness for power operation.
- 5) Data full compliance will be achieved.
The District is in full compliance with the requirement cited in that a the comprehensive PM program has been implemented. 7 C.2-2 NilREG-0940 1.A-241
l I l ATTACRMENT 4 ! DISTRICT RESPONSE TO NRC INSPECTION 86-06 & 86-07 NOTICE OF VIOIATION NRC Violation D.1 Rancho Seco Technical Specifications 6.8.1.a states that the applicable procedures recommended in Appendix A of Regulatory Guide 1.33 (November, 1972) shall be established and implemented.
- 1) Emergency Procedure (EP) E.05, " Excessive Heat Transfer", Step 3.1, which is recommended by Regulatory Guide 1.33, Appendix A, Section F, requires that Auxiliary Feedwater Pump (AFW) P-318 be stopped if once-Through-Steam Generator (OTSG) level increases to 95 i
percent in the opereting range. Furthermore, Rule 3 of the same procedure states "If excessive primary to j secondary heat transfer exists, then stop AFW flow to the steam generator (s) being overcooled." l ,- Contrary to the above, EP E.05 was not adequately l implemented on December 26, 1985 in that AFW Pump P-318 . was not stopped when the level in "A" OTSG reached 95 l percent. Also, even though excessive primairy to ' secondary heat transfer existed, AFW flow was not stopped to the steam generators being overcooled. i District Response to Violation D.1 < l.
- 1) Admission or denial of the alleged violation. l
, I l The District acknowledges and admits that this item l l occurred as stated.
- 2) Reasons for the violation I
The reason for this violation is that the plant operating staff incorrectly concluded that auxiliary feedwater flow should not be interrupted since it was providing core cooling. l l D.1-1 l l NUREG-0940 I.A-242 l l
- 3) Corrective steps that have been taken and results achieved.
As part of the licensed operator training and retraining program, specific emphasis has been placed on overcooling transients; i.e., on how to diagnose and mitigate them. . This training is described in more specific detail in the Action Plan for Performance Improvement as Item 48.3.2.1.d. Additional emphasis has been provided in Procedure E.05 " Excessive Heat i Transfer" and Rule 3 of that same procedure to ensure 1 that in any. future overcooling event, the proper I mitigating actions are taken without hesitation. There ! have been comparatively recent inspections of the plant I operating staff on this issue as well as simulator and some NRC examinations of the licensed operators at Rancho Seco. The.results of this training are , evidenced by the results of NRC Inspection number 86- ! 07, dated May 14, 1986, which documented a screening of i the operating staff on this subject. It concluded that the staff was adequately trained.
- 4) Corrective steps which will be taken to avoid further violations.
The reactor operator and senior reactor operator training and retraining programs have been revised to ensure that the operating staff maintains an awareness of the importance of properly diagnosing and mitigating overcooling transients. The program is more specifically described in the Action Plan for Performance Improvement as Item 45.3.2.1.d. This training / retraining includes classroom &nd simulator training on the diagnosis and mitigation of overcooling transients, with specific emphasis on Rancho Seco specifi9 design features. Training will include the EFIC system and its effect on mitigating overcooling transients as well as manual actions which may be required should the EFIC system not be available. ;
- 5) Date when full compliance will be achieved. !
Recognizing that the plant design will be altered significantly with the installation of the EFIC system, the District will ensure that full compliance will be achieved prior to and during restart as appropriate. This will permit the training of operations personnel, not only on overcooling transients (which has been i accomplished) but will permit extensive training of operations personnel on the EFIC system and other design changes which will be installed to minimize the possibility of a recurrence of the December 26, 1985 overcooling event. 3 D.1-2 NUREG-0940 I.A-243
NRC Violation D.2
- 2) Annunciator Response Alarm Procedure H2PSA-7, Revision 14, Window 12 as recommended by Regulatory Guide 1.33, W =tix A, Section F.27, requires in Step 2 that personnel be evacuated from the area being monitored for
- high gas activity upon receipt of a high alarm on Auxiliary Building Stack Gaseous Activity Monitor
R15002B. Contrary to the above, Procedure H2PSA-7 was not : adequately implemented in that upon the receipt of an alarm from Auxiliary Building Stack High Gaseous ,
' Activity Monitor R15002B at approximately 5:05 a.m. on l December 26, 1985 indicating high activity in the auxiliary building, personnel were not evacuated from the auxiliary building as required.
District Response M NRC Violation D.2
- 1) Admission or denial of the alleged violation.
i The District acknowledges and admits that this item occurred as stated.
- 2) Reasons for the violation During the December 26, 1985 event, the control room i operators were directing their attention to the multitude of plant operational responsas needed to
, mitigate the overcooling event, and since local areas' Gas Radiation Monitor R15007 for the auxiliary building ventilation did not alarm and the Containment Building R15002 alarm cleared shortly after the alarm came in, no action was taken to evacuate the auxiliary building. In addition, specific training for radiation monitor r' annunciator procedures had not been performed as part of the operator qualification and requalification training program.
- 3) Corrective steps that have been taken and results achieved.
The annunciator procedures for the H2PSA panel, including Window 12, have been revised to clarify the actions which need to be taken when an alarm is received. l l I I l D.2-1 i NUREG-0940 I.A-244 l
- 4) corrective steps which will be taken to avoid further violations.
Radiation monitor annunciator response actions will be included in the reactor operator and senior reactor operator qualification and requalification training programs. The plant operating staff at the time of restart will have received specific trainfhg on the necessary alarm responses for the radiation monitors which affect personnel and public safety and which are relied upon in the mitigation of offsite releases.
- 5) Date when full compliance will be achieved.
The clarification of the H2PSA panel' annunciator procedure has already been completed. Full compliance , will be achieved when the full complement of plant operators has completed radiation monitor annunciator response training. This training is considered to be a
. prerequisite for restart.
l D.2-2 i NUREG-0940 I.A-245
NRC Violation D.3 Procedure AP.305-28, Revision 1, dated May 25, 1985, "MPC Determination at Site Boundary from Radioactive Releases," which is recommended by Regulatory Guide ] 1.33, Appendix A, Section F.27, states in Paragraph 3.0 that a 10 CFR 50.72 evaluation is required if an unplanned, uncontrolled or accidental release of radioactive material occurs. It also states that part of the input for that report shall be derived from sampling the plant stack for noble gases, tritium, ! particulates and iodine. Contrary to the above, Procedure AP.305-28 was not adequately implemented in that, with the occurrence of an unplanned, uncontrolled accidental release of l j radioactive material on December 26, 1985, an adequate l evaluation was not performed to support 10 CFR 50.72 reporting requirements. Noble gas, tritium, particulate and iodine samples were not taken from the auxiliary building stack monitor and results that should have been derived from that sampling were not used as input for-the 10 CFR 50.72 report. District Response g the NRC Violation D.3 ) 1)- Admission or denial of the alleged violation. The District acknowledges and admits that this item occurred as stated.
- 2) Reasons for the violation The individual who was performing the evaluation initially had difficulty locating the proper procedure (AP.305-28) due to the second volume of the Radiation Protection Manual not having an index. The individual had recently received training on how to perform the evaluation for 10 CFR 50.72 reporting and as a result, acquired an additional copy of the procedure but simply failed to thoroughly complete the procedure. This failure to complete the documentation requirements of AP.305-28 was due to a presumption by the indivi;ual involved that there was sufficient information available, without the use of the auxiliary building stack monitor samples, to determine reportability of the release in accordance with 10 CFR Part 50.72.
l D.3-1 NUREG-0940 I.A-246
- 3) Corrective steps which have been taken and results achieved.
Procedure AP.305-28 has been completely revised and has been reissued as AP.313-3 "MPC Determination at Site Boundary from Radioactive Releases". The purpose of this revision process was to gather those, radiological procedures which relate to plant events (by emergency sampling using the post-accident sampling system, guidelines for plant personnel for areas of unquantified radiological condition, et cetera) into one manual entitled " Radiological Event Directions , Manual". This has been accomplished to facilitate ' radiation protection access to this information and to also facilitate departmental training on these issues. Each radiation protection technician has received training on the revised AP.313-3, "MPC Determination at Site Boundary from Radioactive Releases".
- 4) Corrective steps which will be taken to avoid further violations. .
Each radiation protection technician will receive training on AP.313-3 "NPC Determination at Site Boundary from Radioactive Releases" again prior to restart. Emphasis has been placed on the significance of completing each step of the procedure to ensure that all facets of the. release are understood and well documented. Training will be provided annually to the radiation technicians at Rancho Seco.
- 5) Date when full compliance will be achieved.
4 The District is now in full compliance with the requirement cited. I t { l l I D.3-2 NilREG-0940 I.A-247
l l l 1 ATTACHMENT 5 DISTRICT RESPONSE TO NRC INSPECTION 86-06 & 86-07 NOTICE OF VIOIATION NRC Violation E Item "E" of the NRC Notice of Violation and Proposed Imposition of Civil Penalty deals with the District's failure to adequately implement emergency response procedures during the December 26, i 1985' event. Rancho Seco's Technical Specification 6.8.1.e requires that written procedures be implemented and maintained covering Emergency Plan implementation. The specific items discussed in the NRC Notice of Violation and Proposed Imposition of Civil Penalty and responses to those items follow. NRC Violation E.1 j Procedure AP.502, Step 5.1.3, " Notification of Unusual Event," requires the Emergency Coordinator to
- direct that the emergency alarm be sounded for ten ,
seconds and announce, or have announced, the appropriate message described in Step 5.1.3 over the public address system whenever an Unusual Event has occurred. Contrary to the above, on December 26, 1985, Procedure AP.502 was not adequately implemented in that an Unurual' Event ot. curred and the Emergency coordinator did not ensure that khe emergency alarm sounded nor did he announce or have announced the messages described in Step 5.1.7. t District Response to Violation E.1
- 1) Admission or denial of the alleged violation.
The District acknowledges and admits that this item occurred as stated.
- 2) Reasons for the violation During the December 26, 1986 event the requirements of procedures AP.502, " Unusual Event," were not implemented due to a personnel error.
I E.1-1 i NUREG-0940 I.A-?da l !
l l Corrective actions which have been taken and results 3) achieved.
- Training on the requirements of procedure AP.502 was conducted for operations personnel and Emergency Response Communicators. This training was completed on September 4, 1986. It will be repeated annuilly within the Emergency Plan Training Prograd.
I Command and control. training for decision makers, e.g.,
'~
the control Room staff, which gives proper focus on ; requirements of the Emergency Plan, was completed on ' ' March 13, 1986.' l
- 4) Corrective steps which will be taken to avoid further violations.
As part of the Command and Control Training, tha . s importance of, and requirement for procedure compliance - has been reemphasized. This training will be repeated annually. A number of emergency response drills hirve been successfully performed during the last several months. This effort culminated with the NRC witnessed and graded exercise of October 9, 1986.
- 5) Data full compliance will be achieved.
The District is now in full compliance with the cited requirement.'- - -- l l l i i i
- E.1-2 MIREr,-0940 I.A-249 l
NRC Violation E.2 Procedure AP.506, Step 5.1.2, " Notification / Communication", requires the Emergency Coordinator to direct the Communicator to initiate Attachment 7.2., " Emergency Notification Call-List," and to provide state and county emergency response organizations with an initial notification of the Unusual Event and certain
- . information concerning-the event as identified by i Attachment 7.1, Form A..
Contrery to the above, on December 26, 1985, Procedure AP.506 was not adequately implemented in that initial notification to state and county offsite authorities of the Unusual Event did not include all the information specified on Attachment 7.1, Form A. Specifically, the following Form A information items were not provided: ; (2) that the event was an actual emergency, (5) the ! offsite radiological release status, (6) consideration I of public protective actions, (7) the status of l Emergency Operations Facility activation,, (8) the wind,
)
direction and speed (9) the downwind sectors affected and (10) the initiating conditions Tab. Number used to classify the event. District Response to Violation E.2 l
- 1) Admission or denial of the alleged violation.
l The District a'cknowledges and admits that this item occurred as stated.
- 2) Reasons for the violation During the December 26, 1986 event the requireinents of procedures AP.506, " Notification / Communication", were not implemented due to a personnel error.
- 3) Corrective actions which have been taken and results achieved.
Training on the requirements of procedure AP.506 was conducted for operations personnel and Emergency Response Communicators. This training was completed April 1, 1986. This training will be repeated annually ! within the requirements of the Emergency Plan Training Program. I 1 l l l E.2-1 NUREG-0980 1.A-250
command and control training for decision makers, e.g., the control 1toon staff, which gives proper focus on requirements of the Eanergency Plan, was completed on Marcht 13, 1986.
- 4) .correctivs. steps wikich will be taken to avoid further violations.
As part of the command and Control Training, the ' importance of and requirement for m compliance has been rem =phaatmad. This tre will be repeated annually. A number of emergency response drills were m= fully performed during the last several months. This effort culminated with the NBC witnessed and graded exercise of October 4,1986. .
- 5) Data full compliance. will be achieved.
The District is now in full compliance with the cited requirement. t i J i 5 i E.3~2 NtlREG-0M O !.A-251
NRC Violation E.3 Procedure AP.506, Step 5.1.4, " Notification / Communication" requires the Emergency Coordinator to complete a follow-up Notification Form (Attachment 7.4) which requires that follow-up information be sent to state and county emergency response organizations at least hourly during an emergency. Contrary to the above, on December 26, 1985, Procedure AP.506 was not adequately implemented in that the Notification Form (Attachment 7.4) was not completed. Follow-up notifications after the declaration of an Unusual Event were not made to the appropriate offsite authorities of Amador, San Joaquin, and Sacramento counties until termination of the event. District Response to Violation E.3
- 1) Admission or denial of the alleged violation.
The District acknowledges and admits that this item 1 I occurred as stated. 1
- 2) Reasons for the violation During the December 26, 1986 event the requirements of procedure AP.506, " Notification / Communication" for update notifications, were not implemented. This occurred due to the Control Roon personnel becoming l very involved with the response to the plant events and '
not fully implementing the requirements of procedure AP.506. ; i
- 3) Corrective actions which have been taken and results l achieved.
! Training on the requirements of procedure AP.506 was ! conducted for operations personnel and Emergency Response Communicators. This training was completed April 1, 1986. This training will be repeated l annually. Command and control training for decision makers, e.g., , the control Room staff, which gives proper focus on ; requirements of the Emergency Plan, was completed on March 13, 1986. ; I E.3-1 NIIREG-0940 1.A-252 1
i I
- 4) Corrective steps which will be taken to avoid further violations.
As part of the command and control Training, the importance of and requirement for procedure compliance has been reemphasized. A number of emergency response drills have been successfully performed during the last several months. This effort culminated with the NRC witnessed and graded exercise of October 8, 1986.
- 5) Data full compliance will be achieved.
The District is now in full compliance with the requirement cited. E.3-2 l WilREG-0940 I.A-253
NRC Violation E.4 Procedure AP.501, Attachment 7.2, Tab 4 " Recognition and Classification of Emergencies," Revision 4, datad August 23, 1985, lists an " Emergency Action Level" alarm setpoint for Auxiliary Building Stack Monitor R15002B at 20,000 counts per minute (cpm). Contrary to the above, as of December 26, 1985, ' Procedure AP.501 was not adequately maintained in that the Auxiliary Building Stack Monitor R150025 setpoint
-was changed to 60,000 cpu on July 21, 1984, and the setpoint as listed in Attachment 7.2, Tab 4 still stated that the setpoint was 20,000 cym.
District Response to Violation E.4
- 1) Admission or denial of the alleged violation.
The District acknowledges and admits that this item i occurred as stated.
- 2) Reasons for the violation
- The referenced value was changed on July 21, 1984, but procedure AP.501 was not updated. This procedure change was not made due to the lack of an adequate tracking system within the Emergency Planning organisation to assure that procedures would be revised in a timely and comprehensive manner.
- 3) Corrective actions which have been taken and results achieved.
In order to correct this problem AP.501, Attachment 7.2, Tab 4 was updated.
- 4) Corrective steps which will be taken to avoid further l violations.
The Energency Planning organization has developed a tracking system to assure that changes are incorporated in a timely and comprehensive manner.
- 5) Data full compliance will be achieved.
This tracking system will be documented in a procedure by January 5,1987. E.4-1 j NUREG-0940 I.A-254 I , _-. _ - _ _ -
UNITED STATES 1 [A afog"o NUCLEAR REGULATORY COMMISSION l
-y , REGION 18 I g j 10t h8ARIETTA STREET.NYs.
- t ATLANTA, GEORGIA 30323 )
\ . .'.'. . / APR 151986 !
Docket No. 50-395 License No. NPF-12 EA 86-45 South Carolina Electric and Gas Company-ATTN: Mr. D. A. Nauman, Vice President Nuclear Operations P. O. Box 764 (167) Columbia, SC 29218 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY-(NRC INSPECTION REPORT NO. 50-395/86-06) An NRC inspection was conducted on February 1-28, 1986, of activities authorized by NRC Operating License No. NPF-12 for the V. C. Summer facility. The inspection included a review of operational safety verifications and certain operating events. As a result of this inspection, failures to comply with NRC regulatory requirements were identified. The findings were discussed at a March 4, 1986 exit meeting with members of your staff identified in the referenced inspection report and at an Enforcement Conference held in the NRC Region II Office on February 28, 1986. Items I.A. I.B. and I.C described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty involve your failure to comply with technical specifications in that one of two indeoendent component cooling water (CCW) and service water (SW) loops were inoperable in excess of 72 hours while in Modes 1, 2, 3 or 4 without the plant being put in hot standby within the next 6 hours. In fact, the loops were inoperable for approximately 100 hours without the action statements being satisfied. From January 30, 1986 until February 3, 1986, the B component cooling water loop was inoperable due to an incorrect electrical breaker alignment for the B and C component cooling water pumps. This rendered the B and C pumps incapable of an automatic start due to a safety injection signal. However, both pumps still had manual start capability from the main control board. In fact, as a result of a safety injection signal that occurred on February 3, 1986, the B CCW pump had to be manually started to respond to a safety injection signal. From January 30, 1986 until February 3,1986, the B loop of the service water system which uses the B or C SW pumps was also inoperable. During this pernd, the C pump, aligned to the B loop, ran continuously for approximately 100 hours even though post maintenance testing had not been completed. Therefore, this pump was technically inoperable. Under the system design, if a safety injection signal had occurred, the B SW pump would not have started automatically because of the electrical alignment required for the operating C pump. CERTIFIED MAIL RETURN RECEIPT REQUESTED 4 NtlP.EG-09a0 I.A-755
?-
South Carolina Electric and Gas Company Violation I.D addresses System Operating Procedures SOP-117 and SOP-118 for the SW and CCW systems respectively, which were deficient in that they did not adequately address the correct electrical alignment of the swing pump for an
' idle loop. The pro 61em was further complicated for the SW system because shift reviews of the removal and restoration (R&R) log, as required by Aoministrative Procedure SAP-200 (Conduct of Operations), were deficient in that the personnel did not recognize that the C Service Water Pump, logged out-of-service .in the R&R, was actually operating.
To emphasize the importance of insuring that plant procedures contain adequate operating instructions for plant systems and that plant staff is aware of the status of systems, I have been authorized, after consultation with the Director. Office of Inspection and Enforcement, to issue the enclosed Notice of Violation I and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violations in Item I as described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C-(1985) (Enforcement Policy), i the violations described in Item I of the enclosed Notice have been categorized
- as a Severity Level III problem. The base value of a civil penalty for a Severity Level III violation or problem is $50,000. I considered the escalation and mitigation factors allowed by the Enforcement Policy. While I recognize that you took prompt and extensive corrective actions, mitigation of the civil penalty would not be appropriate in this case because of your prior poor perfomance in the area of concern.
Item II discussed in the enclosed Notice involves the licensee's failure to i maintain an hourly fire watch which was required by technical specifications l Decause of an inoperable fire barrier. No civil penalty is proposed for this
' Severity Level IV violation.
I You are required to respond to this letter and should follow the instructions i specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, , including your proposed corrective actions, the NRC will determine whether further ! enforcement action is necessary to ensure compliance with NRC regulatory I requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in NRC's Public Document Rone. The response directed by this letter and the enclosure are not subject to the clearance procedures of the Office of Management and Budget issued under the Paperwork Reduction Act of 1980, PL 96-511. NUREG-0940 f.A-?56
South Carolina Electric and Gas Company APR 151986 j- Should you have any questions concerning this letter, please contact us. Sincerely, N {[I J J. Nelson Grace 7 Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Inspection Report No. 50-395/86-06 cc w/encls:
- 0. S. Bradham, Director, Nuclear Plant -
Operations J. L.~ Skolds, Deputy Director Operations and Maintenance J. B. Knotts, Jr. Debevoise and Liberman W. A. Williams, Jr., Special Assistant, Nuclear Operations - Santee Cooper A. M. Paglia, Jr., Manager Nuclear Licensing a 1 l NilREG-09d0 I.A-757
NOTICE OF VIOLATION AND PA0 POSED IMPOSITIF0F CIVIL PENALTY i South Carolina Electric & Gas Docket No. 50-395 c V. C. Summer License No. NPF-1? ' EA 8C-45 During a Nuclear Regulatory Consnission (NRC) inspection conducted on February 1-28, 1986, violations of NRC requirements were identified. In accordance with the
" General Statement of Policy and Procedure- for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act, as amended, .
- . ("Act"), 42 U.S.C 2282,-PL 86-295, and 10 CFR 2.205. The particular violations
~ and associated civil penalty are set forth below:
- 1. Violations Assessed a Civil Penalty A. Technical Specification 3.7.3 requires that two independent component cooling water (CCW) loops he operable in Modes 1, 2, 3 and 4. The action statement states that with one loop inoperable, restore at least two loops to operable status within 72 hours or be in at.least hot standby within the next six hours and cold shutdown within the following 30 hours.
Contrary to the above, an incorrect breaker alignment rendered loop B of the component water coolieg water system inoperable from January 30, 1986 until February 3,1986. The loop was inoperable for approximately 100 hours while the reactor was in Modes 1, 2, 3, or 4. I B. Technical Specification 3.7.4 requires that two independent service ,
-water (SW) loops be operable in Modes 1, 2, 3, and 4 The action i statement states that with one loop inoperable, restore at least two loops to operable status within 72 hours or be in at least hot standby within the next six hours and cold shutdown with the following 30 hours.
3 Contrary to the above, loop B of the service water system was technically l inoperable from lanuary 30, 1986 until February 3,1986 for a period of approximately 100 hours because post maintenance testing had not been completed on pump C, which was aligned to and supplying service water to this loop. Under the system design, pump B was incapable of starting l automatically upon a safety injection signal because of the electrical alignment Mguired for the operating C pump. !' C. Technical Specification 6.8.1 requires that the applicable procedures recommended in Appendix "A" of Regulatory Guide 1.33, Revision 2, 1978, be established and implemented. Appendix A of Regulatory Guide 1.33 states that safety-related system procedures should include instructions I for startup, shutdown, and changing modes of operation as appropriate. i System Operating Procedure (50P) 117 for the service water system and 50P 118 for the component cooling water system implement this
- requirement.
l NUREG-0940 T.A-258
l Notice of Violation 2 , 1
~
Contrary to the above, as of February 3,1986, S0P 117 and SOP 118 did i not provide adequate instructions for the startup and shutdown of the CCW and SW systems.in that they did not specify the correct electrical alignment for the swing pump under each possible operating configuration. D. Technical Specification 6.8.1 requires that the applicable procedures recommended in Appendix "A" of Regulatory Guide 1.33 Revision 2, 1978, be established and implemented. Appendix A of Regulatory Guide 1.33 states that safety-related system procedures should include instructions ! for startup, shutdown, and changing modes of operation as appropriate. Station Administrative Procedure SAP 200, Conduct of Operations, requires that the Shift Supervisor, Control Room Supervisor and Reactor Operator review the Removal and Restoration (R&R) log and be aware of the status of plant systems. Contrary to the above, even though the R&R log was reviewed by-the Shift Supervisor, the Control Room Supervisor, and the Reactor Operator , between January 30, 1986 and February 3, 1986, they were not aware of the status of the."C" service water pump (i.e., the pump had been running without being declared operable) until notified by the NRC Inspector on February 3,1986. These violations have been categorized in the aggregate as a Severity Level III' problem (Supplement !J. (Cumulative Civil Penalty - S50,000 assessed equally between the violations.) II. Violation Not Assessed a Civil Penalty Technical Specification 3.7.10 requires that fire barrier assemblies separating safety-related fire areas or separating portions of redundant systems important to safe shutdown within a fire area and all sealing devices in fire rated assembly penetrations shall be operable. The action statement permits operation with an inoperable fire barrier provided the operability of the fire detectors on at least one side of the barrier is verified and an hourly fire watch patrol is established. These requirements are implemented in Operations Standing Instructions SI 86-03, Hourly Fire Watch Patrol. Contrary to the above, on February 20, 1986, while a fire barrier was inoperable, an error in log keeping and review resulted in the deletion of the hourly fire watch patrol for Auxiliary Building Poom AB 12-07 from 11:00 a.m. on February 20, 1986 until the error was detected at 12:00 p.m. on February 22, 1986, a period of approximately 47 hours. This is a Severity Level IV violation ( Supplement 1). Pursuant to 10 CFR 2.201. South Carolina Electric and Gas Company is hereby requtred to submit to the Director, Office of Inspection and Enforcement, USNRC, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Connission, Region II,101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice a written statement or explanation including for each alleged violation: (1) admission or denial of the
'NUREG-0940 I.A-759
Notice of Violation 3-4 - I alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps which have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violation, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order'to show cause why the license should not be
' modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this
{ response shall be submitted under oath or affirmation. l Within the same time as provided for the response required above under 10 CFR 2.201, South Carolina Electric and Gas Company may pay the civil penalty - .by letter addressed to the Director, Office of Inspection and Enforcement, with a 1 check, draft, or money order payable to the Treasurer of the United States in the
! amount of Fifty Thousand Dollars (S50,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should South Carolina Electric and Gas l Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement will issue an order imposing the civil penalty in the amount proposed above. Should South Carolina Electric and Gas Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such l answer may: (1) deny the violations listed in this Notice in whole or in part, l (2) demonstrate extenuating circumstances, (3) show error in this Notice, or l' (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request i remission or mitigation of the penalty.
In requesting mitigation of the proposed penalty, the five factors addressed in l Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written answer
- l. in accordance with 10 CFR 2.205 should be. set forth separately from the statement i or explanation in reply pursuant to 10 CFR 2.201 but may incorporate by specific l reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of South Carolina Electric and Gas Company is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
Upon failure te pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. l FOR THE NUCLEAR REGULATORY COMISSION 1 $'k e J. Ne son Grace l Regional Administrator Dated at Atlanta, Georgia this/5 day of April 1986 l i I HUREG-0940 I.A-760
g*gna meine a ca, cansany pg,,y Cgag29DS Nciear Operaws SCE&G May 15, 1986 Mr. J. M. Taylor Director, Office of Inspection and Enforcement U. S. Nuclear Regulatory Comission Washington, DC 20555
SUBJECT:
Virgil C. Sumer Nuclear Station Docket No. 50/395 Operating License No. NPF-12 Response to Notice of Violation and Proposed Imposition of Civil Penalty NRC Inspection Report 86-06
Dear Mr. Taylor:
On April 15, 1986, the Nuclear Regulatory Comission (Region II) issued a Notice of Violation and Proposed Imposition of Civil Penalty for alleged violations of NRC requirements at South Carolina Electric and Gas Company's (SCE&G) Virgil C. Sumer Nuclear Station. SCE&G has thoroughly reviewed and investigated the incidents described in the Notice and, pursuant to 10 CFR 2.201, is responding to the alleged violations in the enclosed Attachments I and II. Since mid-1985. SCE&G has focused significantly more management attention to the on-shift operational and safety aspects of power operation at the Virgil C. Sumer Nuclear Station. This increased management involvement was initiated by SCE&G to ensure that the excellent startup operating record for the plant was maintained throughout the long-term operating phase of plant life. Importance has been placed on identifying potential problems in an expeditious manner and ensuring prompt corrective actions are pursued. SCE&G is, therefore, concerned that the NRC has proposed escalated enforcement action in the form of a civil penalty for the incidents explained in Attachment I. In accordance with 10 CFR 2.205, SCE&G is hereby providing in Attachment III a discussion of why the civil penalty is not necessary and should not be imposed. This discussion contains information which SCE&G finds material to the issue of mitigation of the penalty and addresses the pertinent factors found in Section V.B of 10 CFR Part 2 Appendix C. The discussion also addresses why the events did not result in consequences which led to a substantial safety concern and, therefore, did not represent such a significant Technical Specification violation as to warrant a Level III violation. MlREG-0940 1.A-261
Mr. J. M. Taylor NRC Inspection Report-86-06 May 15,1986 SCE&G strives for performance excellence in the operation of the Virgil C. Summer Nuclear Station. Continued self-evaluation and a constant desire to improve performance are management goals to be maintained for the life of the plant. Operations have been and will be strongly governed by SCELG's firm commitment to the public's health and safety. The undersigned affirms that the statements and matters set forth in this letter and its attachments are true and correct to the best of my knowledge, information, and belief. r trul .s , i
. A. Na a AMM: DAN /dwf Attachment c: 0. W. Dixon, Jr./T. C. Nichols, Jr.
E. H. Crews, Jr. E. C. Roberts J. G. Connelly, Jr. W. A. Williams, Jr. H. R. Denton J. Nelson Grace Group Managers
- 0. S. Bradham D. R. Moore C. A. Price W. T. Frady C. L. Ligon (NSRC)
R. M. Campbell, Jr. K. E. Nodland R. A. Stough G. O. Percival R. L. Prevatte J. B. Knotts, Jr. Document Management Branch NPCF File 2 i NUREG-0940 I.A-?62
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, i ATTACHMENT I RESPONSE TO NOTICE OF VIOLATION : VIOLATION NO. 50-395/86-06 I A-D
- 1. ' ADMISSION OR DENIAL OF THE ALLEGED VIOLATION South Carolina Electric and Gas Company (SCE&G) is in agreement with the i
,. alleged violation. ~ II. REASON FOR THE VIOLATION !~ SCE&G attributes the cause of the violation to the inadequate dissemination of design information on systems with swing pumps. Station Operating Procedures (SOPS) 117 and 118 address the operating configurations for the Service Water (SW) System and the Component Cooling Water (CCW) System, respectively. At the time of the identified violation, these procedures I accurately stated correct breaker alignment for these systems under normal 4 circumstances; however, they did not contain adequately detailed precautionary notes for certain swing pump alignments. The language of the precautions recognized the preferred alignment of the swing pump under i normal operations but did not detail the electrical design to describe why certain alignments could render a train inoperable. The "8" CCW pump breaker had been racked-in and the pump aligned to standby j ~on the "B" train on January 29, 1986, following completion of maintenance on ! the system and subsequent successful inspection. Furthermore, a regularly scheduled surveillance test on the pump was successfully performed on February 1, 1986. However, paperwork, for which Operations was waiting to clear the Removal and Restoration (R&R) Log,~was not received in the Control
- Room until february 3, 1986. Therefore, the CCW system was aligned from l January 29, 1986, with the "A" CCW pump running on the "A" train and the "B" and "C" CCW pumps aligned to the "B" train with both pump breakers racked-
, in. This alignment rendered the train inoperable due to a design interlock,
- unique to systems with swing pumps, installed to protect the diesel
- generator from overloading by preventing the automatic start of either pump when both are aligned to an inactive train. Since generally a racked-in breaker does not have an interlock which prevents automatic start, and
, because information contained in both the System Design Description and SOP-j 118 was insufficient to relay this unique design feature to the operators, l the alignment was not thought to be improper at the time. j: After performing maintenance activities on valving associated with the "C" SW pump, the "C" pump was placed in service on the "B" SW train (with "B" pump in standby) to perform post maintenance testing. The "C" SW pump ! remained in service on the "B" train; however, paperwork to return the pump i to operable status had not been completed. Operations personnel, due to incomplete informetton on the specific electrical design, believed that in , the event of a Safety Injection (SI) or blackout, the "B" SW pump would i automatically start. Therefore, the "B" SW train was not considered to be i inoperable by Operations personnel. However, the electrical design dictates 1 PAGE 1 of 9 ' 4 I , NUREG-0940 I.A-263 _ - .._ , _ . ~ _ - - _ _ . _ _-- _ _ _____-__.___-- -~
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t _ATTACHMENTIl--Continued t that the running pump on an active train is the pump which starts. automatically for that train as a result of an SI signal. Consequently, on , February 3, 1986, after the SI actuation (LER 86-003), the "C" pump .
- continued to operate on the "B" train and the "B" pump remained in standby.
Subsequent to the SI, Operations personnel verified that both trains of SW were operating, but failed to correlate that the administratively' inoperable "C" pump was running as opposed to the "B" pump on the "B" train. Since i= both trains automatically started and performed their design functions, , safety was not compromised. On the afternoon of February 3, 1986, immediately following a plant i management meeting in which the electrical design situation on swing components was discussed, the NRC Resident Inspector, who attended the meeting, questioned the operability of the "B" SW train. Otscussions at i that time with certain.on-shift Operations personnel who were not at the meeting and had not been made aware of the design situation revealed that they were not fully aware of the inoperable status of the "B" SW train. III. CORRECTIVE STEPS *TAKEN AND RESULTS ACHIEVED i i Following the SI actuation on February 3, 1986, the operators manually i started the "B" CCW pump during the performance of Immediate Operator ! Actions of Emergency Operating Procedure (EOP) 1.0, " Reactor Trip / Safety Injection Actuation." Although the "B" pump was not able to automatically ' start, upon manual start from the Control Board it performed its intended function. -Upon identification of the interlock situation surrounding the ! CCW system on February 3, 1986, the "C" CCW pump was aligned to the "B" train, and the "B* pump breaker was racked out. The paperwork to declare i the "B" pump operable was then completed and the R&R cleared. ! Upon identification on February 3, 1986, that the "C" SW pump was administratively inoperable, the paperwork associated with the pump was returned to the Control Room, the "C" pump was tested, and the R&R was cleared at 1845 hours. Correct breaker alignment was established to ensure operability of the "B" SW train. [ Oesigns of all plant systems which contain swing pumps were reviewed to i determine if the breaker interlocks were provided on any additional systems (Service Water, Component Cooling Water, Charging / Safety Injection, and l ChilledWater). A Special Instruction to Operations personnel including l proper precautions concerning the breaker interlock design on the Service Water, Component Cooling Water, Charging / Safety Injection and Chilled Water i Systems was discussed in a Plant Safety Review Committee meeting and issued j on February 4,1986, prior to restart. The Special Instruction was
- discussed with the on-duty shift, subsequent on-coming shifts, and j' specifically with each shift supervisor prior to assuming watch.-
l I l ! l PAGE 2 of 9 I NllREG-0940 I.A-?64 , l l
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ATTACHMENT I -- Continued IV. CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION
- The information provided in the Special Instruction was incorporated into the Operator Requalification Training Program.
- The System Operating Procedures were revised to include the proper precautions concerning the breaker interlocks for the CCW and the SW systems. Procedure and System Description changes to the Charging / Safety injection and Chilled Water systems were determined by review not to be necessary.
- System Design Descriptions for the CCW and the SW systems were revised to include the information concerning breaker interlocks.
e A program in which the maintenance supervisor consolidates paperwork associated with the close-out of maintenance and modification activites has been instituted to reduce the period of time required to return systems and equipment to an operable status following work completion. This program has the benefit of removing from the shift supervisor the responsibility of coordinating the return of all the paperwork needed to return a piece of equipment to service.
- Operations has instituted a change to the R&R program which requires the tagging of main control board controls for equipment which has been removed from service. These orange tags reflect the inoperable status of equipment entered in the R&R log and prevent the use of this equipment except under emergency conditions.
V. DATE OF FULL COMPLIANCE South Carolina Electric and Gas Company is in full compliance with respect to the corrective actions stated above. PAGE 3 of 9 til' PEG-0940 f.A-265
r 4 4 ATTACHMENT !! RESPONSE TO NOTICE OF VIOLATION VIOLATION NO. 50-395/86-06, II
- (N0 CIVIL PENALTY ASSESSED) 1.- ADMISSION OR DENIAL OF TPE ALLEGED VIOLt. TION South Carolina Electrte and Gas Company (SCE4G) is in agreement with the alleged violation.
II.- REASON FOR THE VIOLATION i The deletion of the hourly fiie watch patrol for Auxiliary Building Room A8 12-07 was caused by personnel error and inadequate review of the fire watch
. log. As required by Technical Specifications, when a Fire Barrier Removal Permit was initiated at 0815 hours on February 20, 1986, to facilitate a core drill and conduit seal in the Auxiliary Building, an hourly fire watch patrol was estabitshed and Zone AS-12-07 added to the fire watch log. At 1200 hours. February 20, 1986, a new fire watch log was initiated and Zone AS-12-07 was inadvertently omitted. Review of the logs at this time by the
- . Fire Protection Coordinator failed to identify the omitted zone. The deletion was identified during a review of the logs by the Control Room ,
Supervisor at 1200 hours, February 22, 1906.
!!!. CORRECTIVE STEF3 TAKEN AND RESULTS ACHIEVED T
! Upon identification by the Licensee of the inadvertently omitted watch, the
- required one hour fire watch patrol was reestablished for the zone.
IV. CORRECTIVE ACTION TAKEN TO AVOID FURTHER VIOLATION ,
- j. 4 4
All individuals involved in this event received formal counseling. In y addition, on March 5, 1906, the Management Review Board, chaired by the Vice i President, Nuclear Operations, conducted an inquiry into this event. As a result of the inquiry, the Board assigned the Fire Protection Codrdinator
- the following action:
- 1. Report to the Nuclear Training Center and prepare a lesson plan
- addressing specific items which can prevent recurrence of this type incident in the future.
- 2. Once this lesson plan has been prepared, receive concurrence from a
- Training representative and the Manager, Operations as to its adequacy.
1 Upon approval of the lesson plan, training sessions were presented to Firewatch personnel to assure both the Fire Protection Coordinator and the Firewatch personnel benefited from the identified mistake. l V. DATE OF FULL COMPLIANCE ) South Carolina Electric and Gas Company is in full compliance with respect j to the corrective actions stated above. PAGE 4 of 9 Nt' PEG-0940 f.A-P66 i
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l q. ATTACHMENT III RESPONSE TO PROPOSED IMPOSITION AND MITIGATION OF CIVIL PENALTY , REQUEST FOR MITIGATION i INSPECTION REPORT NO. 50-395/86-06 The events identified in Violation I cited in NRC Inspection Report No. 50-395/86-06 were described in a Licensee Event Report (LER 86-003) dated March
- 5. 1986. This LER also discussed the Reactor Trip and Safety injection which occurred prior to the identification of the events. Information .
relative to the violation events is also contained in Attachment I to the ! enclosed Response to Notice of Violation. { While SCE&G considers any abnormal event to be a serious matter and strives to take prompt corrective actions, the incidents involved in this violation did not create an adverse safety condition warranting the imposition of a i Level !!! violation and a civil penalty. All equipment involved either i maintained its functional operability or was capable, via manual control board actuation, of performing its intended function. As required, two trains of SW automatically started following the SI signal. Since both trains automatically started and performed their design functions, safety ' was not compromised.
- Verification that two trains of CCW are operating is part of the immediate
! Operator Actions required subsequent to an SI signal per Emergency Operating j Procedure (EOP) 1.0,-" Reactor Trip / Safety Injection." On February 3, 1986, after the SI signal was received, the operators entered E0P 1.0 and I imediately started the "8" pump on the "8" train to establish the second train of CCW flow. Because of these immediate procedural steps which
- required verification of two train flow, the practical safety significance l
of the pump *on the "8" CCW train not automatically starting was minimal. j Overall the events did not result in consequences which led to a substantial
- safety concern and therefore did not represent such a significant Technical j Specification violation as to warrant a Level !!! violation.
L From the language of the Notice of Proposed Imposition of Civil Penalty, j there is no evidence that actions discussed in meetings with the NRC and 4
'SCE4G on October 8, 1985, February 28. 1986, and March 18, 1986, were
! considered as mitigating factors to the Level !!! violation and resulting j civil penalty. SCE44 has reviewed the criteria in 10 CFR Part 2 Apppendix C dealing with the imposition of a civil penalty, and feels that a more j
' detailed discussion of the factors addressed in Section V.8 is warranted to identify the extenuating and relevant circumstances surrounding the j
violation events. 'These circumstances, combined with SCE&G's prompt and corrective actions, establish the basis for mitigation of the proposed civil i penalty. The discussion is provided below in sections titled to correspond j with the five factors contained in Section V.8 and contains an additional j section detailing other pertinent information which is relative to the mitigation of the proposed Level !!! violation and civil penalty: t i l l PAGE 5 of 9 i NijPEG-0940 1.A-267
ATTACHMENT III -- Continued
- 1. Prompt Identification and ReDortina On February 3, 1986, at approximately 0740 hours, a Reactor Trip and Safety Injection (SI) occurred from approximately seven percent power.
Plant systems responded as expected to the SI and Reactor Trip with the exception of the "B" train of Component Cooling Water (CCW). Following the SI actuation, the "B" train CCW pump did not automatically start. At the time, the "A" CCW pump was running on the "A" train and both the"B" CCW pump and the swing "C" CCW pump were aligned to the "B" train. Operators manually started the "B" pump during the performance of the Imediate Operator Actions of Emergency Operating Procedure (EOP) 1.0, " Reactor Trip / Safety Injection Actuation," and the pump performed as expected. During the subsequent post-trip investigation, a system design review revealed the presence of an interlock provided for protection of the power supply. This interlock prevents the start of either pump when both pumps are aligned to an inactive train. Upon identification of this interlock to Operations personnel (approximately 1600 hours on February 3, 1986), the "B" CCW pump breaker was racked-out to establish operability. SCE&G considers that the identification of the problem by the Licensee was completed in a timely fashion subsequent to the Reactor Trip.. The NRC residert inspector was informed of the interlock situation on the afternoon of February 3, 1986. (See also Licensee Event Report [LER 86-0031 sut.nitted en March 5,1986, explaining the circumstances surrounding the entire Reactor Trip and St.) SCE&G, therefore, contends thitt prompt identification and reporting was exercised by the Licensee for this case. Prior to the SI actuation, the "C" SW pump was placed in operation on January 31, 1986, on the "B" SW train to perform testing following l maintenance activities on the pump discharge valve. Following the SI, i the "C" pump continued to run on the "B" train. Because paperwork and I all of the associated testing had not been completed on the "C" pump, ! the operating SW pump subsequent to the SI was administratively inoperable. However, because operators had not been fully apprised of the electrical system design, they were not relying on the "C" pump's operability at the time of the SI; i.e., they assumed that "B" SW pump was capable of automatically starting with the system aligned as it was and therefore did not consider the train to be inoperable. On the afternoon of February 3, 1986, when the electrical design on swing components was clarified in the management meeting, the NRC resident inspector insneolately questioned the operability of the "B" SW train. Investigations at that time did in fact reveal the "C" SW pump was listed in the R&R log and the "B" train was indeed administratively inoperable. The "B" SW pump was then started and the necessary testing and paperwork was completed on the "C" pump to return it to an operable status. PAGE 6 of 9 NUREG-0940 1.A-968
1 ATTACHMENT III -- Continued . At the time the NRC resident inspector questioned the SW pump's status, on-shift operations personnel had not yet been made aware of the unique electrical design surrounding swing pumps. SCE&G is confident that the 4
"B" SW pump situation would have been.self-identified and reported by Operations personnel on the afternoon of February 3,1986, once the design information was relayed to them subsequent to the management meeting.
2.- Corrective Action to Prevent Recurrence e System Alignment Special Instruction Issuance, Training, Procedure and System Description Revisions -- Immediate corrective action was taken to provide correct system alignments for the CCW and the SW systems upon identification that the as found alignments were 4 incorrect. . Additionally, a Special Instruction was reviewed in a Plant Safety Review Committee meeting and issued on February 4, 1986, to Operations personnel concerning the electrical design for , applicable plant systems which contain swing components (Service Water, Component Cooling Water, Charging / Safety Injection, and Chilled Water). This~Special Instruction provided guidance
- concerning the required alignment ~ for various conditions of pump availability. _This instruction was reviewed with on-duty shift personnel and with subsequent on-coming shifts. The information provided in the Special Instruction was also incorporated into the Operator Requalification Training Program. System Operating Procedures were revised for the CCW and the SW systems to include the proper precautions concerning the breaker interlocks. System Design Descriptions were updated to more appropriately address these interlocks.
e Paperwork Consolidation -- Additional concerns which were raised as a result of the events described in the violation have also been addressed to prevent possible recurrence. A program to consolidate paperwork associated with the close-out of maintenance and modification activities has been implemented to reduce the period of time required to return systems and equipment to an operable status following work completion. This program removes the burden from the shift supervisor of coordinating the return of paperwork needed to return a piece of equipment to service and places the responsibility on the on-duty maintenance supervisor. e R&R Log Changes -- Operations has also implemented a change to the R&R program to require tagging of main control board controls for j equipment which has been removed from service. The purpose of these tags is to reflect to the operator the inoperable status of equipment and prevent the use of inoperable equipment except under i emergency conditions. These tags, in addition to the various other i logs and records, will provide a visual aid to the operator in maintaining an accurate status of vital plant systems at all times. i PAGE 7 of 9 4 i NUREG-0940 f.A-269 i l _ _ _ . _ _ _ _ _ _ _ _ _ _ . . _ _ . _ _ , _ ~ _ _ _ _ _ _ _ . - _ _ . _ _ _
ATTACNIENT III -- Continued
.These corrective actions are considered by SCE&G to fully address the problems identified in the violation and have been implemented in a
! timely fashion. 'SCE&G is confident that these corrective measures, had , .they been in place prior to February 3, 1986, would have prevented the violation events from ever occurring. These actions not only correct the specific problems contained in the violation but also address- , general areas in which improvements can be made. Implementation of 1 these corrective actions will enhance overall plant operation. ! 3. Past Performance This violation involved four individual incidents which could all be attributed to a single root cause.- incomplete dissemination of design information regarding swing pump electrical system design. Prior
- performance does not indicate that SCE&G has had difficulties in the general area of understanding design intent.. In the past, dissemination of design information has been sufficient and hence
!- operator understanding.of systems and their designs has enabled them to safely operate the plant. Naturally, as operations continue, increased familiarity with the plant systems will add to the operators' experience level and understanding of all design aspects. SCEM has done a great deal in the past year to address the general ! issue of performance at the Virgil C. Summer Nuclear Station. Various programs have been implemented to ensure that exceptional performance ; is the goal of all individuals involved with the operation of the i plant. These programs individually address team building, professional l improvement, the necessities of different programs, industrial safety i awareness, and human performance error correction. A Management Review Board has been established as a fact finding group to review significant events in order to determine root causes and establish corrective actions to prevent recurrence. Training programs have been revised and new programs have been added to help enhance operator understanding and reduce personnel errors. Additionally, meetings have been held with all plant personnel to stress the importance of positive performance. SCE&G considers that prior performance in the overall operation of tM. Virgil C. Sumer Nuclear Station has been noteworthy. Management attention to all aspects of the design, operation and maintenance of the plant has been increased in the past year in an effort to continue the excellent record the plant establish 3d during startup and initial ' operation. Several programs to instill a sense of pride and dedication in the employees have.been formulated to help improve the concept of teamwork. Because of this increased attention to detail and performance, in the past year SCE&G has significantly improved its ability to self-identify Technical Specification non-compliances and other potential problems. Furthermore, the ability to effectively address the correction of these identified items has been improved. PAGE 8 of 9 i I l NUREG-0940 I.A-270
1 l ATTACHMENT III -- Continued This initiative demonstrates SCEM's continuing pursuit of excellence and desire to maintain a superior operating record. It appears from the Notice of Violation and Proposed Imposition of , Civil Penalty that,the NRC did not consider all of the above stated actions prior to proposing the Level III violation and civil penalty, even though they were discussed in meetings between SCE M and the NRC on October 8, 1985, February 28, 1986, and March 18, 1986. Had these actions been considered by the NRC initially, SCE M believes the civil penalty would have been mitigated or alternatively never proposed.
- 4. Prior Notice of Similar Event SCEM has not obtained prior notification of events similar to those identified in the violation.
i
- 5. Multiple Occurrences 4
The incidents contained in the violation had not been identified during this or previous inspection periods. The lack of dissemination of design information in this incident and the extenuating circumstances surrounding the violation are considered to be a unique situation which has not given rise to problems in the past. Therefore, SCEE does not consider the factor of multiple occurrences to be an issue in the contention of the civil penalty. i
- 6. Additional Pertinent Information 4 As' identified in the preceeding sections, SCEE is striving to correct j any deficiencies found in any aspects of the operation of the Virgil C.
Sumer Nuclear Station. Enforcement conferences held between the NRC and SCEM on October 8,1985 and February 28, 1986, have already ~ attracted additional management attention to plant operation and accordingly, escallated enforcement. action is not necessary to obtain management attention. Employees within the Nuclear Operations Department have been working with renewed vigor and pride to show improvement and demonstrate their abilities to perform. SCEM
- l. management is concerned severe enforcement action in the form of i- imposition of a civil penalty will at this point in time have a l detrimental effect on the attitudes of the plant personnel who have been working so diligently to improve performance. Therefore, in light of the information contained in this letter, SCEM requests the NRC re-evaluate imposition of a Level III violation and reconsider mitigation i
or remission of the proposed civil penalty. PAGE 9 of 9 NUREG-0940 T.A-771
i i l P Bo y py eggma nuc,..,op.r.1,on, scsao May 23,1986
. Mr. J. M. Taylor -
Director, Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission (NRC) Washington,DC 20555
Subject:
Virgil C. Summer Nuclear Station i Docket No. 50/395
- Operating License No. NPF-12 l Supplemental Response to EA 86-45, ;
NRC Inspection Report 86-06 ' l
Dear Mr. Taylor:
On May 15,1986, South Carolina Electric & Gas Company (SCE&G) provided its response to the Notice of Violation and Proposed imposition of Civil Penalty forwarded in the subject enforcement action, in that response, SCE&G asked the Staff to consider mitigating the proposed civil penalty in view of, among other things, SCE&G's past performance. Past performance was evidently the crucial factor in the proposed imposition of the civil penalty. Dr. Grace's April 15,1986 letter, transmitting the enforcement action, stated that mitigation was not appropriate because of SCE&G's prior poor performance in the area of concern." SCE&G expressed the view in its response that its recent efforts to improve performance in the overall operation of the Virgil C. Summer Nuclear Station had evidently not been ! considered by NRC in determining the amount of the proposed civil penilty. Since preparing our response, SCE&G has received modifications to the most recent Systematic Assessment of Licensee Performance (SALP) Board Report. In transmitting the modifications, the Region acknowledged that the NRC assessment regarding
" degradation of management controls" at the Virgil C. Summer Nuclear Station was inaccurate. In his May 8,1986 letter, Dr. Grace revised his finding and provided
< replacement pages showing this change. SCE&G believes that this action by the Region provides further evidence that the Staff's t perception of prior poor performance was bawd in large measure,if not entirely, on what has now been acknowledged to be an inaccurate SALP assessment. This confirms that the proposed civil penalty was not warranted, or at least should be substantially mitigated. Therefore, SCE&G requests that the Staff take this modification of the recent SALP Board Report into account when considering whether to mitigate the proposed civil penalty. The undersigned affirms that the statements and matters set forth in this letter are true
- and correct to the best of my knowledge,information and belief.
i ry. ruly ypurs, f e l DA kaardan NUREG-0940 I.A-772 i,_ _ n_
/pn **%q'o, UNITED STATES
! # h NUCLEAR REGULATORY COMMISSION
, 8 WA$HING TON. D. C. 20656
\.....,
SEP 171986 Docket No. 50-395 License No. NPF-12 EA 86-45 South Carolina Electric and Gas Company ATTN: Mr. D. A. Nauman, Vice President Nuclear Operations P. O. Box 764 (167) Columbia, SC 29218 Gentlemen:
SUBJECT:
ORDER IMPOSING CIVII. MONETARY PENALTY This refers to your letters dated May 15 and 23,1986 in response to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by our letter dated April 15, 1986. Our letter and Notice described violations of certain technical specification requirements. These violations were identified during an NRC inspection conducted on February 1-28, 1986 of activities authorized by" NRC Operating License No. NPF-12 for the V. C. Summer facility. We have completed our review of your responses in which you admit that the viola-tions occurred as stated in the Notice. However, you requested a re-evaluation of the severity level for Violation I and mitigation or remission of the civil penalty proposed for those violations. After careful consideration of your responses, we have concluded, for the reasons given in the enclosed Order Imposing Civil Monetary Penalty and Appendix, that the violations did occur as set forth in tae Notice of Violation and Proposed Imposition of Civil Penalty and that you did not provide in your response a sufficient basis for reducing the severity level or for mitigating or remitting the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on South Carolina Electric and Gas Company imposing a civil penalty in the amount of Fifty Thousand Dollars (550,000). In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10. Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The response directed by the accompanying Order is not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely,
/ .
TV J es M. Taylor irector
..-Office of Inspection and Enforcement CERTIFIED MAIL RETURN RECEIPT REQUESTED NilREG-0940 I.A-773
i UNITED STATES
?
NUCLEAR REGULATORY COMMISSION In the Matter of ) SOUTH CAROLINA ELECTRIC AND GAS COMPANY ) Docket No. 50-395 (V.;C. Summer) ) License No. NPF-12
.) EA 86-45 ORDER IMPOSING CIVIL MONETARY PENALTY I
f . South Carolina Electric and Gas Company (the licensee) is the holder of Operating !. License No. NPF-12 (the license) issued by the Nuclear Regulatory Commission (the NRC'or Commission) on August 6, 1982. The license authorizes the licensee to 1 operate the V. C. Summer facility in accordance with conditions specified therein. II A safety inspection of the licensee's activities under the' license was conducted j by the NRC on February 1-28, 1986. As a result of this inspection, it appeared that the Itcensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was served upon the licensee by letter dated April 15, 1986. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty l proposed for the violations. The licensee responded to the hotice by letters l- dated May 15.and 23, 1986. l l I L NUREG-0940 I.A-274
2 III Upon consideration of the licensee's responses and the statements of fact, explanation, and argument for reduction Of the severity level for Violation I and for mitigation or remission of the proposed civil penalty contained therein, as set forth in the Appendix to this Qrder, the Director Office of Inspection and Enforcement, has determined that the violations occurred as stated, that the Severity Level III categorization was appropriate, and that the civil penalty proposeo for Violation I in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (42 USC 2282, PL 96-295), and 10 CFR 2.205, IT IS HERE8Y ORDERED THAT: The ifcensee pay a civil penalty in the amount of Fifty Thousand Dollars ($50,000) within thirty days of the date of this Order by check, draft, or money order payable to the Treasurer of the United States and mailed to the Director, Office of Inspection ana Enforcement, U.S. Nuclear Regulatory Commission Washington, D.C. 20555. fillP.EG-0940 I.A-275 1
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3 V The licensee may,~ within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director, Office of Inspection and Enforcement, at the above address. A copy of the hearing request also shall be sent to the Assistant General Counsel for Enforcement, Office of the General Counsel, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. If a hearing is requested, the Consnission will issue an Order designating the time and place of the hearing. Upon failure of the licensee to request a' hearing within thirty days of the date of this Orcer, the provisions of this Order shall be effective wiqhout further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee violated NRC requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty, and (b) whether, on the basis of such violations, this Order should be sustaineo. FOR THE NUCLEAR REGULATORY COMMISSION
- -- -L n.W.[f James N. Taylor Director j
,,4ffice of Inspection and Enforcement
- v Dated at Bethesda, Maryland j this frJt_A, day of September 1986 l
l NUREG-0940 1.A-776
APPENDIX On April 15, 1986, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for violations of NRC requirements. South Carolina Electric and Gas Company's (SCE&G) responses to the Notice were provided in letters dateo Mey 15 and 23 -1986. A restatement of the violations, a sunmary of the licensee's responses, the NRC evaluation of the licensee's responses and its conclusions are set forth below. Restatement of the Violations I. Violations Assessed a Civil Penalty A. Technical Specification 3.7.3 requires that two independent component cooling wdter (CCW) loops be operable in Modes 1, 2, 3, and 4. The action statement states that with one loop inoperable, restore at least two loops to operable status within 72 hours or be in at least hot standby within the next six hours and cold shutdown within the follow-ing 30 hours. Contrary to the-above, an incorrect breaker alignment rendered loop B of tiie component water cooling water system inoperable from January 30, 1986, until February 3,1986. The loop was inoperable for approximately 100 hours while the reactor was in Modes 1, 2, 3, and 4. B. Technical Specification 3.7.4 requires that two independent service water (SW) loops be operable in Modes 1, 2, 3, and 4. The action statement states that with one loop inoperable, restore at least two loops to operable status within 72 hours or te in at least hot standby within the next six hours dnd cold shutdown with the f.ollowing 30 hours. Contrary to the above, loop B of the service water system was tech-nically incpe-able from January 30, 1986, until February 2, 1986, for a period of approximately 100 hours because post maintenance testing had not been completed on pump C, which was aligned to and supplying service water to this loop. Under the system design, pump B was incapable of starting automatically upcn a safety injection signal because of the electrical alignment required for the operating C pump. C. Technical Specification 6.8.1 requires that the applicable procedures recceended in Appendix "A" of Regulatory Guide 1.33, Revision 2,1978, be established ano implemented. Appendix A of Regulatory Guide 1.33 states that safety-related system procedures should include instructions fcr startup, shutdown, and changing modes of operation as appropriate. System Operating Procedure (SOP) 117 for the service water system ar.d 50P 118 fur the component cooling water system implement this require-ment. Contrary to the above, as of February 3,1986, S0P 117 and 50P 118 did not provioe adequate instructions for the startup and shutdown of the NilREG-Ona0 f.A-?77
! Appendix 2 L CCW and SW systems in that they did not specify the correct electrical alignment for the swing pump under each possible operating configura-tion. D.- Technical Specification 6.8.1 requires that the applicable procedures recosuended in Appendix "A". of Regulatory Guide 1.33, Revision 2,1978, be established and implemented. Appendix A of Regulatory Guide 1.33 states that safety-related system procedures should include instruc- , tions for startup, shutdown, ahd changing modes of-operation as
- appropriate. Station Administrative Procedure SAP 200. Conduct of -
Operations, requires that the Shift Supervisor, Control Room Supervisor and Reactor Operator review the Removal and Restoration (R&R) log and i be aware of the status of plant systems.
- Contrary to the above, even though the R&R log was reviewed by the Shift Supervisor, the Control Room Supervisor, and the Reactor Operator between January 30, 1986 and February 3,1986, they were not aware of
- the status of the "C" service water pump (i.e...the pump had been l running without being declared operacle) until notified by the NRC Inspector on February 3,1986.
j - These vio1Attons have been categorized in the aggregate as a Severity ' ! ~ Levef III problem (Supplement I). .
- j. (Cumulative Civil Penalty - $50,000 assessed equally br tween the violations).
' Summary o'f the Licensee's Responses
.SCE&G admits that the violations occurred as stated in the Notice but objects
, to the severity level of Violation I and requests mitigation or remission of the associated civil penalty. The licensee believes that the incidents involved in Violation I did not create . an adverse safety condition and that CCW anc Sb system equipment maintained , their functional capability or were capable of performing their intended function via manual control board actuation. The licensee asserts that the practical safety significance of the failure of the Train B CCW pump to automatically start was minimal because of the procedural steps which required 1 verification of two train flow following a safety injection signal. The licensee ! also states that, "Overall the events did not result in consequences which led to a substantial safety concern and therefore did not represent such a signifi-4 cant Technical Specification violation as to warrant a Severity Level III i categorization." In addition, the licensee contends that mitigating factors addressed in 10 CFR Part 2,
- Appendix C were not considered for the Severity Level III problem and associated i civil penalty. SCE&G believes that extenuating and relevant circumstances surrounding the events combined with its prompt corrective actions establish r the basis for mitigation of the proposed civil penalty. The licensee refers I to its prompt identification and reporting of the violation involving the CCW system and its confidence that the violation involving the SW Icops would have been self-identified and reported once design information was relayed to
- operations personnel. SCE&G believes that its corrective actions were prompt, j fully comprehensive, and sufficient to , prevent recurrence and argues that its l
NUREG-0940 I.A-278 i, _ _ _ _ _ _.. _ -. _ __ _ _ _. _ _ _ _ _ . _ _ _ _ _ _ . . _ _ __
Appenoix 3 ' past performance was not poor nor indicative of difficulties in the general area of understanding system design bases. The Ifcensee does not believe the factors of prior notification of similar events or multiple occurrences to be an issue in this civil penalty.
- The licensee's supplemental response of May 23, 1986 states that the correc-tions to the Systematic Assessment of Licensee Performance (SALP) issued by Region !! on May 8,1986 imply that the NRC's reference to prior poor perfonn-ance in the cover letter for the Notice was based "in large measure, if not entirely, on what .'
- ct been acknowledged to be an inaccurate SALP assessment."
The licensee concludes that the proposed civil penalty was not warranted or that the proposed civil penalty should at least ce substantially mitigated. NRC Evaluation of the Licensee Responses While the licensee contends that the incidents which resulted in Violation I did not create en adverse safety condition, one of two trains for each of two safety-related systems was inoperable for approximately 100 hours while the reactor was in Modes 1, 2, 3. or 4. During this time, the affected trains would not have automatically started in response to a safety injection signal. The staff recognized, that redundant trains of the CCW and SW systems remained operable and that the verification of the operation of two trains upon the initiation of safety infection is required by SCE6G procedures. However, the NRC does not typically acknowledge manual operator actions in design basis accident analyses that require the CCW or SW systems to operate automatically. In addition, these conditions are similar to the example found in Supplement I,10 CFR Part 2, Appendix C in which one component is inoperable for a time period-in excess of that allowed by the technical specification action statement. Therefore the staff believes that Violation I was appropriately classified as a Severity Level !!! problem and reduction in severity level would not be appropriate. s Regarding mitigation or remission of the civil penalty, the mitigation and escalation factors addressed in the " General Statement of Policy and Procedure for NRC Enforcement Actions " 10 CFR,Part 2, Appendix C (1965) were considered in the staff's determination of the proposed civil penalty. In evaluating , mitigaticn for prompt identification and reporting, the staff considered, among other things, the lengt's of time the violations existed prior to discovery, the opportunity available to discover the violations, and the promptness and , completeness of any required reports. In this case, one CCW loop was inoperable for 100 hours. Although SCE&G identified and reported the problem involving , the CCW system, SCEAG did not recognize that one of two SW loops was technically inoperable for the same period of time until questioned by the NRC. Although SCE&G is confident it would have identified and reported the problem once design information was relayed to operations personnel the NRC staff cannot allow mitigation of the civil penalty based on actions the licensee believes it would ! have been taken had it recognized the problem. i ( 1 1 NUREG-0940 I.A-?79
'- Appendtx 4 In evaluating mitigation based on SCE&G's prompt and extensive corrective actions, the staff recognizes that there was adequate basis for mitigation of the civil penalty. However, there was also a basis for escalation of the civil penalty because of SCE&G's prior poor performance in the area of plant operations. Although SCE&G believes its past performance was not indicative of difficulties in the general area of understanding system design bases, understanding system design bases is fundamental to understanding plant opera-tions. In this case, prior poor performance was evidenced by the civil penalty of $50,000 issued on January 6,1986 concerning system alignment errors which resulted in both Residual Heat Removal (RHR) system flowpaths being inoperable
- and the most recent Systematic Assessment of Licensee Performance (SALP)
Category 3 rating in plant operations, Although the licensee argues that the staff's perception of poor prior performance was based on a SALP assessment subsequently acknowledged to be inaccurate, changes were made to the SALP assessment only to clarify the finoingh of a September 1985 inspection and to accurately describe the scope of eddy current testing conducted during two outages. No cnanges were made to the evaluation in the area of plant operations and the Category 3 rating. l Therefore, in summary, bases for both mitigation, for prompt and extensive corrective, actions, and escalation, for prior poor performance, existed. The staff maintains 'that, on balance, neither mitigation nor escalation is appro- - priate. The NRC staff agrees with SCE&G that there is no basis for escalation of the civil penalty based on the factors of prior notice of'a similar event or multiple occurrences of the violation. - Conclusion The violation occurred as stated in the hotice and the licensee has not provided any new information to support a reduction in the severity level of the violation or for mitigating or remitting the proposed civil penalty. Therefore, a civil penalty in the amount of Fifty Thousand Dollars ($50,000) has been imposed. l i NUP.EG-0940 I.A-280
aSCEAG
- ~.
=--
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October 17, 1986 Mr. J. M. Taylor Director, Office of Inspection and Enforcement U. S. Nuclear Ryulatory Comission Washington, DC 20555
Subject:
Virgil C. Sumer Nuclear Station Docket No. 50/395 Operating License No. NPF-12 Payment of Civil Penalty Inoperable Component Cooling / Service Water Loops
Dear Mr. Taylor:
In response to the Order dated September 17, 1986, imposing a Civil Penalty for violations which occurred at the Virgil C. Sumer Nuclear Station as described in the Notice of Violation and Proposed Imposition of Civil Penalty dated April 15, 1986, a check in the amount of fifty-thousand dollars ($50,000) is enclosed. Between the dates of January 29, 1986, and February 3,1986, violations of the Virgil C. Sumer Nuclear Station Technical Specifications occurred as a result of unanticipated effects of certain Component Cooling and Service Water swing pump interlocks. These violations surfaced after the actual occurrence of similar events detailed in IE Information Notice (IEN) 86-79, " Degradation or loss of Charging Systems at PWR Nuclear Power Plants Using Swing-Pump Designs", but prior to the actual issuance of the IEN. In this IEN, which described problems with swing pump interlocks which occurred at two operating plants in June 1985, it was pointed out that a specific set of circumstances and/or conditions is necessary to readily identify certain interlock circLitry, and furthermore, that the likelihood of the occurrence of such circumstances and/or conditions is small. The IEN acknowledged that normal tests and design reviews were not likely to identify the problems with the interlocks. SCE&G concurs with these findings of IEN 86-79 and therefore regrets that a Civil Penalty has been imposed for the violations which occurred at the Virgil C. Summer Station in February 1986. However, as stated in SCE&G's initial response to the proposed violation dated May 15, 1986, performance excellence in overall plant operation and a strong commitment to provide safe and efficient nuclear power are SCE&G's primary goals for the operation of the Virgil C. Summer Nuclear Station. Therefore SCE&G will not protest further the imposition of the Civil Penalty. NifREG-0940 I.A-281
Mr. J. M. Taylor Payment of Civil Penalty Page Two October 17, 1986 If you should have any further questions, please advise. Tu ours, A. au n- ! AM: DAN /bjh ENCLOSURE c: 0. W. Dixon, Jr./T. C. Nichols, Jr. E. H. Crews, Jr. E. C. Roberts
- 0. S. Bradham D. R. Moore J. G. Connelly, Jr.
W. A. Williams, Jr. H. R. Denton. J. Nelson Grace Group Managers C. A. Price W. T. Frady C. L. Ligon (NSRC) l R. M. Campbell, Jr. K. E. Modland ) i R. A. Stough ' G. O. Percival R. L. Prevatte J. 8. Knotts, Jr. Document Management Branch NPCF l File 1 l j NUREG-0940 I.A-28?
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.etfpsmes ,jg NUCLEAR REGULATORY s -eennan i n.. ..
2* .$ set anansaTTA sinsar sem ArtAaerA.stonesa assas N. . . . ' SEP 221986 Docket No. 50-3M License No. NPF-12
'EA 86-126 South Carolina Electric and Gas Company ATTN: Mr. D. A. Nauman, Vice President Nuclear Operations P. O. Box 764 (167)
Columbia, SC 29218 Gentlemen: f
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-395/86-12) This refers to the Nuclear Regulatory Commission (NRC) inspection conducted at the V. C. Summer facility on June 1 - July 3,1986. The inspection included a review of the circumstances surrounding the misalignment of the charging pumps which was promptly identified by the licensee and reported to the NRC. As a result of this inspection, significant failures to comply with NRC requirements were identified, and accordingly, the ' violations were discussed with you, members of your staff, Mr. L. Reyes, and other members of the NRC staff in an Enforcement Conference held on July 3, 1986, at the Region II Office. The two violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involve the failure to maintain the charging pumps in an operable status under certain design basis conditions from June 6-11, 1986. Violation I in the enclosed Notice is considered significant because none of the three charging pumps would have automatically started for approximately 3 13\ hours on June 10, 1986 under the conditions of a loss of offsite power followed by a safety injection signal. Specifically, because the A diesel generator was removed from service for maintenance, the A charging pump was inoperable under the conditions of a loss of offsite power as it was aligned to the A electrical train. Because of the status of the B and C charging pumps, one train of the charging system was already rendered inoperable for approximately 110 hours from June 6-11, 1986 as described in Violation II. The B charging pump would not have automatically started because its control switch was in the pull-to-lock position. The C charging pump was prevented from automatically starting because of electrical interlocks for a loss of offsite power followed byasubsequentsafetyinjectionsignal. It is apparent that system operating procedures did not properly specify the electrical alignment of the charging pumps. It is also apparent that training was not adequate for the operators to fully understand the design and operating configuration of the system. The NRC is concerned because of this and other recent escalated enforcement actions involving the operation of your facility and the low rating in the area of plant operations given in the latest Systematic Assessment of Licensee Performance (SALP). While the NRC recognizes that you CERTIFIED MAIL RETURR R CETPT REQUESTED NUREG-0940 T.A-283 l
, , -- 1
South Carolina Electric and Gas Company SEP 2 2126 identified and reported these violations, more attention to detail in system operation and design reviews is required to ensure similar types of violations do not recur. Weaknesses in the training area must be fully addressed in your cor-rective actions in order to achieve improvement in the plant operations area. To emphasize the importance of ensuring th{it your plant staff understands the design and proper operating configuration of systems, the need for complete procedures, and the need for training with appropriate operating guidance and instructions, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Ftfty Thousand Dollars ($50,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level III problem. < The base value of a civil penalty for a Severity Level III problem is $50,000. ! Mitigation of the civil penalty was considered for your prompt identification i and reporting, and your aggressiveness in taking prompt and extensive corrective actions. However, because this event is similar to the component cooling water and service water system event of January 30, 1986, which also involved a proposed civil penalty, bases for escalation of the civil penalty also exist. Therefore, no adjustment of the base civil penalty has been deemed appropriate. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing,y93r response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this' letter and its enclosures will be placed in the NRC Public Document Room. The responses directed by this letter and its enclosures are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980,-PL 96-511. Should you have any questions concerning this letter, please contact us. Sincerely, J. Nelson Grace Regional Administrator l l 1 Enclosures- '
- 1. Notice of Violation and Proposed Imposition of Civil Penalty 1
- 2. NRC Inspection Report No. 50-395/86-12 1 cc w/encls: (see page 3)
NUPEG-0940 1.A-284 l 1
n NOTICE OF VIOLATION AND
- PROPOSED IMPOSITI53I0F CIVIL PENALTY
. South Carolina Electric and Gas Company Docket No. 50-395 V. C. Summer License No. NPF-12 EA 86-126 a
- A Nuclear Regulatory Commission (NRC) inspection was conducted on June 1-July 3, 1986, to review the circumstances involving the misalignment of the 4
charging pumps which was identified by the. licensee and promptly reported to the NRC. The misalignment resulted in significant failures to comply with NRC r?quirements. > In accordance with- the " General- Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: I. Technical Specification 3.8.1.1 requires that two separate and independent i diesel generators be operable in Modes 1, 2, 3, and 4. Technical Specification Action. Statement 3.8.1.1.c requires that if one diesel generator is inoperable, the licensee must verify that all required systems, subsystems, trains, components, and devices that depend on the remaining operable diesel generator as a source of emergency power are also operable. If these conditions are not satisfied within two hours, the unit,must be in at least hot standby within the next six hours and in cold shutdown within the next 30 hours. i Contrary to the above, from 7:00 a.m. until 8:27 p.m. on June 10, 1986 (approximately 13 hours), while in Mode i and with one of the two diesel generators inoperable, the licensee did not properly verify .the operability of all required systems. Charging pumps B and C were aligned to the B electrical train and dependent upon the remaining operable diesel generator as a source of emergency power. Charging pumps B and C were inoperable because neither pump would have automatically started as ; intended under the condition of a loss of offsite power followed by a safety injection signal. The unit was not placed in hot standby within eight hours. II. Technical Specification 3.5.2 requires that two independent Emergency Core Cooling System (ECCS) subsystems;be operable in Modes 1, 2, and 3. Technical Specification Action Statement 3.5.2.a requires that with one inoperable ECCS subsystem, of which a. charging pump is a part, the licensee must restore the inoperable subsystem to operable status within 72 hours or be in at least hot standby within the next six hours and in hot shutdown within the following six hours. Contrary to the above, from June 6-11, 1986 (for approximately 110 hours), while in Mode 1, the B electrical train charging pumps (B and C), which are part of an ECCS subsystem, were inoperable and unable to be automatically started as intended due to the position of a control switch and electrical interlocks. Action was not initiated after 72 hours to be in hot standby within six hours or in hot shutdown within the following six hours. These violations have been categorized in the aggregate as a Severity Level III problem (Supplement I). (Cumulative Civil Penalty - $50,000 assessed equally between the violations.) I l NUREG-0940 1.A-285
Notice of Violation 2 : Pursuant to the provisions'of 10 CFR 2.201, South Carolina Electric and Gas Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice a written statemen$ or explanation including for each violation: (1) admission or denial of the? violation, (2) the reasons for the violation if admitted, (3) the corrective steps which have been taken and.the results achieved, (4) the corrective steps which will be taken to avoid further . violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other 1 action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affireation. Within the same time as provided for the response required above under 10 CFR 2.201, South Carolina Electric and Gas Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check,' draft, or money order payable to the Treasurer of the United States in the
-cumulative amount of Fifty Thousand Dol,lars ($50,000) or may protest imposition of the. civil penalty in whole er in part hy a written answer addressed to the Director, Office of Inspection and Enforcement. Should South Carolina Electr.ic and Gas Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an of, der imposing the civil penalty in the amount proposed above. Should South Carolina Electric and Gas Compant elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.
In requesting mitigation of the proposed penalty, the five factors addressed in . Section V.B. of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and
- . paragraph numbers) to avoid repetition. South Carolina Electric and Gas Company's attention is directed to the other provisions of 10 CFR 2.705 regarding the procedure for imposing a civil penalty.
i NUREG-0940 I.A-786
Notice of Violation 3 Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFit 2.205, this matter may be referred to the Attorney General, and penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. e i FOR THE NUCLEAR REGULATORY COMISSION
./N~' -
J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia thisAR day of September 1986 i i NUPEG-0940 I.A-287
Electric & Gas Company Dan A- n sucear oo.r.oo.,s g um g 2921s SCE&G October 17,1986 M r. J. M. Taylor Director, Office of Inspection and Enforcement U. S. Nuclear Regulatory Commission Washington,DC 20555
SUBJECT:
Virgil C. Summer Nuclear Station Docket No. 50/395 Operating License No. NPF-12 Response to Notice of Violation and Proposed Imposition of Civil Penalty NRC Inspection Report 86-12
Dear Mr. Taylor:
I On September 22,1986, the Nuclear Regulatory Commission (Region 11) issued a Notice of Violation and Proposed impusition of Civil Penalty for alleged violations of NRC requirements at South Carolina Electric & Gas Company's (SCE&G) Virgil C. Summer Nuclear Station. SCE&G has thoroughly reviewed and investigated the incidents described in the Notice and, pursuant to 10 CFR 2.201, and is responding to the alleged violations in the enclosed Attachment 1. SCE&G considers this enforcement action very serious and has implemented extensive corrective actions in response to the violation. As outlined in Attachment 1,5CE&G management has focused its attention on long term corrective actions,in addition to corrective actions specific to the violation,in order to preclude any further occurrences of this nature. These actions will enhance training and will improve the overall educationallevel and professionalism of personnel within the department. The Licensee is in agreement with the basic facts set forth in the Notice of Violation and will not contest the Imposition of Civil Penalty. Enclosed is our check in the amount of fifty thousand dollars ($50,000.00). NtlREG-0940 I.A-?P.8
Mr. J. M. Taylor NRCinspection Report 86-12 October 17,1986 If there are any further questions or comments, please contact us at your earliest convenience. The undersigned affirms that the statements and matters set forth in this letter and its attachment are true and correct to the best of my knowledge, information, and belief. Very trul)h,
- x WRH: DAN /dwf Attachment c: O. W. Dixon, Jr/T. C. Nichols, Jr.
E. H. Crews, Jr. E. C. Roberts O. S. Bradham D. R. Moore J. G. Connelly, Jr. W. A. Williams, Jr. H. R. Denton J. Nelson Grace Group Managers C. A. Price W. T. Frady C. L. Ligon (NSRC) R. M. Campbell, Jr. K. E. Nodland R. A. Stough G. O. Percival R. L Prevatte J. B. Knotts, Jr. Document Management Branch NPCF File 2 NilREG-0940 I.A-289 l
ATTACHMENT l RESPONSE TO NOTICE OF VIOLATION VIOLATION NO. 50-395/86-12,I,il
- 1. - ADMISSION OR DENIAL OF THE ALLEGED VIOLATION South Carolina Electric & Gas Company (SCE&G) is in agreement with the alleged violation.
II. REASON FOR THE VIOLATION SCE&G attributes this event to personnel error and inadequate procedures. The personnel error was a result of the inadequate understanding of the system design. The operating procedures inadequately addressed the various system l contig Adm,mistrative urationsprocedures which arefor created removal byand maintenance restoration of and modification equipment activities. were also l identified as being inadequate for control of equipment for post-maintenance and modification testing. On June 12,1986, the licensee identified a condition for which the breaker alignment of the "B" Train Charging / Safety injection (SI) pumps resulted in disabling the pumps from an automatic start under conditions of a Loss of Offsite Power followed by an 51. Following equipment modification retest activities on June 6,1986, the B" Charging /St Pump was capable of performing its intended function, but it had outstanding modification paperwork to be reviewed and
- signed off for completion of the modification and return of the equipment to operable status. The "B" Charging /SI Pump switch was placed in thepull-to-lock position in order to prevent automatic starting of the pump. The "C Charging /SI Pump was aligned to the "B" Train and was considered to be the operable pump I on that train for the purpose of meeting the Technical Specification Limiting Condition for Operation (LCO). However, the alignment of the "B" and "C Charging /SI Pumps on the "B" Train with the "B" Charging /SI Pump switch in the l
pull-to-lock position would have prevented the automatic start of either pump on "B" Train under the conditions of Loss of Offsite Power followed by an St. This
- l. design feature was not recognized by the operators and was not procedurally addressed at the time the action was taken to place the "B" Charging /SI Pump switch in pull-to-lock.
On June 10,1986, the "A" Diesel Generator (DG) was removed from service for preventive maintenance. Thisincluded the verification of the operability of the "B" Train components in accordance with the Action Statement of Technical Specification LCO 3.8.1.1 item c. Again, it was the operator's understanding that the "C" Charginy/SI Pump wasthe operable pump on "B" Train. Under these conditions, the A" and "C" Charging /SI Pumps would have started on an 51 actuation. For a loss of Offsite Power condition, the Charging /SI Pumps are not required to start automatically. For the situation where an 51 event is followed by a Loss of Offsite Power, both the "A" and "C" Charging /SI Pumps would have automatically started on an SI; however, following the Loss of Offsite Power, only the "C" Pump would have restarted since it was previously running. For the Loss of Offsite Power:followed by an 51 condition, no Charging /SI Pumps would have automatically started. Page 1 of 5 tRIREG-0940 I.A-290
1 ATTACHMENTl-Continued On June 11,1986, an operator questioned the ali nment of the "B" Train Charging /SI Pumps, and following discussions ankevaluation by the Shift I Supervisor, the "B" Charging /SI Pump breaker was racked out. This alignment l would allow the automatic start of the "C" Charging /SI Pump under all the ; conditions previously discussed. ! The consequences to safety for this event were minimal. The Charging /SI Pumps would have functioned per design for all accident scenarios with the exception of a Loss of Offsite Power followed by an 51. However, under these conditions, the "B" or "C" Charging /SI Purnps would have been manually started from the Control . Room as part of the operator's immediate actions. With both the "A" DG and the "B" Train Charging /SI Pumps in the condition that they were in, the Licensee considers this event to be a failure to meet the intentions of both the LCO's for Technical Specifications 3.8.1.1 action item c.1 and 3.5.2 action item a. Ill. CORRECTIVE STEPSTAKEN AND RESULTS ACHIEVED The Licensee has implemented the following interim actions until long term corrective actions have been completed:
- 1. The three operators directly involved in placing the "B" Charging /SI Pump switch in the pull-to-lock position on June 6,1986, were relieved of their shift responsibilities and placed in a special three week intensive training program.
i This special training program included the following topics:
- a. The first two weeks of training consisted of intensive swin,g component dassroom and simulator trainmg conducted jointly by Traming and Technical Services, in addition to their work on the technical aspects of Swing Components, the participants focused attention on the correct implementation of the Removal & Restoration Log, the Station log, and the Shift Turnover Procedure. Also emphasized in this training was the necessity for the operators to approach their job with an inquisitive attitude. To accomplish this objective, training was provided to help them develop effective questioning techniques. The first two weeks was concluded with a comprehensive written, oral, and simulator operating exam.
- b. During the third week of training the operators, through the use of Team Building skills, turned their attention to determining what 4
necessary changes could be made to the Removal & Restoration Log, the Station Log, and Shift Turnover Procedure to preclude such an event from happening again. 'l
- c. Finally the operators developed a lesson plan and student handouts transmitting the knowledge gained during the previous three weeks to alllicensed shift operating personnel. The developed lesson plans and student handout materials were submitted to Training and Technical Services for approval prior to use.
- 2. Breakers for swing components which are not fully operable (either l technically oradministrative!y) are required to be racked out". Racking out breakers for swing components, when their operability is in question, renders the component totally inoperable and, therefore, alleviates the operator of having to rely on his memory of how swing component logics work.
Page 2 of 5 1 1 NUREG-0940 I.A-291 )
ATTACHM ENT l-- Continued
- 3. The use of the pull-to-lock feature will be restricted to situations specifically addressed in procedures or emergency situations to prevent equipment from i- starting or operating. Again, this will alleviate the operator from having to rely on his memory of how swing component logics work.
- 4. A moratorium, on design changes for all equipment and systems that could impact on the operability of the equipment required to support plant operations, was put into effect until all outstanding modification requests were reviewed forinclusion of pre-modification planning and post-modification testing requirements. The indusion of pre modification planning and post-modification testing into the modification packages
- outlined information required to support the modification and to expeditiously return the component or system to operability.
- 5. The event and interim corrective actions were reviewed with the Operations l
personnel to assure.their awareness of the consequences of this event and to 4 address the short term actions implemented for control of swing components. IV. CORRECTIVE ACTIONTAKENTO AVOID FURTHERVIOLATION The following long term corrective actions have been developed in order to f preclude any further violation of this type:
- 1. Corporate management has reviewed the schedules and commitments of the Nuclear Operations Education and Training (NOE&T) to ensure that plant operators receive the highest priority of the training effort. Based on the l
review, the following activities are being initiated:
- a. Effective August 25,1986, the Manager, Operations, was transferred to Manager, Nuclear Operations Education and Training; the Associate Manager, Maintenance Services (a former shift supervisor), was promoted to Manager, Operations; the previous Manager, Nuclear Operations Education and Training was promoted to Group Manager, Nuclear Regulatory and Developmental Services. In this promotion he will coordinate the activities for both operator and craft training. These organizational changes are expected to provide new direction and improved performance in both Operations and Training.
- b. SCE8G is entering into an agreement with the University of Maryland to enroll selected Operations and other Nuclear Operations Department personnelinto a four-year Bachelor of Nuclear Science degree program, starting in early 1987. This program will improve the overall educationallevel and professionalism of personnel within the department by providing an opportunity for those individuals interested in obtaining a four-year degree.
( l c. Qualified contractor assistance will be provided to assist in the review of j training material for accuracy, level of detail, and conformance to current plant design. In addition, contract assistance will be provided for the ongoing simulator testing program. The training material l review, due to its magnitude,is a two-year program (December 1988). l Page 3 of 5 1 l l NUREG-0940 1.A-292
ATTACHMENTI--Continued The simulator testing program is expected to be completed in December 1987. In addition to'the proposed long-term contractor assisted review of training material, NOE&T has initiated a review of training material for . other systems that contain interlocks which may cause operator ) confusion. .This review compares the plant electrical elementary drawings to existing training material to verify accuracy and level of detail. Training materialis being updated as errors are noted. This effort is approximately 80% complete and will be completed prior to the start of the 1987 requalification training program.
- 2. An approved training program, developed by the three operators directly involved in the event, was presented to all licensed shift operating personnel during a four hour block ofinstruction. Nis training consisted of the following four segments.
- a. _ Charging Pump Misalignment, which discussed Licensee Event Report 86-010 and the causes and corrective actions.
- b. Swing Pump Operations, which detailed the various swing component 4
interlocks and use of 208 series drawings for decision making. j
- c. Lessons Learned, which discussed the need for attention to details and challenging activities not addressed by procedures.
- d. Methods to improve Teamwork and Promote an Inquisitive Attitude, plus improvements to the Removal and Restoration Program, Turnover and Administrative Logs, which discussed ways and means to make good decisions and how to improve logs and turnovers.
- 3. Modified simulator software to duplicate the inplant Charging /SI Swing i
Pump logic in order to provide hands-on training.
- 4. Retraining of the logic associated with Engineered Safety Features (ESF) equipment interlocks will be provided annually.
- 5. The licensed operator simulator requalification training has been expanded from 8 to 12 hours per requalification training week to provide more hands-1 on training for normal as well as emergency conditions.
- 6. Technical Services Procedures, TS-128, TS-129. TS-132, and TS-135, have been revised to address pre-modification implementation planning and post-
, modification testing requirements for the design change control program.
- 7. Station Administrative Procedure, SAP-205, has been revised to more
!. effectively address the tracking of equipment removed from service. t incorporated in this revision are guidance for stricter controls on inoperable equipment and lessons learned from this event.
- 8. Station Scheduling Procedure, SSP-001, has been revised to more clearly delineate the responsibilities of the operating and maintenance personnel with respect to ensuring that all areas of concern have been addressed with i
regards to maintenance or modification activities performed on plant equipment. Page 4 of 5 NUREG-0940 I.A-293
ATTACHMENT I-- Continued
- 9. Station Operating Procedure, SOP 102, has been revised to address the interlocks associated with the Charging /SI Swing Pump. This revision includes precautions associated with operating the Swing Pump.
- 10. By the end of the third refueling (currently scheduled for the spring of 1987),
the Charging /SI, Chilled Water, an'd Service Water Swing Pumps will be converted to installed spares. As installed spares, both trains of swing pump ! breakers will be " racked out" unless being used as a replacement for either of 1 the train *.pecific pumps. V. ' DATE OF FULL COMPLIANCE SCE&G expects to be in compliance with the corrective actions stated above, with the exception of the training material review, by December 1987. Due to the scope of work involved in improving the level and quality of training material, SCE&G expects to be in compliance to this additional corrective action by December 31, 1988. Page 5of 5 NUREG-0940 I.A-294
/ 'g UMTED ST4TES I a NUCLEAR REGULATORY COMMISSION i ~1 namon v
*s 1480 MARIA LANE. SUITE 210
%,..... WALNUT CREEK. CALIFORNIA 94568 l
i Docket No. 50-206 License No. DPR-13 EA 86-97 Southern California Edison Company
' ATTN: Mr. D. J. Fogarty Executive Vice President P. O. Box 800 2244 Walnut Grove Avenue Rosemead, California 91770
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NO. 50-206/86-07) Gentlemen: This refers to a special inspection conducted during the period of February 12
- April 25, 1986 at the San Onofre Nuclear Generating Station, Unit 1 of acti-vities authorized by NRC License DPR-13. The report of this inspection (50-206/86-07) was sent to you by letter dated May 16, 1986. This special inspection was conducted as followup to the inspection performed in November and December 1985, by an NRC Incident Investigation Team (IIT) of the loss of power and water hammer event which occurred at San Onofre 1 on November 21, 1985.
The report of this inspection was published in January 1986 as NUREG-1190. Based on the results of these special inspections, it appears that certain of your licensed activities were not conducted in full compliance with NRC require-ments. An Enforcement Conference was held with you and members of your staff at the San Onofre site on May 22, 1986. Item A in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice) involves the failure of five feedwater check valves to close as designed rendering the auxiliary feedwater flow path inoperable. With the check valves not fully closed, the low pressure portion of the feedwater system on the suction side of the pumps was overpressurized when the electricai power ' was lost to the motors driving the pumps. The overpressure condition ruptured the housing of a low pressure evaporator in the system. This in turn permitted the coolant flow from the auxiliary feedwater pumps to be diverted from the steam generators and a portion of the feedwater lines to empty. Closure of selected isolation valves in accordance with system emergency procedures re-stored auxiliary feedwater flow to the steam generators. However, the resto-ration of the flow resulted in a water hammer event in the "B" feedwater line which caused significant line movement and the failure of four pipe supports. CERTIFIED MAIL RETURN RECEIPT REQUESTED NilREG-0940 I.A-?95
T
-Southern California Edison Company !
Item B in the enclosed Notice involves the failure of your. test program to-assure the continued operability of check valves in the feedwater system. , 'Your failure to adequately test and maintain operability of the check valves within the feedwater system resulted in conditions which contributed to the water hammer event of November 21, 1985. Item C in~the enclosed Notice involves the failure to thoroughly analyze, evaluate, and identify the source of noise in the "B" feedwater line during plant operations in June 1985. Both the Onsite Review Committee and the Nuclear Safety Group reviewed and evaluated the results,of. radiographic-examination of a block valve in the line and a noise analysis of the feeddater line. The noise analysis identified that the noise.could be from either a failed block valve or a failed check valve. Neither the engineering group nor the safety committees addressed the safety consequences of multiple check valve failures in,the feedwater lines. The valves were scheduled to be disassembled [ and examined during the next plant outage; however the valves were not inspected during the brief outages in August and September 1985 even though the outages.were of sufficient duration to permit inspection of the valves suspected of being defective. l To emphasize the importance which the NRC attaches to maintaining operability of. safety-related systems, effective testing programs, and the proper correc-tion of identified deficiencies, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of One Hundred Eighty 'housand Dollars ($180,000) for the violations set forth in the' enclosed Notice. Violation A has been categorized as a Severity Level i II. violation under the " General Statement of Policy and Procedure l- for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1986) (Enforcement i Policy), based.on the inability of the auxiliary feedwater system to perfore its. intended safety function of providing auxiliary feedwater to the steam . generators until operator actions were taken and because it is of very significant regulatory concern. Violations B and C have been categorized as
- Severity Level III violations. The base civil penalties for Severity Level II
! and III violations are $80,000 and $50,000, respectively. The escalation and mitigation factors of the Enforcement Policy were considered and no mitigation or escalation _has been deemed appropriate. l You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. NUREG-0940 I.A-296 l
Southern California Edison Company In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter, its enclosure, and your response will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, e n JL O- - y, Jo . wa'rtin Regional Admin ator
Enclosure:
- 1. Notice of Violation and Proposed Imposition of Civil Penalties cc w/ enclosure:
K. P. Baskin, SCE H. B. Ray, SCE (San Clemente) H. E. Morgan, SCE (San Clemente) S. B. Allman, SDG&E State of California i NUREG-09B0 I.A-?97
NOTICE OF VIOLATION AND , PROPOSED IMPOSITION OF CIVIL PENALTIES Southern California Edison. Company Docket No. 50-206 San Onofre Unit 1 License No. DPR-13 EA 86-97
.\
As a result of the inspection conducted during the period of February 12 - April 25, 1986, certain violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalties are _ set forth below: A. Technical Specification 3.4.3. A requires both steam generator auxiliary feedwater pumps and associated flow paths be operable in Modes 1, 2, and 3. Contrary to the above, on November 21, 1985 while in Mode 1, the auxiliary feedwater flow path was not operable and automatic delivery of auxiliary feedwater would not have been assured. Flow was diverted from the steam generators to the east flash evaporator condenser after a manual reactor scram because five feedwater check valves failed to seat. This is a Severity Level II violation (Supplement I). (Civil Penalty - 580,000). B. 10 CFR Part 50, Appendix B, Criterion XI, Test Control, as implemented by the Southern California Edison Company Topical Report SCE-1-A, Section 17.2.11, requires that testing required to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures and that the test program shall include, as appropriate, preoperational and operational tests. Contrary to the above, the test program in effect prior to November 21, 1985 for check valves in the feedwater system did not assure that the valves would perform satisfactorily while in service in that on November 21, 1985, five check valves (FWS-345, -346, -398, -438, and -439) did not prevent backflow through the feedwater system. This is a Severity Level III violation (Supplement I). (Civil Penalty - $50,000). C. 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Actions, as implemented by SCE-1-A, Section 17.2.16, requires that measures be j established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that 1 I NUREG-0940 I.A-298
r i Notice of Violation the cause of the condition is determined and corrective action taken to preclude repetition. Contrary to the above, the licensee's program failed to assure that adequate corrective actions'were taken when a noise was identified on June 24, 1985-i in the "B" feedwater line near check valve FWS-346. The investigations and subsequent reviews-by the Onsite Review Committee on July 18,'1985 and the Nuclear Safety Group on September 3, 1985 failed to identify the potential for, or the safety consequences of, check valve failures.which could cause the draining of the feedwater lines or diversion of auxiliary feedwater flow
- from the steam generators. Also, corrective actions to investigate the
-valve conditions, planned for outages in August and September 1985, were not conducted.
This is a Severity Level III violation (Supplement I). (Civil Penalty - $50,000).
' Pursuant to the provisions of 10 CFR 2.201, Southern California Edison Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U. S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, Region i 3 V, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if~ admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will bs achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to_ extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affireation.
Within the same time as provided for the response required above under 10 CFR
. -2.201, Southern California Edison Company may pay the civil penalties by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treast.rer of the United States in the amount'of One Hundred Eighty Thousand Dollars ($180,000) or may protest imposition of the civil penalties in whole or in part by a written answer
- addressed to the Director, Office of Inspection and Enforcement. Should
!~ Southern California Edison Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should Southern California Edison Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations . listed in this Notice in whole or in part, (2) demonstrate extenuating
- circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties.
G 1 l l Nt! REG-0940 I.A-799 i i
Notice of Violation In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Southern California Edison Company's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalties due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to section 234c of the Act, 42 U.S.C. 2282.
&. gg /l Q -
4 J. . artin Regional Admintstrator Dated at Walnut Creek, California thisfZf day of September 1986 ) HilREG-0940 I.A-300
Southem Califomia Edison Company PO.BOM800 2244 WALNUT GROVE AVENUE DAvaD J. FOGARTY I
- ttLEs**ont usev,,v c ne ..c ,
....m v..
October 16, 1986 Mr. James M. Taylor Director, Office of Inspection and Enforcement U. S. Nuclear Regulatory Conraission Washington, D. C. 20555
Dear Mr. Taylor:
Subject:
Docket No. 50-206 Response to Notice of Violation and Proposed Imposition of Civil Penalty - EA-86-97 San Onofre Nuclear Generating Station, Unit 1 By letter to Southern California Edison (SCE) dated September 17, 1986, the NRC forwarded a Notice of Violation And Proposed Imposition of Civil Penalty related to events at San Onofre Nuclear Generating Station, Unit 1. In accordance with 10 CFR 2.201 and 2.205, please find enclosed the SCE response to the subject notice and a check payable in the amount of $180,000. If you require any additional information regarding this subject, please contact me. Subscribed on the Ib d ay of bb ,1986. Sincerely, Subscribed and sworn to before me on this / (, day of L9fi fm , 1986. OFFICIAL SEAL C. SALLY SEBO Enclosure Notary Put*c-Cahfomia i LoS ANGELES COUNTY j My Comm. Esp Acr.20.1990 cc: John B. Martin, Region V (NRC) ' R. Huey, Senior Resident Inspector p 'gQ qie d-MllREG-0940 1.A-301
l J ENCLOSURE Response to Notice of Violation (10 CFR2.201) In accordance with110 CFR2.201, this enclosure provides the Southern. California Edison Company (SCE) response to the Notice of Violation (NOV) forwarded by NRC letter dated September-17,1986. Three specific violations are addressed in the NOV. A response for each violation is provided below. A.' The Notice of Violation states in part:
" Technical Specification 3.4.3.A requires'both steam generator auxiliary feedwater pumps and associated flow paths be operable '
l- in Modes 1, 2, and 3. Contrary to the above.-on November 21, 1985 while in Mode 1, the auxiliary feedwater flow path was not operable and automatic delivery of auxiliary feedwater.would not have been assured. Flow was diverted from i the steam generators to the east. flash evaporator. condenser after a l manual reactor scram because five feedwater check valves failed to seat. This is a Severity Level II violation (Supplement I). j (Civil Penalty - $80,000)." A.1 Admission or Denial of the Alleaed Violation f SCE admits that on Novemb2r 21, 1985 while in Mode 1, the auxiliary feedwater flow path was not operable and automatic delivery of auxiliary.feedwater would t not have been assured. A.2 Reason for the Violation The Auxiliary Feedwater System was inoperable on November 21, 1985 due to
, failed check valves in the Feedwater System. Upon demand for auxiliary feedwater subsequent to the reactor trip, water was diverted from the steaa generators to the Condensate System. Auxiliary feedwater flow to the steam j generators was restored by operator action in accordance with procedure, approximately 5 minutes after the reactor trip, by isolating the Feedwater System through the closure of motor operated block valves in the feedwater lines.
The check valves which failed were damaged by the mechanism described in the Hater Hammer Investigation Report provided to the NRC by SCE letter dated April 8,1986, and the subsequent SCE submittal of May 1,1986. The failure mechanism described in these submittals can be summarized as having the following contributing factors: (1) The proximity of upstream flow disturbance sources, such as control valves and elbows, (2) The non-integral design of the check valve disc and hinge arm, NUREG-0940 I.A-302
_.__ - . _ - -- - . -- - = _ . - . - -
- 4 (3) Reduced power, reduced flow operation for an extended period 'of.
time prior to the event, which resulted in increased check valve disc 4 flutter and (4) The fa'ct that.the check valves were oversized for the application in which they were used. The combination of the conditions described above resJited in the accelerated degradation of the check valves and their failure to seat properly at the time when they were required to perform their design function. A.3 Corrective Stens Which Have Been Taken and the Results Achieved The corrective steps which have been taken in response to the event of i' November 21, 1985 are described in the SCE submittal of April 8,1986. These steps include the replacement and, to the extent practical, relocation of the failed check valves with appropriately sized valves of an improved
' design which is less susceptible to the mechanism that caused the failure. An 4
additional check valve was installed inside containment in each feedwater line i ' to each of the three steam generators to provide added redundancy fo'r the feedwater line isolation function. Finally,-the main feedwater flow control valve logic was modified to provide for automatic isolation using the main feedwater flow control valves. These improvements in design, and' additional redundancy, have significantly enhanced feedwater line isolation capability, thereby assuring the operability of the Auxiliary Feedwater System In addition, demonstration testing has been, and will be, performed on the replacement check valves as described in response to Question No. 3 of Enclosure 2 of the submittal provided to the NRC by letter dated May 1, 1986. The testing has two phases. The first phase, which was completed in March 1986, consisted of flow stability testing to demonstrate acceptable performance of the new design. The second phase, which is scheduled for 4 completion by the end of 1986, involves accelerated wear tests which will be used to verify the acceptability of the surveillance intervals used in the IST , program. , In order to evaluate the condition of swing. type check valves in other systems, a comprehensive design review and inspection effort was performed. The results of this effort were provided to the NRC by SCE letter dated May 1,
- 1986 (Enclosure 4).
i A.4 Corrective Steos Which Will be Taken to Avoid Further Violations The corrective steps which will be taken in response to the event of November 21, 1985, are described in the SCE submittal of April 8,1986. These steps i include enhanced inspections to assure the operability of the newly installed
- . check valves.
These actions will be completed prior to startup from the next refueling ] outage. i l [ NUREG-0040 I.A-303
A.5 Date When Full enmaliance Will be Achieved Full compliance was achieved on July 10, 1936, when a verification effort was completed to determine that restart. commitments resulting from the event of November 21, 1985, either had been completed or would be completed at the appropriate point in the start-up process. Mode.2 was *ntered on July 15, 1986. i i i NilREG-0940 I.A-304
4
.c l
, 8.- The Notice-of Violation states in Part: I "10 CFR Part 50, Appendix B, Criterion XI, Test Control, as implemented by the Southern California Edison Company Topical Report SCE-1-A, Section 17.2.11, - requires that testing required.to demonstrate that structures,' systems, and components will perform satisfactorily in service' is identified and performed
.in accordance with written test procedures and that;the test program shall include, as appropriate, preoperational and operational tests.
Contrary to.the above, the test program in effect prior to November 21', 1985
-for check valves in the feedwater system did not assure that the valves would i perform satisfactorily while in service in that on November 21, 1985, five j check valves (FHS-345,--346, -398, -438 and -439) did not prevent backflow through the feedwater system. .t i This is a Severity Level III violation (Supplement I).
(Civil Penalty - $50,000)." 8.1 Admission or Denial of the Alleaed-Violation SCE admits that the test program in effect prior to November 21, 1985 for , check valves in the Feedwater System did not assure that tha valves would perform satisfactorily while in service .in that cn November 21, 1985, five
. check valves (FHS -345. -346, -398, -438, and -439) did not prevent backflow through the Feedwater System.
B.2 Reason for the Violation Although testing of the Feedwater System check valves was in compilance with the Inservice Testing (IST) Program at San Onofre Unit 1 prior to November 21, 1985, these check valves failed in a manner that IST does not effectively
- predict. The ASHE Code and the IST Program include criteria that the systems under consideration be designed in such a manner that any degradation in component function can be identified within the defined surveillance intervals. As a result of the failure mechanism discussed in A.2 above, the check valves experienced accelerated degradation during the period of operation following their last successful IST and the event on November 21, 1985. This accelerated degradation was not detected by testing conducted in accordance with the Program.
l r NUREG-0940 I.A-305 l .
. _ . ~ ._. . . . - -
9 i B.3 Corrective Steos Which Have Been Taken and the Results Achieved ( The corrective steps which have been taken in response to the event'of November 21, 1985 are described in the SCE submittal of April 8, 1986. These included restoring the feedwater line isolation capabilities, through the design changes discussed in A.3 above, to the assumed operating criteria of
- the ASWE. Code and the IST_ program. In order to verify the acceptability of L these changes in restoring the desired capabilities, the enhanced inspections indicated in A.4 will be performed. In addition, demonstration testing has !
been, _and will be, performed on the replacement check valves as described in response to Question No. 3 of Enclosure 2 of the submittal provided to the NRC -] by SCE letter dated May 1,1986. The testing has two phases. The first
. phase, which was completed in March 1986, consisted of flow stability testing to demonstrate acceptable performance of the.new design. The second phase, which is scheduled for completion by the end of 1986, will involve accelerated wear tests which will be used to verify the acceptability of the surveillance intervals used in the IST program.
Finally, the_ valve IST Program has been revised to test check valves based on quantitative leak-rate measurements. The guidelines for this new procedure were also provided in the question response referenced above. B.4 Corrective Stans Which Will Be Taken to Avoid Further Violations The corrective steps which will be taken in response to the event of November _21, 1985, are described in the SCE submittal of April 8,1986. Upon- ! completion of the accelerated wear testing described in B.3 above, and the check valve inspections to be conducted at the next refueling outage, the IST program will be modified'as necessary to institute any improvements identified to be necessary. These additional changes, in conjunction with the action i described in 8.3 above, are considered sufficient to prevent the recurrence of i. the accelerated degradation which led to the check valve failures. B.5 Date When Full ramnliance Will be Achieved Full compliance with the actions required to be implemented prior to return to i service was achieved on July 10, 1986 when a verification effort was completed which established that restart commitments resulting from the event of November 21, 1985, either had been completed or would be completed at the appropriate point in the startup process. Mode 2 was entered on July 15, 1986. I i NIIREG-0940 I.A-306 I
.- .. . ~
/
~
\
R C. .The' Notice of Violation states in part:
"10 CFR Part 50,-Appendix S, Criterion XVI, Corrective Actions, as implemented by SCE-1-A, Section 17.2.16, requires that measures be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment and nonconformances 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, the Itcensee's program failed to~ assure that adequate corrective actions were taken when a noise was identified on June 24, 1985 in the "B" feedwater line near check valve FHS-346. The investigations and subsequent reviews by the Onsite Review Committee on July 18, 1985 and the Nuclear Safety Group on September 3,1983 failed to identify the potential for, or the safety consequences of, check valve failures which cotid cause the draining of the feedwater lines ~or diversion of auxiliary feedwater flow from 4 the steam generators. 'Also,-corrective actions to investigate the valve conditions, planned for outages in August and September 1985, were not conducted. ' This is a Severity Level III violation (Supplement I). l (Civil. Penalty - $50,000)." C.1 Admission or Denial of the A11eaed Violation f SCE admits that the safety review program failed to assure that adequate + corrective actions were taken when a noise was identified on June 24, 1985, in the "B" feedwater line near check valve FHS-346. The investigations conducted i by the or. site and offsite safety review organizations failed to identify the l potential for, or the safety consequences of, check valve failures which could
- cause draining of the feedwater lines or diversion of auxiliary feedwater flow
- from the steam generators. SCE also admits that action to investigate the d
valve conditions, planned for the next available outage which occurred in l August and September, was deferred to the planned refueling outage scheduled t to begin in November. C.2 Reason for the violation A detailed' description of the actions taken by SCE in response to the feedline noise identified on June 24, 1985 is contained in the Water Hammer . Investigation Report of April 8,1986. The evaluation of the "B" Steam i Generator feedwater line noise included consideration of the possibility that a check or block valve had failed, however, postulation of multiple failures was not considered. p i l L NUREG-0940 I.A-307
ib ?. 7 The determination reached during the safety review process that it was safe to continue operating was subsequently. extended to allow continued operation until the then upcoming refueling outage. The correctness of this determination was supported by the fact that the noise intensity did not change.
~
C.3 Corrective Stens Which Have Been Taken and the Results Achieved The corrective steps which have been taken in response to the event of November 21 c 1985, are described in the SCE submittal of April 8,1986. Actions have been taken to_ strengthen the safety review process by providing an independent consultant,1with operating experience and a broad background, to the Onsite Review Committee in order to bring an added and diverse perspective to OSRC deliberations.
-The safety review processLis'being strengthened by including more in-depth review of plant history as a factor in investigations of abnormal conditions.
Improvements in maintenance tracking and trending which had been irplemented prior to the event of November 21, 1985, as described in the Water Hammer Investigation Report of April 8, 1986, will facilitate the above described improvement in the safety review process. Finally, the need for insightful questioning as part of the safety review process has been demonstrated to be a necessity when studying the implications of abnormal situations which arise during the operation of a nuclear plant. This need has been emphasized to the' staff assigned to perform safety reviews. C.4 Corrective Stoos Which Will be Taken to Avoid Further Violations The improvement'in the safety review process discussed in C.3 above are considered suffic!ent to avoid the future recurrence of conditions similar to those leading to tne event of November 21, 1985. F C.5 Date When Full ramaliance Will be Achieved Full compliance was achieved on July 10, 1986 when a verification effort was completed to determine that restart commitments resulting from the event of November 21, 1985 either had been completed or would be completed at the appropriate point in the start-up process. Mode 2 was entered on July 15, 1986. l 7521:9105u:7557F i NUREG-0940 I.A-308
unsTEo : TATE:
/ ... gg NUCLEAR REGULATORY COMMISSION mEoion si j j 101 MAnlETTA :TREET. N.W.
ATLANT A, GEORGI A 30323
'a,
\ ;.'... /p SEP 0 81986 4
Docket Nos. 50-259, 50-260, and 50-296 License Nos. DPR-33, OPR-52, and DPR-68 EA 86-56
- Tennessee Valley Authority ,
ATTN: .Nr. S. A. White ' Nanager of Nuclear Power 6N 38A Lookout Place 1101 Narket Street . Chattanooga, TN 37402-2801 Gentlemen: i
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVIL PENALTIES ' (NRC INSPECTION REPORT NOS. 50-259, 50-260, 50-2 % /85-41; 50-259, 50-260, 50-296/85-45; 50-259, 50-260, 50-296/85-53; 50-259, 50-260, 50-296/85-57; 50-259, 50-260, 50-296/86-05; AND 50-259, 50-260, 50-296/86-20) This refers to the NRC inspections conducted during the periods August 12-16, 1985; August 21 - September 30, 1985; October 26 - December. 31, 1985; and January 1-31, 1986, of activities authorized by NRC Operating License Nos. OPR-33, OPR-52, and DPR-68 for the Browns Ferry Nuclear Plant. The inspections included a review of cable trays and supports, vendor's recommended maintenance for the standby diesel generators, secondary containment isolation damper timing and configuration control, and cable separation design criteria for reactor safety systems. As a result of these inspections, failures to comply with NRC : requirements were identified, and accordingly, an Enforcement Conference to , discuss these matters was held in the NRC Region II Office on Nay 28, 1986. The inspection reports were issued separately on September 24, 1985; October 28, 1985; December 4, 1985; February 11, 1986; and March 5, 1986. Violation I.A in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (NOV) involves certain cable tray supports that were not adequately designed to withstand a design basis earthquake. You identified that cable tray si:pports in the Control Bay Area were not designed to meet seismic requirements, and some supports in the Diesel Generator and the Reactor Buildings did not have adequate conservatism in their designs to ensure their ability to perform their intended functies during a seismic event. In addition, a number of design calculations used to qualify many of the typical cable tray supports at Browns Ferry were neither checked nor verified as required. l Violation I.B involves failures in your corrective action program. On February 18, i 1981, you identified overfilled cable trays and cable penetrations in the cable spreading rooms (Corrective Action Report 81-035). Various actions were taken 1 from February 1981 until July 1985, none of which succeeded in correcting the
- overloaded condition of the cable trays. In addition, on August 14, 1985, you
! CERTIFIED NAIL E70RK"IRTIPT REQUESTED NUREG-0940 I.A-309 l - _ - - -
. _. =- . _- _. . . _ _
Tennessee Valley Authority ${p QS 19@$ discovered that corrective action taken in response to a previous Notice of Violation involving routine diesel generator maintenance inspections had not been accomplished. As a result of this failure, you then discovered and reported on September 24, 1985, that the diesel generators were technically inoperable since the vendor-required inspections for the three, six, and twelve year - intervals had not been performed. Simultaneously, you also reported the standby diesel generators inoperable because the diesel battery racks were determined not to be seismically qualified as a result of stud welding deficiencies that occurred in April 1985. Two other failures involving diesel generator maintenance were also identified. Violation I.C involves failures to ensure that activities were accomplished in accordance with appropriate drawings and procedures. You identified that the 4160 volt shutdown board control power was not connected in accordance with the . appropriate drawing. Because of the existing wiring configuration, the time I the shutdown board would have been functional following an accident was reduced, ' and the error could have confused operators in an accident and further complicated .I the accident scenario as described in Licensee Event Report 85-56, dated July 8, 1986. You also identified that the diesel generator oil pressure switches were
; not connected in accordance with plant drawings. In addition, procedures to conduct a Local Power Range Monitor (LPRM) change-out were inadequate, which I resulted in part of an LPRM surfacing in the spent fuel pool, and you also identified a failure to ensure that design drawings referenced the correct design specifications for the separation and identification of reactor safeguards electrical equipment.
The above violations indicate again that significant improvements are needed in the performance of licensed activities at the Browns Ferry Nuclear Plant. The violations were identified in many of the areas involved in the operation of a nuclear facility and reflect an unacceptable level of compliance to NRC require-ments. More attention should be provided to the interactions between the engineering organization and various groups within your plant staff to ensure design and analyses are correct and have the appropriate approvals. More-attention is also required in the area of corrective actions. Although you identified most of the violations, they existed for an extended period of time during the operation of the facility. The NRC expects its licensees to promptly evaluate and correct problems they identify. As the exampMs in the enclosed Notice indicate, you have not achieved that level of performance. In addition, the existing configurations of plant equipment that were not in accordance with the appropriate drawings may be indicative of inspection pregram inadequacies. , l Similar types of deficiencies must be corrected prior to the restart of the ! Units at Browns Ferry to ensure that all plant equipment is installed in accordance l with the required drawings. The violations described herein are additional examples of the general management breakdown for which Tennessee Valley Authority (TVA) was cited by the NRC and ! because of which the Browns Ferry units were shutdown in March 1985. The root ! cause of the general management breakdown was the lack of strong leadership necessary to develop and maintain (1) the high level of discipline required for nuclear operations, and (2) the mutual trust between management and staff needed I NUREG-0040 f.A-310
i Tennessee Valley Authority SEP 0 8 586 to ensure good communications throughout the organization. To correct these 4 problems, TVA this year has made significant changes in " corporate" management and, very recently, has installed a new Site Director at Browns Ferry. While this represents a good start, it is essential that there be evidence that TVA has corrected these fundamental problems throughout their organization before startup of any unit at Browns Ferry. These violations have been categorized as three Severity Level III violations in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy).
, The base civil penalty for a Severity Level III violation is $50,000. After considering the escalation and mitigation factors permitted in the Enforcemenc ~
Policy, the staff considered that the base civil penalty for each violation could have been increased substantially because the plant operated for an extended period of time with many of these equipment deficiencies. However, after consultation with the Director, Office of Inspection and Enforcement, I l have decided not to escalate the civil penalty ,and to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of One Hundred Fifty Thousand Dollars ($150,000). The civil penalty was not escalated
, in this case because many of the violations were identified by you as a result 4
of the actions you have taken since the shutdown.of the three units at Browns Ferry in March 1985 to improve licensed activities, i Violation II in the enclosed NOV involves the failure to determine pursuant to 10 CFR 50.59 whether changing secondary containment isolation damper closure time from the time specified in the Final Safety Analysis Report (FSAR) involved an unreviewed safety question. Because your subsequent review indicated that this change did not constitute an unreviewed safety question requiring prior NRC approval, this violation has been categorized as a Severity Level IV violation. Another issue involving a licensing submittal was also discussed during the May 28, 1986, Enforcement Conference. On February 25, 1985, an Amendment Request was submitted to delete the Limiting Condition for Operation (LCO) and surveillance requirement from the Browns Ferry Technical Specification at aciated with the Residual Heat Removal (RHR) system crosstie between adjacent reactor units. The safety analysis associated with the. proposed change was incomplete in that it failed to address the licensing basis for the crosstie feature as discussed in paragraphs F.7.16 and I.3.3.2 of the FSAR. These paragraphs clearly described the original plant licensing concerns related to flooding of the Reactor Building basement corner rooms which could possibly render all of the affected units of the Emergency Core Cooling Systems (ECCS) inoperable. When the original plant i licensing basis was examined by the NRC reviewers, the amendment request,was deferred pending further justification by the licensee. It is imperative that future licensing submittals contain complete safety analyses which fully address j the design bases for plant features affected by the submittals and you are i requested to direct your attention to this matter in future submittals. You are required to respond to the enclosed Notice and should follow the instruc-tions specified therein when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to , prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further enforcement j action is necessary to ensure compliance with NRC regulatory requirements. l l NUREG-0440 T.A-311
Tennessee Valley Authority SEP 0 8 906 In accordance with 10 CFR Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Nanagement and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Should you have any questions concerning this letter, please contact us. Sincerely,
, h J.' Nelson. Grace Regional Administrator l
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalties cc w/encis: H. Poorehn, Browns Ferry Nuclear Site Director R. L. Lewis, Plant Manager M. J. May, Site Licensing Manager R. L. Gridley, Director, Safety and Licensing l NIJREG-0940 I.A-312 i
NOTICE OF VIOLATION AND PROPOSED IMPOSITIOTTIF CIVIL PENALTIES Tennessee Valley Authority Docket Nos. 50-259, 50-260, and 50-296 Browns Ferry License Nos. OPR-33, OPR-52, and DPR-68 Units 1, 2, and 3 EA 86-56 As a result of the inspections conducted during the periods August 12-16, 1985; August 21 - September 30, 1985; October 26 - December 31, 1985; and January 1-31, 1986, violations of NRC requirements were identified. In accordance with the
" General Statement of Policy and Procedure for NRC Enforcement' Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, (Act), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The violations and the associated civil penalties are set forth below:
I. Violations Assessed Civil Penalties A. Technical Specification 5.6, Seismic Criteria, specifies that station i Class I structures and systems are designed to withstand a design basis earthquake. 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires that measures be established to assure that applicable requirements are correctly translated into specifications, drawings, procedures, and instructions and that these measures include provisions to assure that appropriate quality standards are specified and included in design documents. These design control measures must also provide for verifying or checking the adequacy of the design. Contrary to the above, as of the NRC inspection conducted August 12 - 16, 1985, design discrepancies existed that indicated that some of the cable tray supports in areas of the Control Bay, Diesel Generator and Reactor Buildings, station Class I structures or systems, were not adequately designed to withstand a design basis earthquake and may not have been able to perform their intended function during a seismic event. In addition, a number of design calculations used to qualify many of the 2 typical cable tray supports were not checked or verified. This is a Severity Level III violation (Supplancent I). (Civil Penalty - $50,000)
- 8. 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, requires that measures be established to assure that conditions adverse to quality are promptly identified and corrected. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken must be documented and reported to the appropriate levels of management.
Contrary to the above, the licensee failed to take adequate measures to assure conditions adverse to quality were promptly identified and corrected in the following circumstances:
- 1. On February 18, 1981, the licensee identified a significant condition adverse to quality and initiated Corrective Action NUPEG-0940 I.A-313
Notice of Violation OCT e 1 m Report (CAR) 81-035 that. addressed overfilled cable trays and cable penetrations in the cable spreading rooms. Various actions were taken from February 1981 until July 1985, none of which succeeded in correcting the overloaded condition of the' cable trays.
~
- 2. The licensee discovered on August 14, 1985, that the corrective action taken in response to a previous Notice of . Violation
.(Inspection Report 50-259, 50-260, 50-296/84-23) had not been accomplished.' Mechanical Maintenance Instruction (MMI)-6 implements the Browns Ferry Technical Specification surveillance requirement 4.9.A.1.d for routine diesel generator inspections.
~
The licensee committed in response to the NOV to revise MMI-6 to include, by October 5, 1984, the manufacturer's inspections /. maintenance recommendations given in Electro-Motive Division Maintenance Instruction MI-1742. Revision E; Scheduled Maintenance Program 999 System Generating Plants. The recommended six and twelve year maintenance intervals were neither included in the revised instruction nor was an evaluation performed to determine whether or not the intervals should have been included in the instruction.
- 3. A Notice of Violation (Inspection Report 50-259, 50-260, and 50-296/85-28) involved incorrect service mounting of the diesel generator battery racks. The licensee responded to the Notice of Violation and indicated that the battery racks were seismically qualified. During battery rack maintenance on April 20, 1985, four foundation mounting studs were broken that were replaced by.
l April 22, 1985. A metallurgical evaluation was requested by the licensee to evaluate the failure mechanism of the four studs. The evaluation revealed that the stud material was unacceptable for welding; thus, the battery racks were seismically unqualified. Corrective action was not taken and the condition was not reported to appropriate levels of management until September 24, 1985, when the diesel generators were declared inoperable.
~
- 4. During the inspection conducted October 26 - November 20, 1985, it was found that the licensee had not taken action to correct a significant condition adverse to ~ quality.~ The FSAR, Section 8.5.5, specifies that maintenance on the diesel generators be conducted in accordance with manufacturer's recommendations. A l
vendor diesel generator newsletter ' (Power ' Pointer) dated November 28, 1979, indicated that any viscous crankshaft vibration damper bearing with a 1969 or earlier serial number should be removed from service immediately and returned to the manufacturer , due to potential for failure. However, the licensee never acted upon the newsletter although this type of damper was installed in the plant diesel generators. In addition, notwithstanding the FSAR, the licensee has no program to review vendor recommended equipment modifications to assure diesel reliability.
- 5. An emergency design change request (OCR 2675) was written in 1981 for the replacement of the diesel generator turbocharger drive gears. The turbocharger drive gears were known to be inadequate NUREG-0940 I.A-314
' Notice of Violation 4 for no load / light load operations and failure could occur if the , engine was operated in excess of 200 hours at less than 20 percent load. Although this condition adverse to quality had been corrected by the Sequoyah Nuclear Plant (Supplement 2, NUREG-0011, August 6,1980), as of the time of the inspection on October 26 -
November 20, 1985, the change had not been implemented by Browns Ferry. The replacement was completed on April 6, 1986. This is a Severity Level III violation (Supplement I). (Civil Penalty - $50,000) C. 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures and Drawings, requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings of a type appropriate i to the circumstances and that these activities be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, the licensee failed to prescribe adequate instructions, procedures, or drawings to implement such instructions, procedures, or drawings in the following circumstances:
- 1. During surveillance testing on November 19, 1985, the licensee discovered that the 250 voit DC control power to the 4160 volt shutdown board "A" was not connected per Plant Drawing 010608860.
The electrical supply cables for the normal control power supply (250 volt DC shutdown board "A" battery) and the alternate control power supply (250 volt DC battery board "2" to the Unit 2 battery) were reversed. This wiring error resulted in control power being supplied from a 30 minute rated source in lieu of the required 3-hour rated source. This condition may have existed since 1973.
- 2. During the inspection conducted November 21 - December 31, 1985:
- a. The licensee discovered that the Units 1 and 2 diesel generators oil pressure switches PS-82-29 A, B, C, and D (PS-3) were not functional. The oil line connection block was not ported (drilled out) in accordance with Plant Drawing 45N767-4 for the oil line connecting the pressure switches.
This prevented the pressure switches from functioning as a backup to the speed sensor to prevent engagement of the , mmber two bank of air start motors if oil pressure was not i maintained after the diesel started.
- b. The NRC discovered that Plant Operating Instruction 01-82 for the diesel generators was not appropriate to the circumstances i
because it did not address the function of the Low Low Lube Oil Pressure Light. Because there was no oil pressure to the pressure switch when the engines were running, no oil pressure in the sensing line should have caused illumination of the
- Low Low Lube Oil Pressure Light next to the emergency stop
! button on the diesel generator control board in the control
- room. However, all four of the lights in both units were not functional.
l i l l fillP.EG-0940 I.A-315 l l t
Notice of Violation 3. Plant Instruction SMI 192.2, Local Power Range Monitor (LPRM) Maintenance Instruction, was inappropriate to the circumstances for the LPRM changeout conducted in Unit 2 on November 20, 1985. The instruction did not address the abnormal operation for a LPRM changeout with a LPRM tip broken in the LPRM tool or a LPRM stuck behind a source pin rack. Continued operation resulted in the
" hot" tip of the LPRM breaking the water surface of the spent fuel pool, creating excessive radiation levels in the area and an unnecessary radiation hazard to personnel.
- 4. The licensee failed to ensure that design drawings referenced the 1 correct design specifications. On October 22, 1985, the licensee discovered four design drawings:(730E918, Engineered Safeguards; 73730E915, Reactor Protection System; 730E930, Core Spray; and 730E927, Primary Containment Isolation) referenced design specification 22A1421 which is not applicable to Browns Ferry instead of the correct specification 22A2809. This specification
, defines the criteria for the separation and identification of reactor safeguards electrical equipment. This is a Severity Level III viol & tion (Supplement I). (Civil Penalty - $50,000) II. Violation Not Assessed a Civil Penalty
- 10 CFR 50.59(a) allows the holder of a license to make changes in the
! ; facility as described in the Final Safety Analysis Report (FSAR) without
- prior Commission approval unless it involves a change to the Technical Specifications or is an unreviewed safety question. An unreviewed safety question is created if the consequences of an accident or the malfunction of the equipment important to safety previously evaluated in the FSAR may be increased.
10 CFR 50.59(b) requires that the licensee maintain records of changes in !~ the facility to the extent that such changes constitute changes in the facility as described in the FSAR. These records shall include a written safety evaluation which provides the bases for the determination that the change does not involve an unreviewed safety question.
-Contrary to the above,.the licensee changed the facility as described in j the FSAR without having determined whether the change involved an unreviewed '
safety question. On November 25, 1985, the licensee changed the acceptable l closure time of secondary containment isolation dampers from two seconds 1 as specified in Section 5.3.4.2 of the FSAR to ten seconds. Although the l licensee performed an analysis, it did not determine whether the change involved an unreviewed safety question. The change was implemented by the licensee through an internal memorandum pending a change to the FSAR to be submitted as part of the routine annual update per 10 CFR 50.71. This is a Severity Level IV violation (Supplement I). Pursuant to 10 CFR 2.201, Tennessee Valley Authority is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory NUREG-0940 I.A-316
a Notice of Violation l Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice a written statement or explanation including for each violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps which have been taken and the results achieved. (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received ' within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, the y response shall be submitted under oath or affirmation. >
- Within the same time as provided for the response required above under 10 CFR 2.201, Tennessee Valley Authority may pay the civil penalties in the amount of One Hundred Fifty Thousand Dollars ($150,000) for the violation, or
. may protest imposition of the civil penalties in whole or in part by a written Should Tennessee Valley Authority fail to answer within the time answer.
specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should Tennessee Valley Authority elect to file an answer in accordance with 10 CFR 2.205 I protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties i should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties. In requesting mitigation of the proposed penalties, the five factors addressed in Section IV(8) of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of Tennessee Valley Authority is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing civil penalties. Upon failure to pay the penalties due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless compromised, remitted, } or mitigated og be collected by civil action pursuant to Section 234c of the
- Act, 42 U.S.C. 2282.
i FOR THE NUCLEAR REGULATORY COMISSION
&e f
- C xx i J. Nelson Grace i Regional Administrator Dated at Atlanta, Georgia l this 8 day of September 1986 l
l l NUREG-090 I.A-317 l r .
TENNESSEE VALLEY AUTHORITY CHATTANOOGA. TENNESSEE 37401 6N 38A Lookout Place October 8,1986 Mr. James M. Taylor Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555
Dear Mr. Taylor:
BROWNS FERRY NUCLEAR PLANT - NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES - ENFORCEMENT ACTION EA-86-56 This is in response to J. Nelson Grace's letter dated September E., 1986 which transmitted the subject Notice of Violation and Proposed Imposition of Civil Penalty. Dr. Grace's letter and its enclosure refer to a number of NRC inspections conducted during the August 1985 to January 1986 timeframe that identified areas for which the Browns Ferry Nuclear Plant (BFN) cid not comply with NRC requirements, and to~the related Enforcement Conference held on May 28, 1986. TVA does not contest'the imposition of the civil genalty. My response to the specifics of the BFN enforcement action issues is ;,tovided in the enclosure, and my views concerning the need and value of this and other related enforcement matters are addressed by separate correspondence. Fees in response to the civil penalty of $150,000 are being wired to the NRC, Attention: Office of Inspection and Enforcement. To the best of my knowledge, I declare the statements contained herein are complete and true. Very truly yours, TENNESSEE VALLEY AUTFORITY teh@ Manager of Nuclear Power Enclosure cc (Enclosure): U.S. Nuclear Regulatory Commission i Region II l Attn: Dr. J. Nelson Grace, Regional Administrator
- 101 Marietta Street, NW, Suite 2900 Atlanta, Georgia 30323 Mr. G. G. Zech Olrector, TVA Projects U. S. Nuclear Regulatory Commission Region II 101 Marietta Street, NW, Suite 2900 Atlanta, Georgia 30323 An Equal Opportunity Employer NUREG-0940 I.A-318 l l
l 1 RESPONSE l ENFORCEMENT ACTION REPORT BROWNS FERRY NUCLEAR PLANT (BFN) 50-259/86-56, 50-260/86-56, AND 50-296/86-56 DR. J. NELSON GRACE'S LETTER TO S. A. WHITE DATED SEPTEMBER 8, 1986 Violations Assessed Civil Penalties Item I.A. Technical Specification 5.6 Seismic Criteria, specifies that station Class I structures and systems are designed to withstand a design basis earthquake. 10 CFR Part 50, Appendix 8, Criterton III, Design Control, requires that measures be established to assure that app 11 cable requirements are correctly translated into specifications, drawings, procedures, and instructions and that these measures include provisions to assure that appropriate quality standards are specified and included in design documents. These design control measures must also provide for verifying or checking the adequacy of the design. Contrary to the above, as of the NRC inspection conducted August 12 - 16, 1985, design discrepancies existed that Indicated that some of the cable tray supports in areas of the Control Bay, Olesel Generator and Reactor Buildings, station Class I structures or systems, were not adequately designed to withstand a design basis earthquake and may not have been able to perform their intended function during a seismic event. In addition, a number of design calculations used to qualify many of_the typical cable tray supports were not checked or vertfled. This is a Severity Level III violation (Supplement I). (Civil Penalty - $50,000)
- 1. Admission or Dental of the Alleged Violation TVA does not contest the violation.
- 2. Reasons for the Violation Inadequate design controls resulted in a failure to coordinate design requirements within and between engineering disciplines. This lack of design control also resulted in engineering calculations which were not adequately prepared nor properly documented.
I f 4 i ! NUREG-0940 I.A-319
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- 3. Corrective Steps Which Have Been Taken and Results Achieved Nuclear Engineering Procedures (NEP) were issued in July 1986. The stringent NEPs place rigorous controls on the design process of cable tray systems in the following areas:
4 NEP 3.1, Engineering Calculations ! NEP 3.2, Design Input I- .NEP 3.3, Interface Control NEP 5.1, Design Output 4 NEP 5.2, Review and Design Verification
- NEP 6.1, Change Control L The result of the NEPs is a closely controlled design process which will j ensure the adequate design and verification of seismic qualification of cable tray support systems.
In order to ensure that engineering personnel are quallfled to perform design activities on cable tray systems, periodic training in all pertinent documents and procedures is required. Individual training records are maintained for each person to ensure that the latest - requirements or revisions to documents are made known. Periodic internal ! audits are conducted to verify training and design compilance, l The following discussion'outilnes seismic cable tray programs which are being implemented to (1) allow restart and safe operation of unit 2 and (2) provide seismic qualification of cable trays for all three Browns i Ferry Nuclear Plant (BFN) units. These two programs have taken into consideration the overfilled cable trays specified in vlotation I.B.(1.). i i 1. To verify that cable tray supports are adequate to allow restart and ! interin operation of unit 2, TVA contracted with United Engineers and Contractors (UE&C) to perform an interim seismic qualification of the , unit 2 cable tray system. UE&C issued a formal report containing support qualification calculations and modifications required before unit 2 restart. This report is presently under review by NRC. Those modifications identifled will be completed before restart of unit 2. i 2. For the long-term resolution of cable tray integrity BFN is planning
- to use the methodology of NUREG-1030 which was developed to resolve ,
- Unresolved Safety Issue A-46, Seismic Qualification of Equipment in ;
- Operating Nuclear Power Plants. This method of resolution, jointly i developed by NRC and the Seismic Qualification Utility Group (SQUG) !
uses the results of damage surveys conducted in conventional power ! i plants and industrial facilities which have expertenced actual earthquake ground motions. ( 4 !~ i NUREG-0940 I.A-320 I.- ,. _, ,____.m -- .m- . - . - _ _ _ _ _ _ , _ _ . _ , , . _ _ _ . . __ ,__,,__,~._,..-__,,_,.._m,mm,---,--.,.v.,m_m,m_.,,_m-_,.,__,
The surveys show that nonnuclear grade equipment similar to that in nuclear plants, including cable trays, is seismically rugged in general and does not fall under seismic loading. Direct comparison, i using qualification criteria jointly developed by NRC and SQUG, will be used to show long-tera qualification of BFN cable trays. TVA contracted with Earthquake Engineering (EQE) to evaluate all BFN cable trays for the long-term resolution of concerns regarding the integrity of cable tray supports under selsmic loading. Based on preliminary results of EQE's review, all BFN cable trays would withstand design basis seismic events without modification and continue to function normally.
- 4. Corrective Steps Which Will Be Taken to Avold Further Violations The Nuclear Performance Plan (NPP), Volume i provides the actions being implemented at the corporate level to avoid the root cause of inadequate design control. The actions related to the improvement in the design control process for 8FN are contained in the NPP, Volume 3. Specific corrective steps for this issue are:
- a. The cable tray modifications for unit 2 will be completed using the interim seismic qualification.
, b. The long-term qualification of cable trays will be completed using the methodology of NUREG-1030 to resolve Unresolved Safety i
Issue A-46, Selsmic Qualification of Equipment in Operating Nuclear Power Plants.
- 5. Date When Full Compliance Will Be Achieved Seismic qualification (including any modifications required) of the unit cable tray systems or common cable tray systems needed to support the units will be accomplished before their respective startup dates.
MtfREri-0940 I.A-321
. - - . - __ . - . ~ - - - _
l 1 4 Item I.B. (1 throuch 5) 10 CFR 50, Appendix 8. Criterton XVI,~ Corrective Action, requires that measures be estabitshed to assure that conditions adverse to quality are- , promotly identified and corrected. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken must be documented and reported to the appropriate. levels of management. Contrary to'the above, the Itcensee failed to take adequate measures to assure 1 conditions adverse to quality were promptly identified and corrected in the
-following circuestances:
Item I.8.(1) On February 18, 1981, the Itcensee identified a significant condition adverse to quality and initiated Corrective Action Report (CAR) 81-035 that addressed , overfilled cable trays and cable penetrations in the cable spreading rooms. Various actions were taken from February 1981 untti July 1985, none of which succeeded in correcting the overloaded condition of the cable trays. , '1. , Admission or Dental of the Alleged Violation
- - TVA does not contest the violation.
- 2. Reasons for the Violation The contributing factor was that the importance of the CAR program was not 4
always recognized by Itne management. As a result, inadequate responses I were frequently received to disposition the' problem documented. The , Inadequate responses required additional attention by QA personnel. This additional attention was often delayed because of inadequate staffing. 1 For most of the period that CAR 81-035 was being handled, SFN Quality Assurance (QA) Staff had one person assigned part-time to the CAR program. l Requests for additional personnel did not receive the necessary attention of higher management.
- The combination of inadequate staffing and inadequate responses to CARS l resulted in some CARS remaining open for long periods of time, as was the case
- of CAR 81-035.
l
- 3. Corrective Steps Which Have 8een Taken and Results Achieved l
1
- a. Corrective Action Reports Management is committed to resolving CARS expeditiously. CARS are i discussed in daily Quality Assurance Staff meetings, and the Site L Ofrector meets periodically with the Site Quality Manager and NUREG-09do I.A-3?2
quarterly with the Corporate Otractor of Nuclear Quality Assurance to discuss CAR status and escalate corrective actions. Managers at all levels are being held accountable for timely resolution of CARS in their area of responsibility. The site QA organization has been expanded to better track and evaluate CARS. A Quality Assurance Technical Services Staff has been established and is responsible for tracking the issuance verification, and closure of CARS. The staff is assigned the responsibility of preparing monthly reports to management to keep them apprised of the status of plant-Initiated CARS.
- b. Cable Tray F1111ng Corrective actions have been taken to preclude future overfilling of cable trays. Stringent NEPs were issued in July 1986 which place rigorous controls on the design process of new cable loaded in existing or new cable trays in the following areas:
NEP 3.1 Engineering Calculations NEP 3.2, Design Input NEP 3.3. Interface Control NEP 5.1, Design Output NEP 5.2, Review and Design Verification NEP 6.1, Change Control The result of the NEPs is a closely controlled design and training process which will ensure the adequate design and verification of cable loading in existing or new cable trays. It was decided to resolve the overloading by qualifying the cable tray supports. CAR 81-035 stated that an effort was required to qualify caole tray supports that are already in existence and loaded with cables. Two programs, discussed in detall in our response to Violation IA, outilne seismic programs which are being implemented to (1) allow restart and safe operation of unit 2 and (2) provide long-term seismic quallfication of cable trays for all three BFN units. NUREG-0040 I.A-3?3
- 4. Corrective Stoos Which Will Be Taken to Avold Further Violations The Nuclear Performance Plant (NPP), Volume 1 provides the actions being implemented at the corporate level to avoid the root cause of inadequate design control. The actions related to the improvements in the design control process for BFN are contained in the NPP, Volume 3. Specific corrective steps for this issue are:
- a. BFN is committed to completing the cable tray modifications for unit 2 using the interim seismic qualification,
- b. BFN is committed to completing the long-term qualification of cable trays using the methodology of NUREG-1030 to resolve Unresolved Safety Issue A-46, Selsmic Qualification of Equipment in Operating :
Nuclear Power Plants.
- 5. Date When Full Comollance Will Be Achieved Seismic qualification (including any modifications required) of the unit cable tray systems or common cable tray systems needed to support the units will be accomplished before their respective startup dates.
t' 4 { l l , i i lillREG-0940 1.A-324
l Item I.8.(2) l The licensee discovered on August 14. 1985, that the corrective action taken in response to a previous Notice of Violation (NOV) _(Inspection Report 50-259, 50-260, 50-296/84-23) had not been accomplished. Mechanical Maintenance Instruction (MMI)-6 Implements the Browns Ferry Technical Specification surveillance requirement 4.9.A.I.d for routine diesel generat v inspections. The licensee committed in response to the NOV to revise MMI-6 Mclude, by October 5, 1984, the manufacturer's inspections / maintenance re oendations given in Electro-Motive Division Maintenance Instruction MI-17 2. Revision E: Scheduled Maintenance Program 999 System Generating Plants. "..e recommended six and twelve year maintenance intervals were neither included in the revised instruction nor was an evaluation performed to determine whether or not the intervals should have been included in the instruction.
- 1. Admission or Denial of the Alleged Violation TVA does not contest the violation.
- 2. Reason for the Violation The failure was apparently due to an oversight on the part of the Mechanical Maintenance Supervisor and the Mechanical Maintenance Section cognizant engineer.
) 3. Corrective Steps Which Have Been Taken and Results Achieved Following revision of the Mechanical Maintenance Instructio.n detalling the scheduled maintenance program for the diesel generators, implementation of , the replacement components began in October 1985. All 8FN diesel j generator recommended maintenance had been accomplished as of April 6, 1986. The manufacturer's multtyear inspections have been incorporated into the plant's preventive maintenance program.
- 4. Corrective Steps Which Will Be Taken to Avoid Further Violations
. The Nuclear Performance Plan (NPP), Volume 1 provides the actions being implemented at the corporate level to avoid the root cause of inadequate maintenance practices. The actions related to the improvements in the maintenance process for 8FN are contained in the NPP, Volume 3. Specific corrective steps for this is that 8FN management has and will continue to stress the importance of proper attention to component replacement or maintenance, including performing the diesel generator recommended maintenance. Placement of the multlyear inspections in our formal preventive maintenance program should prevent future violations. 1
- 5. Date When Full Compliance Will Be Achieved TVA is in full compilance. The manufacturer's multlyear inspections have been incorporated into the plant's preventive maintenance program.
NUREG-0940 f.A-325
Item I.B.(3) A Notice of Violation (Inspection Report 50-259, 50-260, and 50-296/85-28) involved incorrect service mounting of the diesel generator battery racks. The licensee responded to the Notice of Violation and indicated that the battery racks were seismically quallfled. During battery rack maintenance on April 20,'1.985..four foundation mounting studs were broken that were replaced by April 22, 1985. A metallurgical evaluation was. requested by the licensee to evaluate the failure mechanism of the four studs. The evaluation revealed that the stud material was unacceptable for welding; thus,-the battery racks were seismically unquallfled. Corrective action was not taken and the condition was not reported to appropriate levels of management until September 24, 1985, when the diesel generators were declared inoperable.
- 1. Admission or Dental of the Alleged Violation TVA does not contest the violation. Additional details are provided in item 2.
- 2. Reason for the Violation Inspection Report 85-28 involved a seismicity problem with the mounting detatis of the diesel generator battery racks. The corrective action was to install shims to restore seismic qualification. During this repair process, an unrelated condition involving the stud configuration on the battery rack mounting rack was encountered which ultimately caused the selsmic quallfication to again be revoked in September 1985. Details of the problem follow below.
The repair process to shim the diesel generator battery racks involved physical removal and reinstallation of the racks. During the , reinstallation work, four anchor stud welds separated from the embedded base plate while torquing the holddown nuts. There are 64 studs altogether for eight battery racks. This problem was attributed to weld deficiencies during the original installation of the battery racks. Weld repairs were made to the four studs and the battery racks put back in service in April. In mid-June 1985, the repair package was transmitted to quality assurance ! (QA) for a detailed postwork review before lifetime storage. In early July 1985 the QA review noted minor discrepancies with the repair package and issued a Discrepancy Report to document their findings. One of their findings was that the repair procedure did not specifically reference the appilcable stud material specification for the stud to baseplate weld procedure. 1 a i NtfREb 0940 1,A-376
The acceptability of the welds was not in question in this timeframe since the weld procedure had been reviewed. .To fully close out the work package
- - and Discrepancy Report, it was thought prudent to verify material l
- traceability in the original installation package of the battery racks (circa-1975). The installation package was located and reviewed in early August but did not contain the material certification for the studs. The 1
alternative was to actually take samples of the stud material for < metallurgical analysis. The samples were taken in August and sent to offsite laboratories for analysis. The final results of the analysis were transmitted to the site in late September 1985. The analysis showed the stud material was not the material specified in the design drawings and that the material was not suitable for welding appIlcation. This
, conclusion affected all 64 studs. The battery racks could not be demonstrated to be seismically quallfled and the diesels were declared
, inoperable on September 24, 1985. As can be seen by the preceding
- ' explanation, the timeliness of corrective action was lengthened by the delayed recognition of the fact that a material deficiency existed, rather than welding deficiencies which had been repaired, j 3. Corrective Steps Which Have Been Taken and Results Achieved
- The diesel generators were immediately declared inoperable (maintained
!~ aval Nble) due to the nonconforming material. Corrective action to ! replace the stud bolts with a suitable type was promptly initiated. The diesel generator battery rack stud bolts were replaced in a planned i sequence and completed by October 24, 1985.
- Current procedures for modifications and additions to the factitty are rigorous in terms of work control and documentation for requirements, such
, as materlat certiff. cation and traceability. These procedures alnletze the Ilkelihood of recurrence of this type material problem.
- 4. Corrective Steps Which Will Be Taken To Avoid Further Violations The Corporate Nuclear Performance Plan (CNPP), Volume 1 provides the actions being implemented at the corporate level to correct the root cause i concerning poor control and timeliness of corrective action. The actions 3
related to the improvements in the corrective action control process for ) 8FN are contained in the Browns Ferry NPP, Volume 3. Additional corrective steps for this issue are that Standard Practice 8F-7.6, Attachment F. Standard Gdidelines for the Preparation / Review of Maintenance Requests (MR), will be revised to include a requirement to i list the base material specifications for safety related welding repairs. The responsible section will include the material specification when
- preparing the MR package that requires welding, and QA will ensure the material is acceptable when they perform their independent review.
l S. Date When Full Compilance Will Be Achieved Full compliance will be achieved by November 30, 1986, which is the l anticipated date of the implementation of revised Standard Practice BF-7.6. l i i i f NUREG-0940 I A-37.7
-Item'I.8.(4)
.During the inspection conducted October 26 - November 20. 1985, it was found that the licensee had not taken-action to correct a significant condition
. adverse to quality. The FSAR, Section 8.5.5, specifies that maintenance on the diesel generators be conducted in accordance with manufacturer's recommendations. A vendor diesel generator newsletter (Power Pointer) dated November 28. 1979, Indicated that any viscous crankshaft. vibration damper bearing with a 1969 or earlier sertal number should be removed from service immediately and. returned to the manufacturer due to potential for failure.
However, the Itcensee never acted upon the newsletter although this type of damper was installed in the plant diesel generators. In addition. l notwithstanding the FSAR, the licensee has no program to review vendor recommended equipment modifications to assure diesel. reliability.
- 1. Admission or Dental of the Alleged Violation TVA does not contest the violation.
- 2. Reasons for the Violation In June 1980 purchasing contract 81P69-302736 was initiated to procure the recommended replacement type dampers. The plant maintenance staff planned to replace the dampers installed on the diesel generators upon receipt of material. However, as the replacement dampers were of a fundamentally different design, Design Change Request (DCR) 2547 was initiated in January 1981 to replace the viscous damper with the improved design gear type damper. The DCR package was subsequently reviewed and was assigned a routine priority. Modifications for which no formal commitment existed were given lower priority during the modification review process. Final issue of drawings for DCR 2547/ Engineering Change Notice P0570 was May 1, 1984. The proper attention wss not given to the diesel generator newsletter.
- 3. Corrective Steps Which Have 8een Taken and Results Achieved Implementation of the eplacement components began in October 1985. All SFN diesel generator dampers had been replaced as of April 6. 1986.
Various vendor Information letters are routinely reviewed by plant section supervisors, as addressed in Standard Practice 8F-21.17, which stipulates that the assigned section supervisors are responsible for their review and subsequent recommended actions. NUREG-0940 f.A-328
The recent increase in the design staff located at the site, and a formal improved priority ranking system for DCRs has significantly decreased the time required to request and implement priority modifications of this nature.
- 4. Corrective Steps Which Will Be Taken to Avoid Further Violations 8FN management has and will continue to stress the importance of proper attention to vendor information letters or instructions requiring component replacement or maintenance. In addition, as is emphasized in the Corporate NPP, Volume 1, several measures are in process to enhance operating expertence review and vendor information control systems. The actions related to the improvements in the operating experience review area relating to pertinent vendor information at 8FN are contained in NPP, Volume 3. These will provide a method to ensure that all pertinent vendor information is reviewed, tracked, and appropriate corrective actions are taken in a timely manner. We will review the progress of these enhancements and evaluate if further or interim measures are necessary to ensure timely and correct responses to safety significant vendor information bulletins.
- 5. Date When Full Compilance Will 8e Achieved TVA is in full compilance. The diesel generator damper replacements were complete on April 6, 1986.
NUREG-0940 f.A-329
- -- - . . . . -.= _- - _. . - . . _ -
4 Ites !.S.(5) - An emergency design change request (DCR 2675) was written in 1981 for the replacement of the diesel generator turbocharger drive gears. The turbocharger drive gears were known to be inadequate for no load / light load operations and failure could occur if the engine was operated in excess of 200 hours at less than 20 percent load. Although this condition adverse.to quality had been corrected by the Sequoyah Nuclear Plant (Supplement 2 NUREG-0011 August 6, 1980), as of the time of the inspection on October 26 - November 20, 1985, the change had not been implemented by Browns Ferry. The replacement was completed on April 6, 1986.
- 1. Admission or Dental of the Alleged Violation
< TVA does not contest the violation in that a condition adverse to quality, the manufacturer's recommended replacem nt of the standby diesel generator turbochargers,- was not accomplished in a timely manner. ,
- 2. Reasons for the Violation I
DCR 2675 was initiated in late 1981 to accomplish the turbocharger replacement. Caution statements were added to plant instructions to reduce, whenever possible, no-load /11ght-load operation. The DCR was assigned a routine priority since total diesel generator operating hours in the Ilght load /no load mode were believed to be well below the minimum > .noted failure time of 200 hours. However, in May 1982 the OCR was placed on hold as no formal commitment existed to complete the turbocharger changeout. Modifications for which a formal commitment existed were given higher priority during the modification review process.
- 3. Corrective Steps Which Have Been Taken and Results Achieved i
Following a review of all existing DCRs related to the diesel generator system in November 1984, it was determined to accomplish the component replacement as 1 maintenance item. All SFN diesel generator turbochargers 2 were replaced with the recommended replacement featuring the heavy duty drive gear train as of Aprl) 6, 1986. Vendor information letters or instructions are routinely reviewed by plant
- section supervisors and addressed in Standard Practice 8F-21.17 which I
stipulates that the assigned section supervisors are responsible for their review and subsequent recommended actions. i \ 1 I l l NUPEG-0940 1 A-330 \- . . - . - . . - . - - . - - - . - - _ __ _ .- _ - ._ --.-
The recent increase in the design staff located at the site, and a formal improved priority ranking system for DCRs has significantly decreased the time required to request and implement priority modifications of this nature.
- 4. Corrective Steps Wh.ch Will Be Taken to Avoid Further Violations 8FN management has and will continue to stress the importance of proper attention to vendor information letters or instructions requiring component replacement or maintenance. In addition, as is emphasized in CNPP, Volume 1, several measures are in process to enhance operating experience review and vendor information control systems. The actions related to the improvements in the operating experience review area relating to pertinent vendor information at 8FN are contained in NPP, Volume 3. These will provide a method to ensure that all pertinent vendor information is reviewed, tracked, and appropriate corrective actions are taken in a timely manner. We will review the progress of these enhancements and' evaluate if further or interim measures are necessary to ensure timely and correct responses to safety significant vendor information letters.
S. Date When Full Compilance Will 8e Achieved TVA is in full compilance. The replacement featuring the heavy duty drive gear train was completed on April 6, 1986. NllREG-0040 f.A-331
Item I.C. (1 through 4) 10 CFR Part 50, Appendix B. Criterton V. Instructions, Procedures and Drawings, requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and that these activities be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, the licensee failed to prescribe adequate instructions, procedures, or drawings to implement such instructions, procedures, or drawings in the following circumstances: Item I.C.I. , During surveillance testing on November 19, 1985, the licensee discovered that the 250 volt DC control power to the 4160 volt shutdown board "A" was not connected per Plant Drawing 010608860. The electrical supply cables for the normal control power
- supply (250 voit DC shutdown board "A" battery) and the alternate control power supply (250 volt DC battery board "2" to the unit 2 battery) were reversed. This wiring error resulted in control power being supplied from a 30-minute rated source in lieu of the required 3-hour rated source. This condition may have existed since 1973.
- 1. Admission or Dental of the Alleged Violation TVA does not contest the violation.
- 2. Reason for the Violation A wiring error was identifled by TVA that reversed the normal and alternate power feeder cables to the 4160 volt shutdown board "A" control power bus. However, the allegation that the wiring error resulted in control power being supplied from a 30-minute rated source instead of a three-hour rated source is incorrect. Both the normal and alternate control power sources are 30-minute rated sources in accordance with design requirements (reference Final Safety Analysis Report (FSAR),
section 8.6). Although the design requirements for the normal and alternate control power batteries specify 30-minute rated sources, all the shutdown board batterles are conservatively sized and can supply their i required loads for three' hours. TVA believes this is an important fact in l evaluating the safety significance of the violation. The reason for the violation was an error in the installation and testing of the modification in 1973 which added the dedicated control power battery to 4kV shutdown board "A." Personnel involved in the modification in 1973 did not give the proper attention to the installation or testing details. N11PFG-0940 I.A-332 t ___ .. - - ... ~ --. ,- - -_---- .=--. ,- --
; 3. Corrective Stoos Which Have Been Taken and Results Achieved l Significant leprovements have been made in the modification process since 1973 when the failure to implement the wiring modification occurred. The '
present modification procedure requires detailed instructions, workplan's. and inspectioc records-including quality control holdpcints before comunencement of the modification. The wiring error was discovered on November 11, 1985 during lineup of board control power for performance of the battery surveillance procedure on shutdown battery "A." Selecting the alternate source and beginning ' isolation of the normal source caused a temporary loss of control power to 4kV shutdown board "A." Control power was restored, and the surveillance was immediately stopped. An investigation was initiated. Wiring to the t normal.and alternate sources was found reversed at the shutdown board. The wiring error was corrected on November 22, 1985. Physical inspections of the other 4kV shutdown boards with the same type control power ' arrangements were conducted, and a review of the drawings and documentation was performed for the modification which added the dedicated batteries. No other wiring errors were found on the other boards. 1 ), 4. Corrective Steps Which Will Be Taken to Avoid Further Violations ' ' The Nuclear Performance Plant (NPP), Volume I provides the actions being Implemented at the corporate level to alleviate the root cause of inadequate control of modifications. The actions related to the i improvements in the modification control process for SFN are contained in the NPP, Volume 3. I The detailed instructions, the workplan reviews, the inspection records, and the post modification testing documentation requirements which exist today preclude recurrence of this problem. The present policies of
- encouraging employees to question and report apparent discrepancies (as i
seen during the November 11, 1985 battery surveillance immediate stop work) also help preclude recurrence, i 5. Date When Full Comollance Will Be Achieved i Full compliance was achieved on November 22, 1985 when the wiring error
- was corrected.
1 ? 4 l l l l i-l l NUREG-0940 1.A-333 - [
l l Item I.C.(2) ' During the inspection conducted November 21 - December 31, 1985:
- a. -The licensee discovered that the units 1 and 2 diesel generators oli pressure switches PS-82-29 A, B. C, and 0 (M8-3) were not functional. The oli line connection block was not ported (drilled -
out) in accordance with Plant Orawing 45N767-4 for the oli line-connecting the pressure switches. -This prevented-the pressure switches from functioning as a backup to the speed sensor to prevent
~. engagement of the number two bank of air start motors if oli pressure was not maintained after the diesel started. *
- b. NRC discovered that Plant Operating Instruction 01-82 for the diesel i generators was not appropriate to the circumstances because it did l not address the function of the Low Low Lube Oil Pressure Light. i Because there was no oli pressure to the pressure switch when the
. engines wer6 running,'no oil pressure in the sensing line should have caused illumination of the Low Low Lube Oil Pressure Light next to the emergency stop button on the diesel generator control board in the control room. However, all four of the lights in both units.were not functional.
- 1. Admission or Dental of the Alleged Violation
, TVA does not contest the violation.
- 2. Reasons for the Violation The reason for violation I.C.(2.a.) was improper installation and testing. The installation occurred during the construction phase before 1977. The preoperational test apparently failed to identify-the problem.
Violation I.C.(2.b.) was the result of a procedural deficinncy in that the
- function of the low low lube oli pressure light is not addressed.
Thorough procedure review in conjunction with proper attention to the indicating light should have identifled this deficiency. The subject switches provide two functions: (a) disengagement of the-j No. 2 air start circuit and (b) control room Indication of low low oil . pressure.
- a. Olsengagement of No. 2 starting circuit - The pressure switch can l either fall open er fall closed. A fall open condition would prevent -
! the No. 2 air start circuit from starting the diesel; however, this I would not prevent in any way the No. I air start circuit from starting the diesel. A fall closed condition (existing configuration) would not prevent the No. 2 air start circuit from l NUREG-0940 1.A-334
2^ [ E l' 7 starting the diesel. It would prevent the switch from disengaging - the No. 2 air start circuit upon diesel oli pressure reaching 30 7-i psig; however, a speed sensing switch disengages this circuit when the diesel speed reaches 125 RPM. Therefore, t. failure of the pressure switch does not prevent the diesel generator from starting. -
- b. Indication - A fall open condition would cause the loss of low low oli pressure indication in the control room when the diesel is running. A fall closed condition should cause the indicating light i to remain lighted continuously while the diesel is running. 3 l
0I-82 did not address this light; therefore, no operator action would be taken in the event low oil pressure was thus indicated. However, - the control room has a separate indication of low oli pressure ; (annunciator). Different switches provide inputs to this annunciator, f An unresolved safety question determination approved on November 29, 1985 > documented that an unreviewed safety question (USQ) was not involved in - this problem. 01-82 does address the low oil pressure annunciator located = in the main control room. This annunciator alarms if the diesel speed has _ been greater than 125 RPM for two minutes and if either of the following two conditions is met. (4 (1) 011 pressure at the engine instrument manifold is less than 20 h pst if the diesel speed is between 125 RPM and 870 RPM. (2) Oli pressure at the engine instrument manifold is less than 44 f-pst if the diesel speed is above 870 RPM. In the event the annunciator alarms 01-82 contains instructions for the operator to follow; therefore, the operator has sufficient information available in the event a low oil pressure event occurs. In summary, this self-identified deficiency would not prevent the diesel l-generators from starting or prevent the low oli pressure from being identified due to the annunciator. TVA believes these are important facts in evaluating the safety significance of the violation. 2 Y. r Y. i r 5 i NtlPFG-0940 I.A-335 {
- 3. Corrective Steps Which Have Been Taken and Results Achieved This condition had not been detected by BFN personnel in tne past because the pressure switch was periodically tested by disconnecting the oil line at the pressure switch. The condition was found by BFN personnel by pressurizing the oil line upstream of connection block with no observed response from the pressure switch. This condition was found to be common to all four unit I and 2 diesels. The unit 3 diesels were not affected as the oil lines were connected by a series of "T" connections. The condition has been corrected, and a complete test, which included the control room indicating lights, has been performed for the unit I and 2 diesel generators. The subject switches are now properly functional.
Annunciator Response Procedure, Panel 9-23, is currently in Document Control for processfag. It includes identification of the low low lube oil pressure light and contains instructions for the operator to follow in the case of illumination of the light. The operators have been trained in the instructions *to follow in the case of illumination of the light.
- 4. Corrective Steps Which Will Be Taken to Avoid Further Violations The Nuclear Performance Plan (NPP), Volume 1 provides the actions being implemented at the corporate level to alleviate the root cause of inadequate emphasis to maintenance and surveillance procedures. The actions related to the improvements in the maintenance and surveillance procedural process for BFN are contained in the NPP. Volume 3.
Operators are continually reviewing annunciator response procedures for inclusion of any detail which would further improve operational performance.
- 5. Date When Full Compliance Will Be Achieved Full compliance will be achieved November 30, 1986 which is the anticipated date for issuance of Annunciator Response Procedure, Panel 9-23.
i l I l NUREG-0940 I.A-336
l l l i Item I.C.3 Plant Instruction SMI 192.2 Local Power Range Monitor (LPRM) Maintenance Instruction, was inappropriate to the circumstances for the LPRM changeout conducted in unit 2 on November 20. 1985. The instruction did not address the abnormal operation for a LPRM changeout with a LPRM tip broken in the LPRM tool or a LPRM stuck behind a source pin rack. Continued operation resulted in the " hot" tip of the LPRM breaking the water surface of the spent fuel pool, creating excessive radiation levels in the area and an unnecessary radiation hazard to personnel.
- 1. Admission or Dental of the Alleged Violation TVA does not contest the violation.
- 2. Reasons for the Violation Operations persorinel were transporting an old LPRM from posttion 16-49 in the unit 2 reactor to the spent fuel pool. While being dragged across the edge of the vessel flange, the tip of the spring (hot) end of the LPRM was pulled off. The tip and LPRM remained in the LPRM tool. This allowed the LPRM to slide through the LPRM hook, preventing a cinch hold. The LPRM safety hook,had been installed before this event. After the LPRM was placed in the spent fuel pool, the cold end was secured to the southeast corner of the spent fuel pool. Attempts were made to create a downward bow on the LPRM to allow storage. The assistant unit operator (AUO) attempted to remove the tool, but the sliding effect of the LPRM through the tool hampered efforts to store the LPRM. During this movement of the LPRM tool, the LPRM was caught behind the source pin rack. The AVO attempted to remove the LPRM from behind the source pin rack by overriding the limit switch on the monorail holst. This permitted him to bring the LPRM closer to the pool surface than five feet. The monorail hoist and LPRM tool were abandoned at this point after returning the tool five feet below the water surface of the spent fuel pool. Manipulations now continued using J-hooks and the LPRM safety hook to get the LPRM placed properly. During this phase of the operation, trying to free the LPRM from behind the rack of source pinr, the AUO and boilermakers pulled the LPRM closer than five feet to the si;rface of the water. At this time, the health physics (HP) technician was located on the south side of the spent fuel pool monitoring the" surface of the water over the middle (highest dose rate) of the LPRM. The boilermaker foreman and HP technician noted the LPRM hot end had risen to about 18 inches below the water's surface.
The HP technician relocated to the west end of the spent fuel pool to monitor the LPRM hot end. The HP technician noted a dose rate increasing to two rems / hour. NilREG<00a0 1.A-337 i l
The following actions occurred almost simultaneously:
- a. The HP technician turned to inform Operations to stop raising and to lower the LPRM.
- b. The Ludlum 300 ARM on the refueling bridge and the ARM on the north wall (see Attachment 2) of the refueling floor alarmed.
- c. The LPRM was lowered by Operations.
The above events occurred sufficiently fast that the operator lowered the LPRM before the HP technician could verbally transmit the direction to stop raising and lower the LPRM. The HP technician estimated the event to last about two seconds. The increased dose rate initiated secondary , containment isolation and standby gas treatment. The alarm returned to normal (cleared immediately upon lowering the LPRM). Root Cause of the Incident:
- a. The use of a procedure which did not minimize the potential for physical damage to the LPRM which resulted in increased difficulty in moving the LPRM.
- b. A prejob briefing which did not include all aspects of the' operation.
- c. An unanticipated and unplanned configuration with the damaged LPRM caught behind the source pin rack.
The greatest exposure received by an individual was 30 m1111 rem. TVA believes this is an important fact in evaluating the safety significarce of the violation.
- 3. Corrective Steps Which Have Been Taken and Results Achieved The LPRM procedure was reviewed by all responsible sections and revised to incorporate the following changes:
~
- a. Additional radiological caution statements added.
- b. A statement added to require a formal operational briefing before the start of work.
l
- c. The method of physically moving the LPRM was revised to preclude the l recurrence for future similar events.
- d. Personnel responsible for this task have been informed of the corrective actions and have received a critique on the incident.
i I i HUREG-0940 I.A-338
21-
- 4. Corrective Steps Which Will Be Taken to Avoid Further Violations The Nuclear Performance Plant (NPP), Volume 1 provides the actions being implemented at the corporate level to alleviate the root cause of inadequate emphasis on the conduct of operations. The actions related to the improvements in the conduct of operations for BFN are contained in the NPP, Volume 3.
A formal operational briefing will be required before the start of work. The briefing will review in detail the steps necessary to accomplish each LPRM changeout without necessary difficulties or hazards. Corrective actions as a result of the LPRM changeout on November 20, 1985, will be emphasized.
- 5. Date When Full Compliance Will Be Achieved TVA is in full compliance.
i NUREG-0940 I.A-339
i
-22
Item 1.C.(4)-
.The licensee failed to ensure that design drawings referenced the correct design specifications.. On October 22, 1985, the licensee discovered four design drawings (730E918, Engineered Safeguards; 730E915, Reactor Protection System; 730E930. Core Spray; and 730E927, Primary Containment Isolation) referenced design specification 22A1421 which is not applicable to Browns-Ferry instead of.the correct specification 22A2809. This specification defines the criteria for the separation and identification of reactor safeguards electrical equipment.
- 1. Admission or Denial of the Alleged Violation TVA does not contest the violation.
- 2. Reasons for the Violation TVA concurs that'four BFN active design drawings, and one superseded design drawing referenced an incorrect design specification. They are as follows:
730E918, Engineered Safeguards 730E915, Reactor Protection System 730E930, Core Spray System 730E927, Primary Containment Isolation 730E921 Superseded by 45N626 The following chronological listing should explain the reasons for this finding: On July 19, 1968 General Electric (GE) issued generic separation criteria 22A1421, revision 0, while TVA was still reviewing tn~e draft specification. TVA was never aware that this specification was issued. On December 20, 1968 TVA returned their comments on the generic separation criteria (draft 22A1421) to GE to be resolved for BFN.'
- On May 7,1969 GE issued drawing 730E915-1, reviston 0, for- BFH with the general specification (22A1421) referenced.
On June 5, 1969 GE issued drawing 730E918-1, revision 0, for BFN with the generic specification (22A1421) referenced. On August 18, 1969 GE submitted separation criteria 22A2809, revision 0, to TVA. This criteria is a BFN unique separation criteria. On September 22, 1969 GE issued drawing 730E927-1, revision 0, for BFN with the general specification (22A1421) referenced. t i NUREG-0940 I.A-340
-23 :
On October 8, 1969 GE lssued drawing 730E930-1 revision 0, for BFN with the generic specification (22A1421) referenced. On March 25, 1970 TVA approved "with corrections noted" the BFN unique separation criteria 22A2809, revision O. On October 19, 1970 GE submitted separation criteria 22A2809, revision 1, for review. On December 1, 1970 TVA approved 22A2809, revision 1. On June 9, 1972 GE submitted separation criteria 22A2809, revision 2, for review. On September 25, 1972 TVA approved 22A2809, revision 2. From this listing it can be seen that GE issued separation criteria 22A1421 while.TVA was still reviewing the draft specification, and that the drawings in question were.lssued for BFN by GE referencing the generic separation specification (22A1421) during the same time period. In reviewing the drawings, TVA did not find the discrepancy because TVA reviewed just for interfaces, not for total content and design verification. Although TVA approved the BFN unique separation criteria and its revisions, GE never revised their drawings to incorporate 22A2809 for BFN. t 3. Corrective Steps Which Have Been Taken and Results Achieved Significant Condition Report (SCR) BFNEEB8606, revision 1, was written to document and track this condition adverse to quality. An engineering report / failure evaluation was performed on this SCR which documents the reviews of the design specifications (one review performed by TVA and the other review performed by GE). These identify the differences between the design specification and resolve the differences. The conclusion to this report states that "each system affected by the differences in the incorrect referenced design _ specification 22A1421, revision 1, and the correct design specification 22A2809, revision 2, has been designed and installed consistent with the intent of design specification 22A2809, revision 2." With regard to the safety significance of this issue, the Integrity of separation requirements as applied to plant design has not been compromised.
- 4. Corrective Steps Which Will Be Taken to Avoid Further Violations The Nuclear Performance Plan (NPP), Volume 1 provides the actions being implemented at the corporate lavel to avoid the root cause of inadequate design control. The actions related to the improvements in the design control process for BFN are contained in the NPP, Volume 3.
t t N!! REG-0940 I.A-341
An engineering change notice was issued to correct the wrong design specification on the drawings identified, thus removing the potential of the wrong design specification being used on future design modifications. Corrections of the design specification references were completed on June 1, 1986-and the active drawings reissued. To evaluate for generic.impitcations, TVA implemented a sampling program on the residual heat removal system to review the conceptual drawings for design specifications and ensure that the design specifications identified from the drawings are the correct design specifications for BFN. The sampling program was completed on July 1, 1985 and no discrepancies were noted; thus, the incorrect references were deemed to be an isolated event.
- 5. Date When Full Como11ance Will Be Achieved TVA is in full compitance, l
l Nt! REG-0940 I.A-3A2
.- . . ... - =
Violation Not Assessed a Civil Penalty Item II-10 CFR 50.59(a) allows the holder of & Ilcense to make changes in the facility as described in the Final Safety Analysis Report (FSAR) without prior Commission approval unless.it involves a change to the Technical Specifications or is an unreviewed safety question. An unreviewed safety question is created if the consequences of an accident or the malfunction of the equipment important to safety previously evaluated in the FSAR may be increased. 10 CFR 50.59(b) requires that the licensee maintain records of changes in the , facility to the extent that such changes constitute changes in the factitty as described in the FSAR. These records shall include a written safety evaluation which provides the bases for the determination that the change does not involve an unreviewed safety question. Contrary to the above, the licensee changed the facility as described in the FSAR without having determined whether the change involved an unreviewed safety question. 'On November 25, 1985,-the licensee changed the acceptabis closure time of secondary containment isolation dampers from two seconds.as specified in Section 5.3.4.2 of the FSAR to 10 seconds. Although the licensee performed an analysis, it did not determine whether the change involved an unreviewed safety question. The change was implemented by the licensee through an internal memorandum pending a change to the FSAR to be submitted as part of the routine annual update per 10 CFR 50.71. This is a Severity Level IV violation (Supplement I). I. Admission or Dental of the Alleged Violation TVA disagrees that a viclation of 10 CFR 50.59 occurred. We believe the situation regarding isolation damper timing did not constitute a change in the facility or a change to any procedure within the scope of 10 CFR 50.59. Our justification for this position is detailed below. Secondary containment at BFN is divided into three reactor zones and a 4 common refueling zone. Each individual zone has sets of paired redundant supply and exhaust isolation dampers. Radiation monitors are installed in , the vicinity of the exhaust dampers which will automatically isolate the dampers and start the standby gas treatment system (SGTS) on high radiation. This action preferentially exhausts any airborne radioactive products through the filtered SGTS and out the main stack in order to minimize offsite releases. The design basis event of interest with regard to damper timing is the refueling accident and is described in Chapter 14 of the FSAR. An additional discussion of the system design basis was also included in the O E i NUREG-0940 I.A-343 r. l
FSAR, section 5.3.4.2, and is repeated in the following excerpt for reference.* There are no technical specification requirements for response time testing of the dampers. FSAR Section 5.3.4.2 The total time required to switch from the normal containment ventilation system to the SGTS upon detection of high radiation is relatively small. The radiation monitor response time is one second, and the reactor zone isolation dampers (pneumatic drive) are closed in two seconds upon receipt of signals from the monitor. Startup of the SGTS blower motors is within five seconds from the time of the signal. The proper dampers (electric motor-driven) in the SGTS trains are fully opened in 30 seconds. The one-second response on radiation detection, plus the two-second response on the isolation damper, is less than the transport time from the surface of the fuel pool.t6 the isolation damper, and thereby. assures that the release from a fuel handling accident will be contained in the secondary containment. All SGTS trains will be producing full flow within 30 seconds of a secondary containment isolation signal. Important points from the preceding description are:
- a. The exhaust dampers that are assumed to clost in two seconds to limit offsite releases are apparently the refuel zone dampers.
- b. Original analysis assumed that damper closure time was short compared to the transport time of airborne fission products and, therefore, that the fission product release via the ventilation system was zero,
- c. The description does not make a specific reference to the refuel zone
, exhaust dampers with regard to assumed closure. times. Only reactor zone dampers are addressed. In preparation for a changeout of the air solenoids on these exhaust i dampers for the environmental qualification program, a request for l post-modification test criteria for damper closing times was directed to
-the engineer for secondafy containment. The cognizant engineer reviewed the FSAR basis, preoperational test results, procurement specifications, and also tested the actual damper closing times. The test results of September 23, 1985 showed that refuel zone exhaust and supply dampers met the two second criteria except for two of the 12 dampers. Minor adjustments to the pressure regulator were made, and the refuel zone exhaust damper came back within the two seconds. The reactor zone dampers averaged about three seconds with the high value being five seconds and could not be. appreciably speeded up. The reactor zone dampers are physically larger than the refuel zone dampers which basically accounts for the closure time difference.
*(This excerpt is as the FSAR read during the period of the TVA evaluation.)
l NUREG-0940 I.A-344
- These findings were weighed against the FSAR description and Chapter 14 analysis of the fuel handling accident. It was obvious that the speed of the reactor zone dampers would have very little effect on the accident analysis. This is due to the geometric separation of the respective zones and ductwork, coupled with the fact that the refuel zone ductwork is physically arranged such that any releases from fuel handling accidents are preferentially exhausted through the refueling zone exhaust ducting.
The plant staff concluded that the FSAR wording was incorrect with regard to the damper nomenclature. From an engineering and safety viewpoint, the closure time of the reactor zone dampers posed no problem. Nevertheless, as a conservative action, an administrative restriction on fuel handling was imposed on September 23, 1985 while the test results were being further investigated. The Resident Inspectors were notified of our findings and kept informed concerning our activities to address the subject. The Residents did express their concerns relative to our decision not to declare secondary containment inoperable and carried the issue as an unresolved item in Inspection Report 85-49 (November 7, 1985). The Plant Engineering Staff had some uncertainty in justifying the assumptions of the original Chapter 14 analysis concerning closure time of the refueling zone exhaust dampers compared to the physical transport time of fission gases through the ductwork. This is because the analysis did not appear to include any ground level release term, which means that no gas escapes through the refuel
- zone ductwork. This assumption seemed to be nonconservative.
To fully resolve the issue, TVA decided to contract GE to perform an entirely new refueling accident analysis and safety evaluation. This analysis was expected to confirm our conclusions relative t.o the importance of the damper closing times and to provide a modern analysis for reference. The new analysis uttilzed Regulatory Guide 1.25 and NUREG-0800 (Standard Review Plan) guidance. We also included in the contract a provision for a sensitivity study assuming two , five , and 10-second damper closure times to gain insight into the effect of this parameter on calculated offsite doses from a fuel handling accident. The new fuel handling accident analysis was completed on November 7, 1985 and the calculated results for the three selected closure times showed that predicted cffsite releases were a small fraction of 10 CFR 100 criteria. The analysis also confirmed that the reactor zone damper timing did not affect the analysis results and that the release dose magnitude varied directly with the timing of the refuel zone exhaust dampers. A decision was made to clarify the FSAR during the annual update to , correctly reference the refuel zone damper function (which was done by our recent FSAR update). An internal plant memorandum was written to the Operations Supervisor summarizing the analysis conciusions, and the administrative restrictions on fuel handling were subsequently Ilfted in late November 1985. The subject memorandum did not authorize changes to ' be made in the closure speeds of the damper, but rather confirmed that the as-found speeds were acceptable. HUREG-0940 I.A-345
. _ _ _ . ~ . _
The Resident Inspectors reviewed the GE analysis and suggested that the , use of the analysis results to justify longer stroke times was a potential USQ as defined in 10 CFR 50.59. They also inquired concerning why a 10 CFR 50.59 evaluation had not been performed. The Plant Engineering Staff was of the opinion that the situation ~was not within the scope of 10 CFR 50.59, since no actual plant changes or procedure changes were necessary. Furthermore. it had been previously demonstrated that the refuel zone exhaust dampers could meet the existing FSAR description, and the new analysis confirmed that they were the only dampers affecting the offsite e release calculations. Closure of the.lssue was planned with a revision of ' the FSAR du' ring the annual update, at which time a formal 10 CFR 50.59 evaluation would be performed. (This year.'s annual FSAR update did subsequently incorporate the new fuel handling accident analysts.) To address the Inspector's concern .the Plant Manager. requested his staff to perform a.10 CFR 50.59 evaluation on the new analysis. The Plant Engineering Staff prepared a 10 CFR 50.59 evaluation and concluded that uttilzation of the new analysis results would not constitute a USQ. The l Plant Operations
- Review Committee' reviewed and concurred with the evaluation. On December 13,= 1985 the Resident Inspector notified the Plant Manager that they disagreed with the 10 CFR 50.59 evaluation, as was later documented in Inspection Report 85-57 as a potential escalated enforcement item. -The Plant Manager reimposed limited administrative fuel
. -handling restrictions pending resolution of the impasse. TVA sought to resolve the disagreement by formally requesting a Nuclear Reactor Regulation _(NRR) review and concurrence with the 10 CFR 50.59 evaluations. The submittal, letter was mailed on January 23, 1986 and requested NRR to review the new fuel handling accident analysis and to concur with the plant staff's conclusions and 10 CFR 50.59 evaluation. On March 28, 1986 NRR responded and agreed with the TVA evaluation. Fuel
- j. handling restrictions were then removed by the Plant Manager.
This item was discussed in the May 28, 1986 enforcement conference and was subsequently categorized as a Level IV violation as a failure to perform a 10 CFR 50.59 evaluation on a facility change. In summary, we do not believe a violation of-10 CFR 50.59 occurred since there was not a change to the facility or-Its procedures.' Also, as can be seen.by the chronology, we treated the situation in an extremely conservative manner in both applying voluntary fuel handling restrictions, as well as purchasing a modern analysis of the fuel handling analysis. We ji .also responded to the Resident Inspector's concerns in a timely manner. ! Accordingly, we request that NRC reconsider this proposed violation. l NilREG-0940 I.A-346
p LanTWD STATE 5
# % NUCLEAR REGULATORY -
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*4 **"*/ 'SEP g 1996 Docket No. 50-483 License No. NPF-30 EA 86-119 Union Electric Company ATTN: Mr. Donald F. Schnell Vice President - Nuclear Post Office Sox 149 - Mail Code 400 St. Louis, MO 63166 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORTS NO. 50-483/86010 AND NO. 50-483/86017) This refers to the inspections conducted during the periods April 15 - May 31, 1986 and June 4-11, 1986 at the Callaway Plant of activities authorized by NRC License No. NPF-30. The inspections addressed three violations of NRC requirements that were identif'ed by your staff and were reported to the NRC. The results of the April 15 - May 31, 1986 inspection were discussed on June 3,1986 during an enforcement conference held in the NRC Region III office between you and others of your staff and Mr. A. B. Davis and others of the NRC Region III staff. A copy of the associated inspection report (50-483/86010) was sent to you by letter dated June 23, 1986. The results of the June 4-11, 1986 inspection were discussed during a meeting between Mr. S. E.'Miltenberger and others of your staff and Messrs. A. B. Davis and R. F. Warnick of the Region III staff during their visit to tie Callaway Plant on June 10, 1986. A copy of the associated inspection report (50-483/860117) was sent to you by letter dated July 2,1986. Violation I.A in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties cccurred on April 12, 1986 when the plant remained in Hot Standby (Mode 3) for six hours and eight minutes with both trains of the Intermediate Head Safety Injection (IHSI) system inoperable and action was not taken within one hour to place the Unit in Hot Shutdown (Mode 4) as required by the Technical Speci f.ication. The system became inoperable during the performance of a surveillance test when licensee personnel closed valve EM-HV-8835 which blocked all IHSI injection paths to the reactor and rendered both IHSI trains inoperable. Plant personnel had improperly changed the procedure for this surveillance test to be performed in Mode 3 rather than Mode 4. Although the safety significance of the violation was reduced because of plant conditions of low temperature and pressure with backup emergency core cooling systems available, the NRC considers this violation significant in that the personnel who changed the procedure were unaware of plant conditions that resulted from the shutting of the valve and the CERTIFIED MAIL RETURN RECEIPT REQUESTED i,uREr-09aC I.A-347
f 4 Union Electric company 2 ~ SEP 9 1986 ensuing Technical Specification (TS) violation. In addition, plant personnel failed to make a timely report of this event to the NRC. This event was reported the day after the problem was discovered, and not within four hours as required. This violation is described in Violation I.B. Violation II in the enclosed Notice occurred on May 30,-1986 while the plant was in Mode 2 at 3% power. Auxiliary Feedwater Pumps (AFP) Engineered Safety Features Actuation System (ESFAS) blocking switches were left in the " block" position
~ after the first Main Feedwater Pump (MFP) was put into service to prevent an inadvertent start of the AFPs. This condition, which is prohibited by TS requirements, was not recognized by licensee personnel and existed for approximately 11 hours. This event is also considered significant because of procedural and .
personnel performance deficiencies. The Shift Supervisor, Senior Reactor Operator, and the unit reactor operators failed to recognize the TS violation. It was not until the next shift that an off going Reactor Operator, during a control board walkdown prior to shif t turnover, observed the mispositioned blocking switches, notified the Shif t Supervisor,o and correctly positioned the switches. i To emphasize the need for: (1) conducting licensed activities in accordance with established procedures, (2) providing adequate attention to detail to minimize personnel errors, and-(3) ensuring that procedures and changes in procedures have the proper level of review and are adequate for performing work activities, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed
' Imposition of Civil Penalties in the amount of Twenty Five Thousand Dollars
($25,000). In accordance with the " General Statement of policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violations have been classified in the aggregate as a Severity Level III problem. The base civil penalty for a Severity Level III problem is 550,000. The staff considered escalation of the civil penalties because of a prior enforcement action issued on October 19, 1984 for similar problems in the general area of concern (EA 84-97). However, the NRC recognized that'your staff identified the violations, and reported them to NRC. In addition, once the violations were identified, they were given management attention and prompt and extensive corrective actions were taken. Therefore, the base civil penalty is being mitigated 50 percent. ! You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further enforcement action is necessary to ensure compliance with NRC
-regulatory requirements.
In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room. NilREG-0940 f.A-348 i l
Union Electric Company 3 SEP g .190-The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, p jip k g %6 - yJames G. Keppler
-Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalties
- 2. Inspection Reports No. 50-483/86010(DRP);
No. 50-483/86017(DRP) cc w/ enclosures: A. P. Neuhalfen, Manager Quality Assurance S. E. Miltenberger, General Manager,-
~
Nuclear Operations DCS/RSB (RICS) Lictnsing Fee Management Branch Resident Inspector, RIII Region IV Resident Inspector, Wolf Creek K. Drey Chris R. Rogers, P.E. Utility Division, Missouri Public Service Commission SNUPPS NilPEG-0940 I.A-349
W NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Union Electric Company Docket No. 50-483 Callaway Station License No. NpF-30 Unit 1 EA 86-119 NRC inspections conducted during the periods April 14 - May 31,1986 and June 4-11,1986 identified violations of NRC requirements. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below: I. A. Technical Specification 3.5.2 requires that two independent Emergency Core Cooling System (ECCS) subsystems be operable with each subsystem comprised of an operable flow path when the unit is in operational Modes 1, 2, and 3. Technical Specification 3.0.3 requires that when a Limiting Condition for Operation is not met, except as provided in the associated Action requirements, within one hour action must be initiated to place the unit in a Mode in which the specification does not apply. When in Hot Standby (Mode 3) the unit must be placed in at least Hot Shutdown (Mode 4) within the following six hours and Cold Shutdown within the subsequent 24 hours. Contrary to the above, on April 12, 1986, at 4:02 a.m., with the unit in Hot Standby, licensee personnel closed safety injection cold leg isolation valve EM-HV-8835 while performing a surveillance test. This action blocked the operable flow path and rendered both trains of the Intermediate Head Safety Injection System, an ECCS subsystem, inoperable. The valve remained closed until 10:10 a.m. The licensee did not take action within one hour to place the unit in Hot Shutdown (Mode 4) within the following six hours, and the valve remained closed until 10:10 a.m. B. 10 CFR 50.72(b)(2)(iii) requires that a licensee notify the NRC within four hours of any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
~
NUREG-0940 I.A-350
Notice of Violation 2 SEP 9 1996 Contrary to the above, on April 12, 1986 the licensee identified at 10:10 a.m. that both trains of the Intermediate Head Safety Injection System had been rendered inoperable, a condition that could have prevented the fulfillment of the safety function of a system needed to mitigate the consequences of an accident, and did not natify the NRC within four hours after identifying this condition. II. Technical Specification 3.3.2 requires that the Engineered Safdty Features Actuation System (ESFAS) instrumentation channels shown in Table 3.3-3 be operable. Table 3.3-3, Item 6.g requires that when the plant is operating in Modes I or 2, a minimum of three of four instrumentation channels be operable to start Auxiliary Feedwater Pumps (AFP) after the trip of all 4 Main Feedwater pumps (MFP). Contrary to the above, from 7:51 p.m. on May 30, 1986 until 6:48 a.m. on May 31,1986 (a period of approximately 11 hours), the plant operated in Mode 2 with all four channels of the AFP ESFAS inoperable (blocked). 14s a result, the automatic start capability of-the AFP on loss of the MFP was defeated. Collectively, the above violations have been evaluated as a Severity Level III problem (Supplement I). (Cumulative Civil Penalty - 525,000 assessed equally among the violations) Pursuant to the provisions of 10 CFR 2.201, Union Electric Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Union Electric Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United Stated in the cumulative amount of Twenty Five Thousand Dollars ($25,000) or may protest imposition of the civil penalty in whole or in part by a written answer NUREG-0940 f.A-351
4 Notice of Violation 3 SEP 9 1996 addressed to the Director, Office of Inspection and Enforcement. Should Union Electric Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Union Electric Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violation listed in this Notice, in whole or in part; (2) demonstrate extenuating circumstances, (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In. requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in rely pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Union Electric Company's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION G =_0 W- Aw jdamesG.Kephe# r , Regional Administrator Datedat,plenEllyn, Illinois, 3 day of September, 1986. this I NUREG-0940 I.A-352
s i a 1901 Grabot Street. St. Loun DoneM F. SchneN Vce Presm l- , Cctober 9, 1986 Mr. James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclear. Regulatory Commission Washington, D.C. 20555 ULNRC- 1384 +
Dear Mr. Taylor:
INSPECTION REPORT NOS. 50-483/86010 AND 50-483/86017 l' This responds to Mr. James G. Keppler's letter dated September 9, 1986 which transmitted a Notice of Violation and Proposed Imposition of Civil Penalties for items of noncompliance identified by inspections conducted at Callaway Plant during the periods April 15'through May 31, 1986 and June 4 through June 11, 1986.. Our respons-es to the items of noncompliance are presented below.in the order listed within the body of the Notice. Also included is our decision with respect to the proposed Ciyil Penalty. None'of the material in this response is considered proprie-l tary by Union Electric Company. 4-(50-483/86010-04) SEVERITY LEVEL III: VIOLATION I.A Technical Specification 3.5.2 requires that two independent Emergency Core Cooling System'(ECCS) subsystems be operable with each subsystem comprised of an operable flow path when
- j. the unit is in operational Modes 1, 2, and 3.
Technical Specification 3.0.3 requires that when a Limiting condition for Operation is not met, except as provided in 1 the associated Action requirements, within one hour action must be initiated to place the unit in a Mode in which the i specification does not apply. When in Hot Standby (Mode 3) the unit must be placed in at least Hot Shutdown (Mode 4) within the following six hours and Cold Shutdown within the subsequent 24 hours. Contrary to the above, on April 12, 1986, at 4 :02 a.m. , with the unit in Hot Standby, licensee personnel closed safety injection cold leg isolation valve EM-HV-8835 while perform-ing a surveillance test. This action blocked the operable 1 Maang Address: P.O. Box 149. St. Lows. MO 63166 l NUREG-0940 I.A-353
- . - , + - - . . - . , - - . - - . . . - . - , ,,---------,,,--r, - , ----..,.,---,--,e,--.n , n -e -n.e------ - - - - - - - -
.1 I
Mr. James M. Taylor Page 2 October.9, 1986 l flow path and rendered both trains of the Intermediate Head Safety Injection System, an ECCS subsystem, inoperable. The licensee did not take action within one hour to place the unit in Hot Shutdown (Mode 4) within the following six
-hours; and the valve remained closed until 10:10 a.m.
Response
Admission or Denial of the Alleged Violation As previously noted in Licensee Event Report 86-009-01 transmitted to the NRC May 16, 1986, Union Electric acknowl-edges'the cited violation. Reasons for the Violation if Admitted This violation occurred because of unintentional personnel errors during the scheduling,~ reviewing, and performance of OSP-EP-V0003 "Section XI Accumulator Safety Injection Valve Operability". The errors and contributing factors are summarized as follows: A. Scheduling personnel identified surveillance test OSP-EP-V0003 as required ~to be performed in Mode 3 prior-to RCS pressure reaching 1000 p.s.i.g., which failed to recognize the Surveillance Task Sheet (STS)
" Task Performance Mode" requirements. The STS stipulated performance of the surveillance in Mode 4 ONLY.
B. The April 12, 1986 Mode 3 change letter confused operating personnel. In an attempt to provide addi-tional information to the' Control Room, mode change-
- letters have been used to identify surveillances due in the near future which would be affected by'the mode change, as well as surveillances required for the mode change. Surveillance tracking personnel identi-fled OSP-EP-V0003 on-the Mode 3 change letter to be performed in Mode 3 when conditions permit (RCS pres-sure greater than 300 p.s.i.g.). This was based on our need to perform the surveillance (18-month surveil-lance - due June 1986) prior to declaring the safety injection accumulators operable.
C. Operations personnel erroneously authorized performance of the OSP in Mode 3. During review of OSP-EP-V0003 prior to running the test,-Operations personnel noted that the OSP initial conditions st.ipulated performance of the procedure in Mode 4 only. They reviewed the NUREG-0940 I.A-354
, . -. . - . . ~
t Mr. James M. Taylor Page 3 October;9, 1986
'OSP, the mode change letter and the schedule, and.
erroneously authorized performance of this surveillance in Mode 3 by a-Temporary Change Notice (TCN) to the procedure overlooking the effect of closing EM-HV-8835 when in Mode 3.- This mistake was caused by confusion i- between the schedule, the initial conditions of the
-procedure, and the mode change letter.
D. Revision of the Surveillance' Task Sheet-did not follow the existing review and approval cycle. With issuance of the TCN, the Surveillance Task Sheet " Task Perfor-mance Mode" was changed by Operations personnel without the appropriate reviews and approvals.
~
Corrective Steps That Have Been Taken and the Results Achieved At 10:10 a.m. on April 12, 1986, during the routine Control Room Shift and Daily Log Readings and Channel Checks, a Reactor Operator found valve position switch EM-HIS-8835 indicating closed. Technical Specification Action Statement :3.0.3 was immediately entered since Technical Specification 3.5.2 does not provide Action Statements for two inoperable Intermediate Head Safety Injection Trains. EM-HV-8835 was restored to the open position within the one
, hour time constraint in Technical Specification 3.0.3.
The following corrective actions address each paragraph listed in the preceding " Reasons for the Violation" section.
~
A. Progressive Discipline was imposed on the responsible 2
' Outage Department personnel and Outage Planning and Scheduling personnel were advised of the necessity to
. comply with programmatic controls. These actions were
- complete as of April 18, 1986.
On. April 30, 1986, Scheduling personnel initiated program changes to assure that OSP-EP-V0003 is performed in Mode 4 as a Mode 3 restraint during future outages. Outage. Department procedure BDP-ZZ-00007, " Outage
' Planning and Scheduling; Schedule Development.and Review Requirements", was issued on August 20, 1986 to specifically address the use of the Surveillance Task Sheet " Task Performance Mode" for scheduling Technical Specification Surveillances.
1 B. Procedure ODP-ZZ-00014, " Operational Mode Change Requirements", was revised May 21, 1986 to assure that i future Mode Change letters reflect only required task l NtlREG-0940 I.A-355 I w , , , - , , ,. - ,m- - ,, ,- m. - -a--------------..w---n----- - - - - - - - - - - . . - - - - -
Mr. James M. Taylor Page 4 October 9, 1986 performance conditions and Technical Specification re-quirements for Mode changes. Surveillances due in the
.near future will not be identified in the mode change letter. These will be identified to the operators separately by the Planning and Scheduling Department or by the Outage Department (for 18-month surveillances).
The Compliance group assists ~other departments by identifying infrequent surveillances that become due within the next 18-month period. All Compliance group personnel have been instructed in the proper method of initiating mode change letters and properly identifying exceptions to the letter in accordance with the above guidelines.- This will remove the ccnfusion experienced by the operating personnel as to when OSP-EP-V0003 should have been performed. C. TCN 86-570, which allowed the performance of OSP-EP-V0003 in Mode 3 was voided on April 12, 1986. This action returned the surveillance procedure to its original correct form. Progressive discipline for the responsible Operations Department personnel was completed on June 13, 1986. This included. reminding the persons involved of their responsibility to be aware of plant conditions resulting from surveillance activities and the need to remain within Technical Specification requirements. Procedure APA-ZZ-00101, " Preparation, Review, Approval and Control of Procedures", was revised on June 2, 1986 to more explicitly define the limits on the use of TCNs.. Subsequently, the use of TCNs was removed from APA-ZZ-00101 and issued as a new procedure APA-ZZ-00114, " Temporary Changes to Procedures". APA-ZZ-00114 was issued August 21, 1986 to define the use and processing of Temporary Change Notices. The procedure does not allow significant changes to initial conditions by using a TCN. Therefore, changing the Mode for performing a surveillance procedure is no longer allowed by a Temporary Change Notice, a complete procedure revision and review is required. D. Management has re-emphasized adherence to administrative controls for revisions to task sheets and surveillance procedures to appropriate plant personnel. Corrective Steps Which Will Be Taken to Avoid Further Violations No further corrective action is considered necessary. NUREG-0940 I.A-356
.- .. - . , ~ . . _ _ . ~ - - - . .. -. .. . - .
a Mr. James M. Taylor Page 5 October 9,=1986 Date When Full Compliance Will Be Achieved Union Electric has accomplished all corrective actions , necessary to prevent recurrence. (50-483/86010-03) SEVERITY LEVEL III: VIOLATION I.B U 10CFR50.72 (b) (2) (iii) requires that a licensee notify the NRC within four hours of any ' event or condition that alone , could have prevented the. fulfillment of the safety function of structures or systems that are needed to mitigate -the ' consequences of an accident. 4 Contrary to.the above, on. April 12, 1986 the licensee l' identified at 10:10 a.m. that both trains of the Intermedi-ate Head Safety Injection System-had been rendered inopera-i ble, a condition that could have prevented the fulfillment j of the_ safety. function of a system needed.to mitigate the
' consequences of an accident, and did not notify the NRC within four hours after identifying this condition.
Response
1 Admission or Denial of the Alleged Violation i As previously noted in Licensee Event Report 86-009-01 transmitted to the NRC May 16, 1986, Union Electric acknowl-
- j. edges the cited violation.-
Reasons for'the Violation if Admitted The reason for this violation was a. failure to recognize
, that the 10CFR50.72 (b) (2) (iii) reporting requirement per- ;
, .tained to the April 12, 1986 event. The requirement was later identified as being applicable during the event *
- - investigation.
, Corrective Steps That Have Been Taken and the Results Achieved l Compliance group personnel have been re-instructed on the 4 applicability of 10CFR50.72 (b) (2) (iii) . t-The Compliance Department transmitted training material to the Training Department which consists of a paragraph-by- t i paragraph explanation of 10CFR50.72 requirements. This material is to be included in the Licensed Operator , Requalification Training. l l l NUREG-0980 I.A-357
.~. . =. .. . . - - . ..
Y Mr. James M. Taylor. Page 6 October 9, 1986.
. Operations personnel have been made aware of,the content of LER 86-009-01,. and the reporting requirements of 10 CFR.50.72.
Corrective Steps Which Will be Taken'to Avoid Further Violations The Training Department will update the Reporting Require-ments Requalification Training Course to include the de-tailed reporting information. Date-When Full Compliance Will Be Achieved Union Electric will achieve full compliance by December 5, 1986. 4 (50-483/86017-01) SEVERITY LEVEL III: ' VIOLATION II
- Technical Specification 3.3.2 requires that the Engineered Safety Features Actuation System (ESFAS) instrumentation channels shown in Table 3.3-3 be operable. Table 3.3-3, Item 6.g requires that when the plant is operating in.
Modes-1 or 2, a minimum of three of four instrumentation channels be operable to start Auxiliary.Feedwater Pumps (AFP) after the trip of all Main Feedwater Pumps (KFP). Contrary to the above, from 7:51 p.m. on May 30, 1986,until 4 6:48 a.m. on May 31, 1986 (a period of approximately 11 hours), the plant operated in Modes 1 and 2 with all four channels of the AFP ESFAS inoperable (blocked). As a result, the automatic start capability of the AFP-en loss of
- the MFP was defeated. -While preparing for the next turnover
, the indication was'noted and corrected.
Response
Admission or Denial of the Alleged Violation As previously noted in Licensee Event Report 86-018-00
. transmitted to the NRC June 30, 1986, Union Electric ac-l
- knowledges the cited violation.
l Reasons for the Violation if Admitted l 1 Placing the switches in the " block" position was addressed in the Final Safety Analysis Report (FSAR) and Safety Evaluation Report (SER) . The Technical Specifications are 1
- NUREG-0940 1.A-358 l
.- . ._ . _ - . .. - - . . . _.-- - - - ~ .. .
Mr..' James M. Taylor Page 7 October 9, 1986 inconsistent with the FSAR and.SER. Leaving the switches in~ the'" block" position was the.rosult of Operations personnel error and inadequate. procedural controls to address.the evolution.in progress (transfer from Auxiliary Feedwater
-Pumps to Main'Feedwater Pumps).
1
' corrective Steps That Have Been~Taken and the Results 3
Achieved ^ ~ The immediate action.taken upon discovery of.the block. l switches.being in-the " block" position was to place:the
- block switches in the " permit" position.
Use of the block switches in Modes 1 and 2 has been prohib-ited on an interim basis-by Operations Department Night Orders (issued June 2, 1986). Subsequent procedural con-trols were provided by issuance of a change to Cperations Department procedure ODP-ZZ-00014,'" Operational Mode Change Requirements". Operations personnel were briefed.on the liabilities.of 4 taking action outside of procedures and were instructed to promptly bring procedure deficiencies to the attention of their supervisor. i A letter (UOMO 86-186) was issued June 10, 1986 to all
- Operations Department personnel to reiterate the importance 4
for all on-shift Operations personnel to be thoroughly , familiar with any-abnormalities associated with their . watchstation. The letter stated that each Reactor Operator and Control Room Supervisor should be able.to. explain the reason for every lighted annunciator and-abnormal' control board indication. Operating procedure OTN-AE-00001, "Feedwater System", has been revised to address the transfer of feedwater between the Auxiliary Feedwater System and the Main Feedwater System, including guidance on the use of the block switches. Corrective Steps which Will Be Taken to Avoid Further . l' Violations i '
- No further corrective action is considered necessary.
.Date When Full Compliance Will be Achieved i
{. Union Electric has accomplished all corrective actions necessary to prevent recurrence. l i NilREG-0940 I.A-359 i i
Mr. James M. Taylor Page 8 October 9, 1986 Related Steps Being Taken For Violation II A Technical Specification amendment request (#1048) is being evaluated to allow use of the block switches as intended by the FSAR/SER. Proposed Civil Penalty Union Electric does not contest the proposed Civil Penalty. Enclosed is a check in the amount of twenty-five thousand dollars ($25,000) payable to the Treasurer of the United States. Please favor us with an acknowledgement of your receipt of this payment. If you have any questions regarding this response or if additional information is required, please let us know. Very truly yours, m Donald F. Schnell DFS/JJW/bjp Enclosure - Check cc: James G. Keppler, Regional Administrator, NRC Region III W. L. Forney, NRC Region III NRC Inspectors, Callaway Plant (2) Manager, Electric Department, Missouri Public Service Commission NUREG-0940 I.A-360
l i i l l I.B. REACTOR LICENSEES, SEVERITY LEVEL III VIOLATIONS, NO CIVIL PENALTY s i NUREG-0940
#pa "f cw UN6TED STATES
/ fo, NUCLEAR REGULATORY COMMisslON yN % REGION il j
I ~'
101 MARIETTA STREET. N W. t ' A TL ANT A. GEORGI A 30323
\,
..,/ NOV 21 '996-
-Docket No. 50-400
' License No. CPPR-158.
EA 86-171 Carolina Power and Light Company ATTN: Mr. E. E. Utley Senior Executive Vice President Power Supply and Engineering
. and Construction
.P. O. Box 1551 Raleigh, NC 27602 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-400/86-66)
-This refers to the NRC inspection conducted at _the Harris facility on August.f5-28 1986 of activities authorized by NRC License No. CPPR-158. The inspection-included a review of the circumstances surrounding requirements fnr ohysical separation of -
electric cables for safety-related systems. The report documenting the results of
.the inspection was sent to you by letter dated October 10, 1986. As a result of.
-this inspection, the NRC identified a significant failure to comply with NRC r:gulatory requirements and accordingly, NRC concerns relative to the insoection findings were discussed by Dr. J. Nelson Grace, Regional Administrator, Region II, with you and members of your staff in an Enforcement Conference held in the Region II office on October'9, 1986.
The violation in the enclosed Notice 'of Violation involved the failures (1) to conduct adequate inspections of electrical installations for physical separation of electrical cables for safety-related circuits, and (2) to take adequate corrective actions based on a previous NRC inspection which identified defi-ciencies in this area (Inspection Report No. 50-400/84-41). NRC inspections
~ in this area revealed that as of July 1986 numerous separatinn deficiencies still_ existed in electrical installations. We view this violation to be sig-nificant because of the importance the NRC places in maintaining the physical -srparation of electrical circuits to ensure their reliability in service and because similar problems in this area had been previously identified by the NRC and effective measures were not taken to prevent recurrence of the deficiencies.
In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1986), the violation described in the enclosed Notice has been classified as a Severity Level III. Normally, a civil penalty is considered for a Severity Level III violation. However, after consultation with the Director, Office of Inspection and Enforcement, I have decided that a civil penalty will not be proposed in this case because of your-prior good performance in correcting conditions adverse to cuality in other functional areas and your unusually prompt and extensive actions to correct the problems once they were identified to you in July 1986. NilREG-09en I.B-1
1 [ NOV 21 PS NOTICE OF VIOLATION Carolina Power & Light Company Docket No. 50 400 Harris Unit 1 License No. CPPR-158 EA 86-171 l During the NRC inspection conducted on August 25-28, 1986, a violation of NRC .I requirements was identified. The violation involved a failure to conduct I adequate inspections of electrical construction and to take effective corrective l action on the basis of previous NRC inspections in the area of electrical ; separation. In accordance with the " General Statement of Policy and Procedure i for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1986), the violation ' is listed below: 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Actions, as implemented by the Shearon Harris Nuclear Power Plant Final Safety Analysis Report (FSAR),'Section 17.1, requires that measures shall be established to assure that conditions adverse to quality, such as deficiencies and deviations are promptly identified and corrected. Contrary to the above, as of July 25, 1986, the licensee failed to estab11sh measures to identify and correct conditions adverse to quality in that the licensee's inspection program failed to identify that electrical installations did not meet the criteria for physical separation of electrical cables for safety-related circuits. In addition, the licensee's corrective actions for electrical separation deficiencies identified during an NRC inspection conducted in 1984 were not effective in preventing recurrence of the deficiencies. This is a Severity Level III violation (Supplement II). 1 Pursuant to the provisions of 10 CFR 2.201, Carolina Power and Light is hereby required to submit to this Office within 30 days of the date of the letter transmitting this. Notice a written statement or explanation in reply including for each violation, (1) the reason for the violation if admitted (2) the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good caus? is shown, consideration will be given to extending the response time. FOR THE NUCLEAR REGULATORY COMMISSION MW J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this 2/ day of November 1986 NUREG-0940 I.B-2
g*""'% usuito states y ', NUCLEAR REGULATORY COMMISSION
$ -l neseON IV
/ sit nVAN PLAZA DalVE. suite 1000 AnLINGTO88. TEXAS 73H1 DEC 2 9156 D:cket No. 50-458 '
License No. NPF-47 EA 86-183 G21f States Utilities ATTN: William J. Cahill, Jr. Senior Vice President River Bend Nuclear Group P. O. Box 220 St. Francisc111e, Louisiana 70775 1
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-458/86-36) This refers to the NRC inspection conducted of activities authorized by License ! No, NPF-47 during the period October 16-23, 1986 at the River Bend Station. This inspection consisted of a review and evaluation of the circumstances and corrective actions associated with the modification of the control building ventilation system. During the inspection, a violation of NRC requirements was identified. The inspection findings were documented in Inspection Report No. 50-458/86-36 s:nt to you be letter dated October 30, 1986, and an enforcement conference was conducted November 10, 1986, at the Region IV office to discuss the violation and your corrective actions. As described in the enclosed Notice of Violation, plant personnel discovered on October 16, 1986 that temporary alterations to the control building venti-lation system had been implemented on October 29, 19815 and June 27, 1986 based on an inadequate safety evaluation. The safety evaluation failed to recognize that the temporary alterations prevented the automatic start of one of the redundant trains of the control building ventilation system ursier certain single failure scenarios. Without this automatic, start capability, manual actuation would have been required to prevent control room, switchgear room, and chiller room temperatures from exceeding their design basis limits during a loss of coolant accident with offsite power available. While it appears that the 1 inadequate evaluation had no impact on plant safety, the NRC is concerned that your engineering review process for these modifications was deficient in ths identification of the system design bases used in the 50.59 safety evaluation. In accordance with the " General Statement of Policy and Procedure for NRC Enfercement Actions," 10 CFR Part 2, Appendix C (1986), the violation described in the enclosed Notice has been classified at a Severity Level III. Nomally, a civil penalty is considered for a Severity Level III violation. However, after consultation with the Director Office of Inspection and Er.forcement, I have decided that a civil penalty will not be proposed in this case because of th) unusually prompt and extensive corrective actions taken to correct the problem and prevent recurrence, and the licensee's prior good perfomance in th2 general area of concern. 1 CERTIFIED MAIL - RETURN RECEIPT REQUESTED 11JREG-0940 I.B-3 1
Gulf States Utilities DEC 2 9 m You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as reqrtired by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, I [fu Robert D. Martin Regional Administrator
Enclosure:
Notice of Violation cc w/ enclosure: State of Louisiana Radiation Control Program Director l l t!UPEG-09a0 T .P.-4 l
NOTICE OF VIOLATION Gulf States Utilities Docket No. 50-458
. River Bend License No. NPF-47 EA 86-183 During an NRC inspection conducted on October 16-23, 1986, a violation of NRC requirements was identified. The violation involved failure to perform an adequate 10 CFR 50.59 evaluation of a temporary modification to the control building ventilation system. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation is listed below:
10 CFR 50.59(a) allows the holder of a ifcense to make changes in the facility as described in the safety analysis report (SAR) without prior Conuission approval unless it involves a change in the technical specifications or involves an unreviewed safety question. An unreviewed safety question is created if the probability of occurrence or the consequences of an accident or the mal-function of equipment impcrtant to safety previously evaluated in the SAR are increased, or if a possibility for an accident or malfunction of a different type than any evaluated previously in the SAR may be created, or if the margin of safety as defined in the basis for any technical specification is reduced. 10 CFR 50.59(b) requires in part that the licensee maintain records of changes in the facility to the extent that such changes constitute changes in the ' . facility as described in the SAR. These records shall include a written safety evaluation which provides the bases for the determination that the change does not involve an unreviewed safety question. Section 9.2.10.5 of the River Bend Final Safety Analysis Report (FSAR) states that low air flow through an air conditionin operating chilled water recirculation pump. gControl unit trips theisassociated logic provided so that low chilled water flow through a chiller automatically starts the redundant system's chilled water recirculation pump. Section 9.4.1.3 of the River Bend FSAR further states that the single failure criterion is met.by the redundant design of equipment and controls so that the controis automatically switch from the failed piece of equipment to the redundant equipment. Contrary to the above, the licensee failed to meet the requirements of 10 CFR 50.59 in that the licensee improperly analyzed changes made to its facility, as described in the FSAR, and concluded that an unreviewed safety question did not exist when, in fact, an unreviewed safety question did exist. The unreviewed safety question was created when the control building ventilation system was modified on October 29, 1985 and June 27, 1986 so that low air flow through an air conditioning unit would no longer trip the associated operating chilled water i recirculation pump. Without this trip, failure of an operating air conditioning unit would not result in the automatic start of the redundant air conditioning unit. Therefore, the change involved an unreviewed safety question because a possibility for a malfunction of a different type than any evaluated in the FSAR was created. This is a Severity Level III violation (Supplement I). NUREG-Ondo I.B-S
Notice of Violation Pursuant to the provisions of 10 CFR 2.201, Gulf States Utilities is hereby required to submit to this Office within 30 days of the date of the letter transmitting including: (this Notice, a written statement or explanation in reply,1) the reason for the vio steps which have been taken and the results achieved (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. Dated :t' Arlington, Texas, this / day of December, 1986. l l i N!! REG-0940 1.B-6
spa ase6 UNITED 5TATES 9 h, NUCLEAR REGULATORY COMMIS$lON g ", nEcsON I E ! sai ...n vanus ( *" *
- j, .... o ,..u u. .. m v.~i. m ..
DEC 2 31c56 Docket No. 50-410 License No. CPPR-112 EA 86-135 Niagara Mohawk Power Corporation ATTN: Mr. William Donlon President 300 Erie Boulevard, West Syracuse, New York 13202 Gentlemen:
Subject:
NOTICE OF VIDI.ATION (NRC 0FFICE OF INVE; ;^AT;C .3 (CI) iU';.;T N0. 1-84-014) This refers to the investigation conducted by the NRC Office of Investigations (OI) in response to alleg&ti':ns that Niagara Mchawk Power Corporation (NMPC) Quality Assurance (QA) auditors were harassed and intimidated as a result of the findings of QA Audit No. 84-4 conducted in January and February 1984. The audit findings were critical of aspects of the QA program, including certain actions by the than Vice President of QA. The investigation disclosed an apparent violation of NRC regulations. A redacted version of the OI Report was provided to your attorney, Mr. Gary Wilson, on June 13, 1986 and on July 25, 1556, an enforcernent conference was conducted with you and members of your staff to discuss the 01 findings. IM violatic- in W '7d Notice cf Viciation cescribes an incicent of discrimination in sici ..on of 10 CFA E. 7 acair.: tw QA auditors assigned to the NMPC QA Department. ;C CFR 50.7 pronitics c.scrimination by a Commission licensee or permittee against an employee for ergaging in certain protected activities. Discrimination includes demotions and other actions that relate to compensation, terms, conditions and privileges of employment. The activities protected include, but are not limited to, reporting safety concerns to the NRC or to the employee's management. Based upon the findings of the OI investigation, the NRC staff has determined that two NMPC QA auditors were the subject of discrimination in that their lead auditor status was rescinded on April 5, 1984 by the former QA Vice President because they made adverse QA findings concerning the NMPC Qt Group at Nine Mile Point Unit 2. The lead auditor status of these individuals was subsequertly restored on June 1, 1984. The root cause of this discrimination appears to have been an underlying deficiency in effective management control of the QA program. The OI findings demonstrate the importance cf having licensee managc: ont that cre:tcs and maintains an 2nviron ent ir dich all e.7;/:yees feel free to raise safety concerns without fear of reprisal. Without such an environment, personnel may be hindered from effectively performing their duties which can have an adverse impact on plant safety. NUREG-0940 I.8-7
Niagara Mohawk Power Corporation In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation described in the enclosed Notice has been classified at a Severity Level III. Normally, a ci dl ;;"-Ity is c:aidared for a Severity Level III violation. However, after consultation with the Director, Office of Inspection and Enforcement, I have decided that a civil penalty will not be proposed in this case because:
~(1) the individual responsible for the alleged discrimination, the Vice President of QA, was replaced in May 1984, (2) lead auditor status was restored to the two auditors discriminated against with no loss of compensation or other privileges of employment through self-initiated action on the part of new QA management, (3) significant QA management changes and program improvements were in process at the time of the alleged discrimination (these changes and improvements included increased QA staffing with experienced personnel, the development of a Quality First Program to provide a vehicle for erployees to raise concerns cer.fidentially within the company, and the development of a Quality Performance Management Program to monitor and assess construction quality trends), and (4) the alleged discrimination appears to be an additional example of the underlying deficiency in effective management control of the QA program which was identified during an NRC Construction Appraisal Team (CAT)
Inspection in November and December 1983 and which resulted in issuance of a Notice of Violation and Proposed Imposition of Civil Penalty ($100,000) and Order on March 20, 1984. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. You should also include a detailed description of the actions taken by you to ensure that all employees of your ermi:ctio- 4el free to bring safety concerns to their management or t: the NT.. without fear of reprisal. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, Thomas E. Murley Regional Administrator
Enclosure:
Notice of Violation NUREG-0940 f.R-8
NOTICE OF VIOLATION Niagara Mohawk Power Corporation Docket No. 50-410 Nine Mile Point Unit 2 Licensee No. CPPR-112 EA 86-135 Duri.1g an NRC investigation by the NRC Office of Investigations (OI) a violation of NRC requirements was identified. 01 Report 1-84-014. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation is listed below: 10 cFR 50.7 prohibits discrimination by a Commission licensee or permittee against an employee for engaging in certain protected activities. Dis-crimination-includes actions that relate to compensation, terms, condi-tions and privileges of emoloyment. The activities protected include, but are not limited to, reporting safety concerns to the NRC or to the employee's managercent. Contrary to the above, Anthony Laratta and Rudolph A. Norman, Quality Assurance (QA) auditors assigned to the Niagara Mohawk Power Corporation QA Department, were the subjects of discrimination in that their lead-auditor status was rescinded on April 5, 1984, by the former QA Vice President in retaliation for making QA findings critical of the QA program at Nine Mile Point Unit 2 during Audit No. 84-4. The lead auditor status of these individuals was not restored until June 1, 1984. This is a Severity Level III violation (Supplement VII) Pursuant to the provisions of 10 CFR 2.201, Niagara Mohawk Power Corporation is hereby required to submit to the Regional Administrator, Region I, within 30 days of the date of the letter transmitting this Notice, a written statement or explanation in reply, including for each violation: (") the reason for the violation if admitted, (2) the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is L min, consid. ration will be given to extending the response time. Dated at King of Prussia, Pennsylvania this d day of hece hr 1986 NUREG-0940 I.B-9
s UNITED STATES [pa nec,,,' *g NUCLEAR REGULATORY COMMISSION t c S REGION HI [ E- l 799 ROOSEVELT no Ao GLEN ELLYN, ILUNO45 60137
***** DEC 11 1986 Docket No. 50-263 License No. DPR-22 EA 86-165 Northern States Power Company ATTN: Mr. C. E. Larson Vice President, Nuclear 414 Nicollet Mall Minneapolis, MN 55401 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-263/86004) This refers to the inspection conducted during the period May 28 - September 5, 1986 at the Monticello Nuclear Generating Station of activities authorized by NRC License No. DPR-22. The inspection included a review of the circumstances associated with a violation identified by your staff and reported to the NRC on June 12, 1986. The violations involved the inoperability of both trains of the Standby Liquid Control (SLC) System during the period November 2,1984 - June 11, 1986. The violations, the causes, and your corrective actions were discussed during an enforcement conference in the Region III office between you, Mr. Dennis Gilbert, and other members of your staff and Mr. A. B. Davis and other members of the Region III staff on September 25, 1986. The violations in the enclosed Notice of Violation (Notice) are considered significant because of the time the violations existed prior to their correction. Violation A in the Notice resulted from the incapability of both trains of the SLC System of providing injection flow upon initiation from the control room. Because of the failure to ensure that electrical fuses were properly coordinated, the actuation of the SLC system explosive valves caused tne firing circuit to be shorted. The short caused t4 electrical circuit breaker for the control power to the SLC pump motor to trip, thereby tripping the pump and rendering the SLC system inoperable. This deficiency was revealed during testing of th? SLC system on June 11, 1986. Violation B in the enclosed Notice involves the failure to assure that timely I and effective ccrrective actions were taken after the potential for this problem was identified to your plant management by the NRC, General Electric, and your I plant engineering personnel. This matter is of particular concern because the NRC sent to you IE Circular 77-09, Improper Fuse Coordination in BWR Standby Liquid Control System Control Circuits, dated May 27, 1977 to alert you to this specific problem. In addition, on August 6, 1977, General Electric sent to you Service Information Letter (SIL) 236, Fuse Coordination in SLC System, which addressed the fuse coordination problem. Had your plant staff followed the diagnostic tests recommended by this 1977 SIL, this problem could have been NilREG-0940 1.B-10
Northern States Power 2 Company DEC 11 1996 identified and corrected in that time period. Furthermore, your plant engi-neering personnel did recognize that the fuse coordination problem existed as early as March 1979. However, a design change was never implemented because your staff concluded that the probability of shorting both detonators in both squib valves was low; therefore, the design change was assigned a low priority with years of delay at various stages of the design change process. It was not until after the testing failures on June 11, 1986 that corrective measures
-were taken.
In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violations described in the enclosed Notice have been classified as a Severity Level III problem. The base civil penalty for a Severity Level III violation or problem is $50,000. However, after consultation with the Director, Office of Inspection and Enforce-ment, I have decided that a civil penalty will not be proposed in this case. Although you had been previously notified of the potential for this problem, this problem appears to be an isolated case and you have prior good performance in this general area of concern. However .it is significant that you had mar.y opportunities to correct this problem considering its duration and that you had knowledge of the potential for this problem to exist. Future violations of this type will result in civil penalty enforcement action. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2./90 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room. NUREG-0940 1.B-11
Northern States Power 3 g gg g Company The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Red"ction Act of 1980, PL 96-511. Sincerely, ko^g MamesG.Keppfer{n Regional Administrator
Enclosures:
- 1. Notice of Violation
- 2. Inspection Report No. 50-263/86004(DRP) cc w/ enclosures:
W. A. Shamla, Plant Manager Licensing Fee Management Branch Resident Inspector, RIII Monticello Resident Inspector, RIII Prairie Island John W. Ferman, Ph.D., Nuclear Engineer, MPCA 1 l l 1 NUREG-0940 I.B-IT l l
NOTICE OF VIOLATION c,.
. Northern States Power Company . Docket No. 50-263 Monticello Nuclear Generating Station License No. DPR-22 EA 86-165
]
During an NRC inspection conducted during the period May 28_- September 5; 1986,-which reviewed an incident identified by the licensee and reported to the NRC on June 12, 1986, violations of NRC requirements were identified. The
. violations involved a failure to assure that the Standby Liquid Control System was operable and to take timely effective corrective actions after the. licensee
~
was informed that a . fuse coordination problem could exist. In accordance with
, the " General Statement of Policy and Procedure for NRC Enforcement Actions,"
10 CFR Part 2, Appendix C (1986), the violations are listed below: A. Technical Specification (TS) 3.4.A requires that the standby liquid i control (SLC) system be operable at all time, when fuel is in the reactor and the reactor is not shut down by control rods, except as specified in TS 3.4.B. TS 3.4.8 provides that from and after the date that a redundant component
.is made or found to be inoperable, Specification 3.4.A shall be considered fulfilled provided the component is returned to an operable condition within 7 days.
T TS 3.4.0 requires that if Specifications 3.4.A through C are not met, an l' orderly shutdown shall be initiated, t Contrary to the above, during various times between November 2, 1984 and-June 11, 1986 when fuel was in the reactor and the reactor was not shut down by control rods, both trains of the SLC system were incapable of providing injection _ flow upon initiation from the control room and actions were not taken to initiate an orderly shut down. The squib valve detonators , installed on November 2,1984 were tested on June 11, 1986 and caused a short circuit which tripped the SLC pump motor, d B. 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Actions, requires that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly < 4 identified and corrected. Contrary to the above, as of June 11, 1986, the licensee's corrective actions program failed to assure that the fuse coordination deficiencies
-in the Standby Liquid Control System were promptly identified and corrected.
The fuse coordination problem was identified to the licensee: (1) by the NRC in IE Circular 77-09, Improper Fuse Coordination in BWR Standby Liquid ' Control System Control Circuits, dated May 1977; (2) by General Electric in a Service Information Letter (SIL) 236, Fuse Coordination in SLC System, issued in August 1977; and (3) by a licensee system engineer in response to a March 1979 plant request. However, the problem was not corrected until after testing on June 11, 1986 which found both trains of the Standby . Liquid Control System inoperable. J NUREG-0940 I.B-13 _ _ ~ _ - _ . _ _ _ . . _ _ . , - _ - - - - _ _ , _ _. . - .. _ _ _ ___ _ _ _ _
Notice of Violation 2 DEC 1 1 1986 Collectively, these violations have been evaluated as a Severity Level III , problem (Supplement I). l Pursuant to the provisions of 10 CFR 2.201, Northern States Power Company is hereby required to submit to this Office within 30 days of the date of the letter transmitting this Notice, a written statement or explanation in rely, including for each violation: (1) the reason for the violations if admitted; i
.(2) the corrective steps which have been taken and the results achieved; (3) !
the corrective steps which will be taken to avoid further violations; and (4) l the date when full compliance will be achieved. Where good cause is shown, i consideration will be given to extending the response time. Dated at glen Ellyn, Illinois this u 7 ay of December 1986 NUREG-0940 1.R-14
#" "'%', UNITED STATES y *; NUCLEAR REGULATORY COMMISSION 4 3 j Reason w 811 RYAN Pt.AZA DRIVE. SUITE 1950 g ARLHIIGTON.TEMAS 74011 ,
l MC 33 W6 ! Docket No. 50-148 1 License No. R-78 EA 86-186 University of Kansas
, ATTN: Mr. R. Bearse, Associate Vice Chancellor 4006 Learned ; Lawrence, Kansas 66045-2223
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-148/86-01) This refers to the inspection conducted on September 11-12, 1986 of the
- ' activities authorized by NRC Operating License No. R-78 at the University of Kansas, Lawrence, Kansas. During this inspection, several violations of NRC requirements were identified. NRC Inspection Report No. 50-148/86-01, which documented the inspection findings, was sent to you on October 30, 1986. An enforcement conference was held at the Region IV office on November 4, 1986 to discuss the inspection findings.
The violations in the enclosed Notices of Violation (NOV) involve the areas of
! health physics, safeguards, and research reactor operations. Violation A in the NOV Appendix A involves the significant failure to receive NRC authorization
! pursuant to 10 CFR 50.82 for dismantisment and disposal of the research reactor i prior to initiating such operations. Although the dismantlement activities had ! been completed safely, it is significant that you failed to receive prior autho-L' rization in accordance with NRC requirements. Therefore, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement .4ctions," 10 CFR Part 2, Appendix C (1986), Violation A has been classified at a Severity Level III. Although the failure to formally comply with 10 CFR 50.82 would normally be categorized at Severity Level IV, you demonstrated careless disregard for this requirement by not complying with 10 CFR 50.82 even after being informed of the requirement by the project manager, Office of Nuclear Reactor Regulation. Therefore, the severity level of the violation has been increased from Severity l Level IV to Severity Level III. Normally, a civil penalty is proposed for a Severity Level III violation. However, after consultation with the Director. Office of Inspection and Enforcement, I have decided that a civil penalty will not be proposed in this case because of your prior good performance in the area of reactor operations. Violations B and C in Appendix A have been characterized as Severity Level V violations. Violation A in Appendix B involving a safeguards violation has been characterized as a Severity Level IV violation. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this , Notice, including your proposed corrective actions, the NRC will determine REMOVAL OF THE PAGES MARKED "$AFEGUARDS INFO AMATioN" DECONTROM THE REMAINDER OF THIS DOCUMENT, LtRT IF IED MA L-Mt t uun Mtt,tiri ntyutai tu NIIPEG-0940 I.P.-15 l l
DEC 2 3 BBS University of Kansas whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures, except Appendix B, will be placed in the NRC Public Document Room. Appendix B contains Safeguards Information as defined by 10 CFR 73.21. Its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, Appendix B of this letter will not be placed in the Public Document Room. When responding to this lette7 and Appendix B, place all Safeguards Information in a separate enclosure. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, ML
# Robert D. Martin Regional Administrator
Enclosures:
Appendix A - Notice of Violation Appendix B - Notice of Violation cc w/o Appendix B: Kansas Radiation Control Program Director j I HUREG-Ogan I.8-16
MC 23 566 APPENDIX A NOTICE OF VIULATION University of Kansas Docket No. 50-148 Lawrence, Kansas License No. R-78 EA 86-186 During an NRC inspection conducted on September 11-12. 1986, several violations of NRC requirements were identified. The violations involve the areas of health physics and research reactor operations. In accordance with the " General State-ment of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violations are listed below: A. Failure to Apply for Authority to Dismantle a Facility 10 CFR 50.82(a) requires that any licensee may apply to the Commission for authority to surrender a license voluntarily and to dismantle the facility and dispose of its component parts. Contrary to the above, the licensee had disassembled the reactor during February 1986 for the purpos'e of dismantlement, without application to the Casuiission for authority to perform dismantling activities. This is a Severity Level I!! violation (Supplement I). B. Failure to Post Required Regulatory Documents 10CFR19.11(a)(1),19.11(a)(2),19.11(a)(3),and19.11(c) require, in (1)part, that Parts 10 CFR the licensee 19 and post current 20, (2) copieslicense the license, of the following conditionsdocuments: documents incorporated into the license by reference, and amendments, (3), operating procedures applicable to licensed activities, and (4) a Form NRC-3, states that if 10CFRpart19.11(b)(1),19.11(a)(2)postingadocumentspecifiedin 10 CFR Part 19.11(a) ,or19.11(a)(3)isnotpracticable, the licensee may post a notice which describes the document and states where it may be examined. Contrary to the above, the NRC inspector determined on September 12, 1986, that the licensee did not have such documents posted or a notice posted describing the documents and stating where the documents may be examined. ThisisaSeverityLevelVviolation(SupplementIV). C. Failure to Identify Radioactive Material 10 CFR 20.203(f) requires, in part, that each container of licensed material shall bear a durable, clearly visible label identifying the radioactive contents. Contrary to the above, the NRC inspectors determined on September 12, 1986, that the licensee had not labeled a fission monitor containing 1 gram of U-235. ThisisaSeverityLevelVviolation(SupplementIV). f:l' PEG-0940 I.B-17
e-DEC 2 3 566 Appendix A Pursuant to the provisions of 10 CFR 2.201, the University of Kansas is hereby required to submit to this Office within 30 days of the date of the letter
' for transmitting this Notice,'a each violation: (1) thewritten statement reason or explanation for the violation in rep (ly, if admitted, including 2).the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time.
l Dated at Arlington, Texas, ; this 22 day of December, 1986, l l l NilREG-0940 f.P-18 l -
I
/
II.A. MATERIALS LICENSEES, CIVIL PENALTIES AND ORDERS NUREG-0940
UNITED $TATES I [pa meh,I*.,
,, NUCLEAR REGULATORY COMMISSION
{ ' i r- ( o REGION 1 L" 'l sss enRK AVENUE j .aua on avma. ,Eaumvania inu AUG 2 o ggg5 Docket No. 030-06219 License No. 37-09928-01 EA 85-86 Astrotech, Incorporated ATTN: L. M"kyta President 7801 Allentown Boulevard Harrisburg, Pennsylvania 17112 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION 85-01) This refers to the NRC inspection conducted on June 20, 25, and July 2, 1985, l at your facility in Harrisburg, Pennsylvania of activities authorized by NRC License No. 37-09928-01. The report of the inspection was forwarded to you on July 18, 1985. During the inspection, twelve violations of NRC requirements were identified, two of which were similar to violations identified during the previous NRC inspection in 1984 (NRC Inspection 84-01). On July 25, 1985, we held an enforcement conference with you during which these violations, their causes, and your corrective actions were discussed. The number of violations identified during the inspection is of significant concern to.the NRC. In particular, the NRC has significant concerns about two of the violations which involve the use of two individuals as a radiographer and a radiographer's assistant who had not been certified to perform the duties i ' of those positions. The performance of radiography activities by uncertified individuals creates a potentially significant hazard to the individual, other workers, and members of the public. Collectively, the twelve violations demon-strate the need for improvement in management cont- ' over activities at Astrotech, Incorporated to assure adherence to NRC requirements and safe performance of licensed activities. To emphasize the importance of adequate oversight and control of your licensed activities, I have been authorized, after consultation with the Of rector, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Thousand Dollars ($5,000) for the violations set forth in the enclosed Notice. The violations have been classified in the aggregate as a Severity level III problem in accor-dance with the " General Statement of Policy and Procedure for NRC Enforcement i Actions," 10 CFR Part 2, Appendix C (1985) (Enforcement Policy). Although Vio-i lation A could by itself be classified at Severity Level III in accordance with i Section C.4 of Supplement VI of the Enforcement Policy, the violations have been estegorized in the aggregate at Severity Level III to focus on their underlying cause, namely, a lack of adequate management control of the radiation CERTIFIED MAIL RETURN RECEIPT REQUESTED ITPEG-ONO II.A-1 l
Astrotech, Incorporated safety program. The base value of a civil penalty for a Severity Level III violation or problem is $5,000. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appro-priate. You are required to respond to this' letter, and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you also should describe those management controls you have instituted to ensure that licensed activities are performed only by certified, trained individuals and that licensed activities are performed in compliance with NRC requirements. In addition, your response should address your proposed actions to promptly identify and correct program deficiencies. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure' compliance with NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, C. I (f f, N k d% Thomas E. urley Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1: Public Document Room (POR) Nuclear Safety Information Center (NSIC) Commonwealth of Pennsylvania NilPEG-0940 II.A-2
NOTICE OF VIOLATION AND PR0p0 SED IMPOSITI0ii~0F CIVIL PENALTY Astrotech, Incorporated Docket No. 030-06219 Harrisburg, Pennsylvania License No. 37-09928-01 EA 85-86 An NRC inspection of activities authorized under NRC License No. 37-09928-01 was I conducted at Astrotech, Incorporated, Harrisburg, Pennsylvania on June 20, 25, ) and July 2,1985. During the inspection, twelve violations of NRC requirements were identified, two of which were similar to violations identified during the previous NRC inspection conducted in 1984. Collectively, these violations indicate that adequate management control and oversight of the. radiation safety program has not been exercised. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1985), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295 and 10 CFR 2.205. The particular violations and the associated civil penalty are set forth below: A. 10 CFR 34.31(a) requires that no individual act as a radiographer until that individual can demonstrate his understanding of the instructions which he has received regarding the subjects covered in Appendix A of Part 34 and has successfully completed a written test on the subject covered. Contrary to the above, one individual was permitted to act as a radiographer prior to demonstrating his understanding of the subjects outlined in Appendix A, and without successfully completing a written test on the subjects covered. Specifically, an in.11vidual was administered a written examination on November 4, 1983 which he did not successfully complete and that individual was permitted to act as a radiographer on November 9, 13, and 14, 1984 and July 1, 1985. B. 10 CFR 34.31(b) requires that no individual act as a radiographer's assistant until that individual has received copies of, and instruc-tion in, the licensee's operating and emergency procedures and has demonstrated understanding of the instructions by successfully com-pleting a written or oral test. Condition 16 of License No. 37-09928-01 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in the application dated December 23, 1981. This application requires that prior to acting as a radiographer's assistant, an employee will receive 30 hours of formal instruction in the subjects specified in the application and successfully complete a written test on the subjects covered. NUREG-0940 II.A-3
. Notice of Violation Contrary to the above, on at least two occasions, one individual was permitted to act as a' radiographer's assistant af ter April 22, 1985 prior to receiving instruction in the licensee's operating and emergency procedures, prior to receiving 30 hours of formal instruction in the subjects specified in the application dated December 23, 1981, and prior to demonstrating his understanding of the instructions by successfully completing a written test.
C. 10 CFR 34.23 requires that locked radiographic exposure devices and storage containers be physically secured to prevent tampering or removal by unauthorized personnel. Contrary to the above, on June 20, 1985, radiographic exposure devices stored in the radiography cell were not physically secured to prevent tampering or removal by unauthorized personnel. .l l D. 10 CFR 20.203(b) requires that each radiation area as defined in 10 CFR 20.202(b)(2) be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words: " Caution Radiation Area." Contrary to the above, on June 20, 1985, a radiation area existed on the roof of the facility, and the radiation area was not posted with i a sign bearing the radiation caution symbol and the words " Caution l Radiation Area.* E. 10 CFR ~20.203(c) requires that each high radiation area as defined in 10 CFR 20.202(b)(3) be censpicuously posted with a sign or signs bearing the radiation caution symbol and the words: " Caution High Radiation Area." Contrary to the above, on June 25, 1985, a high radiation area existed in the storage area above the radiography cell, and the high radiation area was not posted with a sign bearing the radiation caution symbol and the word:," Caution High Radiation Area." F. 10 CFR 34.26 requires that a quarterly inventory be conducted to account for all sealed sources, and records be maintained of the inventories that include the quantities and kinds of by-product material, location of sealed sources, and'the date of the inventory. Contrary to the above, an adequate quarterly inventory was not con-ducted for the second calendar quarter of 1985. Specifically, the records of the quarterly inventory made on April 27, 1985 did not account for a cobalt-60 source and did not indicate that the iridium-192 source was' stored in Bordentown, New Jersey, G. 10 CFR 34.33(c) requires that pocket dosimeters be checked for correct response to radiation at intervals not to exceed one year. Contrary to the above, a pocket dosimeter used by personnel from October 29, 1984 to June 25, 1985 had not been checked for correct response to radiation from February 10, 1983 to June 25, 1985, an interval of more than one year. NUREG-0940 II.A-4
Notice of Violation H. 10 CFR 71.5(a) requires, in part, that no licensee transport any licensed material outside the confines of his plant or other place of use, or deliver any licensed material to a carrier for transport, unless the licensee complies with applicable requirements of the regulations appropriate to the mode of transport of the Department of Transportation (00T) in 49 CFR Parts 170-190. 49 CFR 173.416 specifies, in part, the types of packages authorized for shipment of radioactive material in quantities exceeding the activity of special form radioactive material as listed in 49 CFR 173.435. 49 CFR 173.435 establishes this value to be 20 curies for iridium-192 in special form. Contrary to the above, on July 1, 1985, the licensee shipped 68 curies of iridium-192 in special form in a package not authorized by 49 CFR 173.416 because it lacked a required overpack (a condition of use for the NRC-approved package as described in NRC Certificate of Compliance No. 67178). I. Condition 10 of Licen e No. 37-09928-01 restricts the places of use of Itcensed material to the licensee's facilities at 7801 Allentown Boulevard, Harrisburg, Pennsylvania and at temporary job sites in the United States where the NRC maintains jurisdiction for regulating the use of licensed material. Contrary to the above, as of July 2,1985, an iridium-192 sealed source has been stored at the Certified Testing Laboratories', Inc. , facility in Bordentown, New Jersey, and this location was not a temporary job site. J. Condition 16 of License No. 37-09928-01 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated October 26, 1981. Attachment P of this application requires that the Radiation Safety Officer perform a field site audit of radiographic operations approximately once a week. ' Contrary to the above, between November 1, 1984 and December 18, 1984, weekly field site audits were not performed. K. 10 CFR 34.29(c) requires that the alarm system on the permanent radiographic installation be tested at interv:als not to exceed three months, and records of these tests be maintained for two years. -NUREG-0940 II.A-5 1
Notice of Violation Contrary to the above, as of June 25, 1985, records were not maintained of the tests performed on the alarm system of the permanent radiographic installation. L. 10 CFR 20.401(b) requires that each licensee maintain records showing the results of monitoring of packages required by 10 CFR 20.205(b) and (c). Contrary to the above, records were not maintained of the monitoring performed of incoming packages that were required to be monitored in accordance with 10 CFR 20.205(b) and (c), since the packages con-tained more than three curies of iridium-192. Collectively, these violations have been categorized as a Severity level III problem (Supplements IV, V and VI). Cumulative Civil Penalty - 55,000 assessed equally among the violations. Pursuant to the provisions of 10 CFR 20.201, Astrotech, Incorporated, is hereby required to submit to the Director, Office of Inspection and Enforcement, USNRC, Washington, D.C. 20555, with a copy to the Regional Administrator, USNRC, Region I, 631 Park Avenue, King of Prussia, PA 19406, within 30 days of the date of this Notice a written statement or explanation in reply, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and, (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Astratech, Incorporated, may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Five Thousand Dollars (55,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Oirector, Office of Inspection and Enforcement. Should Astrotech fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Astrotech, Incorporated, elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circum-stances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty. i l PUPEG-0040 II.A-6
Notice of Violation In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Astratech, Incorporated's attention is directed to the other provisions of 10 CFR 20.205 regarding the the procedure for imposing a civil penalty. Upon failure to pay the civil penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42. U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION 6 , Thomas E. Murley LL*
'~ ~'~~
Regional Administrator Dated at King of Prussia, Pennsylvania thisyHay of August 1985 4 NUREG-0940 II.A-7
ROTECMINCo . 7801 Allentown Blvd. Skyline Ww on U. 5. 22 Harrisburg, Pa.17112 Phone 717-6521750 Inspection Testing - Research Cheecal Analysis - Industrial Radiology Soils X Ray W.ter 5,eg September 10, 1985 U. S. NUCLEAR REGULATORY COMMISSION Office of inspectwn and Enforcement Wasithtgton, O.C. 20555 ret pocket No. 030-06219 Licotse No. 37-09928-01 EA 85-86 Dear Sirst in response to your Notice of Proposed imposition of Civil Penalties dated August 20, 1985, we would like to request exception to the amount of penattej imposed on Astratech Inc. for noncomploutce with he items listed ht your tetter of August 20, 1985. We do not dispute any of the itens in your Notice. We do, however, feet that ue severity of the penalty will impose a severe fbtancial burden upon this smalt business corporation. We have enetosed, herewith, a copy of Astratech's fhtancial statemotts for 1982, 1983 and 1984. On July 9,1985, Astratech Inc. applied for Amendmott to our NRC License for Tech / Ops Camena 660 and Seated Source Assembly No. 424-9. As of this date, we did not rece.ive either Amendment er denial. Should Astratech receive Amendment, the cost of came>ta and source assembly is approuma.tely $7,000.00. At the present, we have Al camera Triditron 100, uhicJt does not meet 8 packaghtg and; therefore, cannot be transported, uhite nbtety per cent (901) of our work uns in the field. Dae to tlte above facts, any reduction of the amount of the potat.ty utitt be greatty(appreciated. twelve 12l equal mootthty We further request that any penalty imposed be payable. in instattnents. Sincerely, ASTR0 TECH INC. n -
/,
L. Myky % LMsfn 6tets. cet U.S. Nuclear Regatatory Comission 631 Park Avotue K4tg of Prussia, PA 19406 m ,.. . % . #4 .. . ,,,.s. w s. a.,,s . ... 4 .., w a s.. ., ,.. .... .#.,. , ... .. .. NilREG-0940 II.A-8 l
,g_.
7801 Ateneewn Rive Skvane View on U. S. 22 Harrisburg, Pa.17112 Phone 717 6521750 inspurion Teseen, .,. nessereb .. Chemical Analysis . . IndusMal Radiology soi ls x Ray water steel September 16, 1985 Okector Office of inspection and Enforcement , U. S. NUCLEAR REGULATORY COMMISSION Washington, O. C. 20555 REs License No. 37-09918-01 00cke.t No. 030-06219 EA 85-86 Dear Sirr in response to your letter of August 20, 1985, concernatg items of noncompliance. to Nuclear Regulatory Comission requirements by Astratech 1:tc., de followotg'is our planned steps of act<en to evaluate. ite.ms of noncompliance, correct all. 41'un%cs.s of noncompliance uhich exist and prevent repstition of une itenst item A. PeMon actu* tg as radiographer in New Jeuey has been ZAained and worked for over ten (10) yeau for Certified Testing Laboratories, Inc, h New York. He did receive Asttotech's Manual. o prior to performing radiography for Astrate.ch.f Operating Since, thisand peAson,Emergencil Procedure received eight (8) houn af hstructions conducted by Mt. R. Plumstead, RSO of CertifLed Testing Laboratories, Inc. and eight (8) houu' classroom instruction with wtstten test conducted by Mr. R. Plumstead, RSO of Certified Testing. Eight (8) hours classroom instAuctions were attended and tests were admotistered to two of Astratech's radiographeAs and assistant radiographeA. Att four (4) peAsons successfully completed a wtitten test on the sub* As of Julig 11 1985, de radiographer h New Jeueg is workectscovered. ing under Certified Testute btboratories License ushg Certified esting Laboratories source and projector. He is under jurisdiction of de Certified Testing R.S.0. Iten 8. Individuat, hat acted as radiographer's asdstant k New Jeuey, on several oecasions, tats not quat.ified as an assistant. Upon my knowledge of this fact radiographer uns told not to use him. This person also attended eight (8) houu' classroom instAuctions with penannet mentioned in item A. He, also, if successfatty completed written tests, will be under Certified Testing R.S.O. jwtisdiction.
............u,..,,,,,,,,,,,,,,,,.a,,,,,,,,,wg,,w,,,,,,u,g,,,,,,,,,,,,,,,,,,,,,,
NUREG-0940 II.A-9
. Director September 16, 1985
- 0ff4ce'of inspection and Enforcement Page. t
- U. S. NUCLEAR REGULATORY COMMISSION 4
i iten C. 'F=M*Han expotute devices at Astratech h Harrisburg, Pe jtvania are stored ise ne exposure cell. The cell is twMacked at att times, except when under radingapher's suuurve.illance. Nuclear Vensity gauges are also stored i e de cett br de entrance. The cett must have been left unlocked by a per4en removhg a gauge. Att personnet wete instructed as to the. Ampor.tance of de gate to de cett to be. padlocked at att times. Additionalty, a tag is posted next to de Lock which reads, "This Gate Must Be Padlocked At All. Times." Iten 0 . The roof k question is 15 feet above de grcund wiu no access t.o it except win an extension ladder, which is stored beide de buildhg. The roof is posted with four-(4) "High *ndia_ tion" signs, i iten E. The storage area above de radiography cett. is not attended when j~ rad 4agraphy is performed h de ceti. i - The storage area is screened off and posted, " CAUTION HIGH RADIATInN l AREA." i Iten F. It uns an cversight dat C0 do and Ir 192 were not transversed from working sheet used durkg performance of hventory to de page in de hventary book,
~
i in de future, quartstly hventory witt. be performed directly into inventory book. 1 Iten G. Pocket 00sineter 81107 has been used until July 19, 1984. From i 'KiTTine, 00sinster 49732 had been used until September 13, 1984. After ' i this date, 00sinster 81107 has been used again. Astratech Inc. received first group of calibrated dosine.ters on July 18, 1984, and second group af e calibra,ted desinsters on August 8,1984. Suce Oosineter 81107 uns used i by de same radiographer, ne gap, for his dosimeter not being used, cekten July 18, 1984 thru August 8,1984, coincides with time that second group wu i at calibration. Af ter the second group rsturned, 00sineter $1101 wu used l agan. Subject dosineter uns not listed with fitst nor second group on calibration certificate. Therefore, I cannot attest that it has been catibrated. i. i list of dosimeters with calibration da.te due. was prepared and kept up. Also, list of desine,ters behg sent for catibration is kept and checked against MMWan certificates. I Iten H. Astrotech Inc uns not aware dat Iriditton 100 cannot be Ltauported i without approved overpack after June 30, 1985. Upon notification by i Mt. J. MilleA, on July 2,1985 that our o.xposure. devices are not h compliance
- ;with 10 CFR 71.5 and 49 CFR 173.416, openations outside. cf radiography cell. l were stopped. Appliention for Amendment to Asttotech's license uns submitted \
to use Tech / Ops exposure device 660, and Certificate of Compliance, sats l received from NRC.
- NtlREG-0940 II.A-10 1
_ a._... - ~ _ _ _ s-. ._ - - _ _ _ _ _ _ _ _ ,_ . _ _ _ . . . _ , . - , _ _ _ - - . , _ , _ . _ , - _ _ _ - . _ - _ , . ~
e. i
*4tector Septem6 m I6,'!985 .i Offict af Inspection and Enfoncement Page 3 U, S. NUCLEAR REGULATORY COMMISSICN i Item 1. Astuteek a radiagnaphic opstation h New Jerset wu tlwinated
'5R~T2 4 11,1985 and source shipped to Teckl0ps for disposal. l Item J. Aldough no field wonk is performed after July 1,1985, weekly y . inspection is performd by R.S.0. when work is pstformed sn nadiagnaphy cett.
Item K. Atana system on psnmanent radiographic hetallathn is tested and { ruults recorded on quartsely hventory page. Tute are performd on the day : of hventory or after any repair. Att tests will. 6e documented. ; t ' item L. Att incoming and outgohg packages containing radioactive matenial.s
. are monitored and documented on Pad &thn Surveg Report. i Arrangemnts have been made niu Csttified Tuting Laboratoriu R.S.0., Mr. R. Plumstead, to audit Astrate.ch's licensed optAatwn not less 1
#an eveAy Arte monds untit our goal of twtning our Pad &thn Safe.tg Program into an effectivs safsty prognan k futt compliance. is achieved.'
i L. Mykyta, upon resolvhg his psuonal. pro 6 ten, will attend Tech /0ps Padiaten
- . Safety Courst, week of October 7 nru October iT,1985.
s
. I expect dat our 4afety ptogram will be fully achieved by Octo6er 31,1985..
Sheerely, ASTR0TECN INC. i A. A i-f L. Myky , LMtfn cet 'U.S. Nuclear Regulatory Catanission 63i Ruth Avenua . { Khg af Prussia,-PA 19406 I
+
i 5
- NifREG-0940 II.A-11 I
# #q, UNITED STATES n NUCLEAR REGULATORY COMMISSION
[
; u s.nuarow o.c. names NOV 2 8 M Docket No. 030-06219 Licens, No. 37-09928-01 EA 85-86 Astrotech, Incorporated ATTN: L. Mykyta President 7801 Allentown Boulevard Harrisburg, Pennsylvania 17112 Gentlemen:
Subject:
Order Imposing A Civil Monetary Penalty This refers to your letters dated September 10 and 16,1935 in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you with our letter dated August 20, 1S85. Our letter and Notice described violations identified during NRC Inspection No. 85-01 conducted in June and-July 1985. In your response you: (1) admit the cited violations; (2) request that the civil penalty be reduced; and (3) request that payment of any imposed civil penalty be made in twelve monthly installments. After careful consideration of your response, we have concluded, for the reasons given in the enclosed Order and Appendix, that a sufficient basis was not provided for reduction of the amount of the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Astrotech, Incorporated imposing a civil penalty in the cumulative amount of Five Thousand Dollars ($5,000). If you do not contest imposition of the civil penalty, you may pay the imposed civil penalty in the full amount or, as requested, in twelve monthly installments. In the event that you choose to pay in monthly installments, we are enclosing a promissory note, which you should read carefully, sign on Page 3, and return to l the Director, Division of Accounting and Finance. Office of Resource Management, NRC with the first installment payment of $416.67 on or before January 1,1986. Please note the confess judgment provision which empowers the United States to obtain a judgment against you without a hearing in the event you fall to make l a required payment. Further, you are cautioned that if the Director, Division of Accounting and Finance does not receive your signed promissory note and your first installment payment by January 1,1986, and you do not contest imposition of the civil penalty, we shall take appropriate action under Section 234c of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 12282c. CERTIFIED MAIL RETURN RECEIPT REQUESTFD NUREG-0940 II.A-12
1 l l l Astrotech, Incorporated In your September 16, 1985 response to the Notice, sufficient infonnation was n:t provided regarding the corrective actions for Items D and H of the Notice. In response to Item D, you state that corrective action included posting the roof as a "High Radiation Area." It was our understanding that the roof was a
" Radiation Area" and should be appropriately posted. If you have concluded that the roof is actually a "High Radiation Area" as defined in paragraph 20.202(b)(3) !
cf 10 CFR Part 20, please submit to the NRC Region I office within 30 days of ' the date of this letter a description of the controls you have established to meet ! the requirements of paragraph 20.203(c) of 10 CFR Part 20 and paragraph 34.29 of 10 CFR Part 34. In response to Item H, you did not provide a description of an NRC approved Qualit paragraph 71.12(b)ofy10 Assurance CFR PartProgram 71, and you for your Type did not 8 packages indicate that youas required by have registered as a user of the Type 8 package as required by paragraph 71.12(c)(3) of 10 CFR Part 71. Please submit this information to the NRC Region I office within 30 days of the date of this letter. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2. Title 10 Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Order are not subject to the clearance procedures of the Office of Management and Budget, as required' by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely. l rig --- ames M. Taylor, Director
. Office of Inspection and Enforcement
Enclosures:
- 1. Order Imposing a Civil Monetary Penalty with Appendix
- 2. Promissory Note in Repayment of Preexisting Debt cc: w/encls.
Comonwealth of Pennsylvania Joseph Citardi, President Certified-Testing Laboratories, Inc. 155 U.S. Route 130 Bordentown, NJ l lNUREG-On40 II.A-13
UNITED STATES NUCLEAR REGULATORY COP 9t!SSION In the Matter of ASTR0 TECH, INCORPORATED ) Docket No. 30-06219 Harrisburg, Pennsylvania License No. 37-09928-01 EA 85-86 ORDER IMPOSING A CIVIL MONETARY PENALTY I 1 Astrotech, Incorporated. Harrisburg, Pennsylvania, (the "licer.see") is the holder of l License No. 37-09928-01 (the " license") issued by the Nuclear kegulatory Com-mission (the "Conunission" or "NRC") which authorizes the licensee to perforin l 1 industrial radiography at its Harrisburg facility and at temporary job sites. The license was last issued on January 26, 1982 and will expire on January 31, 1987. II An NRC safety inspection of the licensee's activities under the license was conducted on June 20, 25 and July 2, 1985. During the inspection, twelve viola-tions of NRC requirements were identified. A written Notice of Violation and l Proposed Imposition of Civil Penalty was served upon the licensee by letter dated August 20, 1985. The Notice states the nature of the violations, the ; provisions of the NRC's requirements that the licensee had violated, and the amount of the proposed civil penalty for the violations. Two letters in response, dated September 10 and 16, 1985, to the Notice of Violation and Proposed Imposition of Civil Penalty were received from the licensee. l l NilREG-0040 II.A-14 i __ -. _ _ _ .
L III Upon consideration of the answers received, and the statements of fact, explanation, and arguments for remission or mitigation of the proposed civil penalty contained therein, the Director, Office of Inspection and Enforce-ment, has determined, as set forth in the Appendix to this Order, that the penalty proposed.for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed, but the licensee should be allowed to pay the imposed civil penalty in twelve monthly installments, as requested in their September 10, 1985 letter. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT the licensee pay a civil penalty:
- a. in the full amount of Five Thousand Dollars ($5,000) within thirty days of the date of this Order by check, draft, or money order, payable to the Treasurer of the United States and mailed to the Director , Office of Inspection and Enforcement, USNRC, Washington, D.C. 20555; or
- b. in monthly installments, with interest accruing from January 1,1986 at the rate of 8 percent per year, as described in the schedule of monthly installments provided with the enclosed " Promissory Note in Repayment of NUREG-0940 II.A-15
Pre-existing Dett," which the licensee must provide with the first payment to the Director Division of Accounting and Finance Office of Resource Management NRC within thirty days of the date of this Order. V The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director, Office of Inspection and Enforcement. A copy of the hearing request shall also be sent to the Executive Legal Director, USNRC, Washington, D.C. 20555, and to the Regional Administrator, Region I, at 631 Park Avenue, King of Prussia, Pennsylvania 19406. If a hearing is requested, the Comission will issue an Order designating the time and place of hearing. Upon failure of the licensee to request a hearing within thirty days of the date of this Order, the provisions of this Order shall become effective without further proceedings and, if payment has not been made in accordance with Section IV.a or IV,b of this Order by that time, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee violated NRC requirements as set forth in the Notice j of Violation and Proposed Imposition of Civil Penalty, and i i l NUREG-0940 II.A-16 l
l (b) whether, on the basis of such violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY COP 911SSION
/
-My arnes M. Tagor Director Office of Inspection and Enforcement Dated at Bethesda, Maryland thi$$%ay of November 1985 NilREG-0940 II.A-17
APPENDIX EVALUATIONS AND CONCLUSIONS In the licensee's two responses dated September 10 and 16,1985 to the Notice of Violation and Proposed Imposition of Civil Penalty dated August 20, 1985, the licensee admits the twelve violations and provides a description of its corrective actions, but claims that imposition of the civil penalty in the amount of $5,000 will impose a severe financial burden on the licensee. The licensee requests reduction of the amount of the civil penalty and also requests that payment of the amount of any civil penalty imposed be made in twelve monthly instaliments. Provided below are (1) a restatement of each violation, (2) a summary of the licensee's response, and (3) the NRC evaluation of the licensee's response. Restatement of Violations A. 10 CFR 34.31(a) requires that no individual act as a radiographer until that individual can demonstrate his understanding of the instructions which he has received regarding the subjects covered in Appendix A of Part 34 and has successfully completed a written test on the subject covered. Contrary to the above, one individual was permitted to act as a radiographer prior to demonstrating his understanding of the subjects outlined in Appendix A, and without successfully completing a written test on the - subjects covered. Specifically, an individual was administered a written examination on November 4,1983 which he did not successfully complete and that individual was perinitted to act as a radiographer on November 9,13, and 14, 1984 and July 1, 1985. B. 10 CFR 34.31(b) requires that no individual act as a radiographer's assis-tant until that individual has received copies of, and instruction in, the licensee's operating and emergency procedures and has demonstrated under-standing of the instructions by successfully completing a written or oral test. Condition 16 of License No. 37-09928-01 requires that licensed material bel l possessed and used in accordance with statements, representations, and ! procedures contained in'the application dated Decerber 23, 1981. This application requires that prior to acting as a radiographer's assistant, 1 an employee will receive 30 hours of formal instruction in the subjects l specified in the application and successfully complete a written test on the subjects covered. Contrary to the above, on at least two occasions, cne individual was per-mitted to act as a radiographer's assistant after April 22, 1985 prior to receiving instruction in the licensee's operating and emergency procedures, prior to receiving 30 hours of formal instruction in the subjects specified in the application dated December 23, 1981, and prior to demonstrating his understanding of the instructions by successfully completing a written l test. I NUREG-0940 II.A-18
Appendix C. 10 CFR 34.23 requires that locked radiographic exposure devices and storage containers be physically secured to prevent tampering or removal by unauthorized personnel. Contrary to the above, on June 20, 1985, radiographic exposure devices stored in the radiography cell were not physically secured to prevent tampering or removal by unauthorized personnel. D. 10 CFR 20.203(b) requirits that each radiation area as defined in 10 CFR
'20.202(b)(2) be conspicuously posted with a sign or signs bearing-the radiation caution symbol and the words: " Caution Radiation Area."
Contrary to the above, on June 20, 1985, a radiation area-existed on the roof of the facility, and the radiation area was not posted with a sign bearing the rautation caution symbol and the words " Caution Radiation Area." E. 10 CFR 20.203(c) requires that each high radiation area as defined in 10 CFR 20.202(b)(3)'be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words: " Caution High Radiation Area." Contrary to the above, on~ June 25, 1985, a high radiation area existed in the storage area above the radiography cell, and the high radiation area was not posted eith a sign bearing the radiation caution symbol and the. words " Caution High Radiation Area." F. 10 CFR 34.26 requires that a quarterly inventory be conducted to account for all sealed sources, and records be maintained of tDe inventories that include the quantities and kinds of by-product material, location of sealed sources, and the date of the inventory. Contrary to the above, an adequate quarterly. inventory was not conducted for the second calendar quarter of 1985. Specifically, the records of the quarterly inventory made on April 27, 1985 did not account for a cobalt-60 source and did not indicate that the iridium-192 source was stored in Bordentown, New Jersey. G. 10 CFR 3A.33(c) requires that pocket dosimeters be checked for correct response to radiation at intervals not to exceed one year. Contrary to the above, a pocket dosimeter used by personnel from October 29, 1984 to June 25, 1985 had not been checked for correct response to radiation from February 10, 1983 to June 25, 1985, an interval of more than one year. NUREG-0940 II.A-19
- _ - _ - --_____ ______-_ \
A Appendix H. 10 CFR 71.5(a) requires, in part, that no licensee transport any licensed material outside the confines of his plant or other place of use, or i deliver amp licensed material to a carrier for transport, unless the licensee couplies with applicable requiwaents of the regulations appropriate to the mode of transport of the Department of Transportation (DOT) in 49 CFR Parts 170-190. 49 CFR 173.416 specifies, in part, the types of packages authorized for shipment of radioactive material in quantities exceeding the activity of special form radioactive material as listed in 49 CFR 173.435. 49 CFR 173.435 establishes this value to be 20 curies for iridium-192 in special fom. Contrary to the above, on July 1, 1985, the licensee shipped 68 curies of iridium-192 in special form in a package not authorized by 49 CFR 173.416 because it lacked a required overpack (a condition of use for the NRC- l approved package as described in NRC Certificate of Compliance No. 67178). !
- 1. Condition 10 of License No. 37-09928-01 restricts the places of use of licensed material to the licensee's facilities at 7801 Allentown Boulevard,
! Harrisburg, Pennsylvania and at temporary job sites in the United States where the NRC maintains jurisdiction for regulating the use of licensed,
- material .
Contrary to the above, as of July 2,1985, an iridium-192 sealed source has been stored at the Certified Testing Laboratories, Inc., facility in Bordentown, New Jersey, and this location was not a temporary job site. , J. Condition 16 of License No. 37-09928-01 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated October 26, 1981. Attachment P of this application recuires that the Radiation Safety Officer perfom a field site audit of radiographic operations approximately once g, week. Contrary to the above, between November 1,1984 and December 18, 1984, weekly field site audits were not performed. K. 10 CFR 34.29(c) requires that the alarm system on *.he permanent radio-graphic installation be tested at intervals not to exceed three months, and records of these tests be maintained for two years. l l
?!UREG-0940 II.A-20
Appendix Contrary to the above, as of June 25, 1985, records were not maintained of the tests perfomed on the alam system of the permanent radiographic installatie#. L. 10 CFR 20.401(b) requires that each licensee maintain records showing the results of monitoring of packages required by 10 CFR 20.205(b) and (c). Contrary to the above, records were not maintained of the monitoring perfomed of incoming packages that were required to be monitored in accordance with 10 CFR 20.205(b) and (c), since the packages contained more than three curies of iridium-192. Collectively, these violations have been categorized as a Severity Level III problem (Supplements IV, Y and VI). Cumulative Civil Penalty - $5,000 assessed equally among the violations. Susunary of License Response: The licensee does not dispute any of the violations cited in the Notice of Violation and Proposed Imposition of Civil Penalty but requests (1) a reduction of the civil penalty amount claiming that the proposed amount will impose a : severe financial burden upon the licensee, and (2) that the amount of any civil i penalty imposed be payable in twelve monthly installments. In support of its request, the licensee has provided a copy of its financial statements for 1982, 1983, and 1984. NRC Evaluation of Licensee Response: Although the NRC Enforcement Policy recognizes that a licensee's ability to pay is a proper consideration in determining the amount of a civil penalty, the licensee's financial iaformation submitted in its September 10, 1985 letter does not demonstrate that imposition of the civil penalty would create a severe financial burden. Specifically, certain infomation, for example wi'h regard to retained earnings and management fees, seems to indicate that you can . acconsnodate the payment of this civil penalty without severe financial impact. Therefore, the NRC finds, consistent with its Enforcement Policy, that the imposition of the civil penalty will not result in ecoromic termination of the licensee's business or financial hindrance of the licensee's ability to safely conduct licensed activities. NRC
Conclusion:
The licensee has not provided an adequate basis for reduction of the civil penalty amount, and full payment of the proposed civil penalty should not place a severe financial burden on the licensee. Accordingly, the NRC is imposing a civil penalty in the amount of $5,000. Payment of the imposed civil penalty in twelve installments at the required interest rate is considered acceptable. i l NUREG-0940 II.A-21
UNITro STATES
/g aseg#', ,
NUCLEAR REGULATORY COMMisslON E O e j, htoloN lie 7se noosavaLT noao cLEN ELLvN. ILLsNoss 40137
***** June 30, 1986 Docket No. 03005165 License No. 24-13998-01 EA 86-51 Combustion Engineering, Inc.
ATTN: Mr. Reynold L. Hoover Corporate Director Health, Safety and Environmental Control Windsor, CT 06095 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSID IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NO. 030-05165/86001(DRSS)) This refers to the inspection of activities authorized by NRC License No. 24-13998-01 conducted during the period February 11 through March 6,1986, at facilities in St. Louis, Missouri that were formerly owned by C-E Glass, Incorporated, a Division of Combustion Engineering. During the inspection two violations of NRC requirements were identified. The results of the inspection were discussed on March 19, 1986 during an enforcement conference attended by you and John Brett of your staff and A. B. Davis and others of the NRC staff. The two violations described in the enclosed Notice of Violation and Proposed
.lmposition of Civil Penalties demonstrate a significant breakdown in the management oversight and control of your radiation safety program. When the licensee, C-E Glass, Incorporated, sold its facilities located at 81 Angelica Street, St. Louis, Missouri on October 2,1981 it not only failed to notify the NRC, as required, that it was terminating licensed activities at that location but it also, in effect, abandoned a gauge containing a nominal 1.2 curie cobalt-60 sealed source. The new owners of the facilities used the gauge containing licensed material, although they were not authorized to do so, and eventually sold the facilities and the gauge to a salvage company.
Employees of the salvage company frequently handled and worked in the vicinity of the gauge and when the gauge was surveyed by an NRC Inspector it was noted that the shutter was open, thereby creating a significant radiation hazard. This event illustrates the consequences of failing to control licensed material and demonstrates the need for licensee management to ensure that in the future adequate management oversight will be maintained, licensed material will be transferred only to authorized individuals, and the NRC will be informed whenever licensed activities are terminated. To emphasize the importance of adequate oversight and control of licensed activities, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of l CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-2? l
Combustien Engineering, Inc. 2 June 30, 1986 Violation and Procosed Imposition of Civil Penalties in the amount of Fifteen Thousand Dollars ($15,000) for the violations set forth in the enclosed Notice. The violations have been classified in the aggregate as a Severity Level III problem in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR part 2, Appendix C (1986). The base civil penalty for a Severity Level III problem is $500. However, to emphasize the significance which the NRC places on the need to assure aggressive and effective management control over licensed activities to prevent the unnecessary exposure of members of the general public to radiation, as occurred in this case, the NRC is increasing the base civil penalty to Fifteen Thousand Dollars (515,000). You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence at other divisions or subsidiaries of Combustion Engineering, Incorporated. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, h ; g_Qr /s) 62 James G. Keppler Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalties
- 2. Inspection Report No. 030-05165/86001(DRSS) cc w/ enclosures:
State of Missouri NilREG-0940 II.A-23
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES C-E Glass, Incorporated Docket No. 030-05165 A Division of Combustion License No. 24-13998-01 Engineering, Incorporated EA 86-51 - .St. Louis, MO 63147 During a special safety inspection conducted on February 11 thrcugh March 6, 1986, two violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions,"
~10 CFR Part 2,' Appendix C (1985), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended,'("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205.
The particular. violations and associated civil penalties are set forth below: A. 10 CFR 30.41(a) provides that no licensee may transfer byproduct material to any person or entity except as specifically authorized in Section 30.41(b). Contrary to the above, on October 2,1981, C-E Glass, Incorporated, the licensee, transferred a Robertshaw Model 770-A5 source holder (gauge) containing a nominal 1.2 curie cobalt-60 sealed source to Hordis Brothers, Incorporated, an entity not authorized to receive this byproduct material under terms of 10 CFR 30.41(b). B. 10 CFR 30.34(f) (1981) [now codified as 10 CFR 30.36(b)] requires that each licensee notify the Commission in writing when the licensee decides to terminate all activities involving materials authorized under the license. Contrary to the above, on October 2,1981, the licensee, C-E Glass, Incorporated terminated all activities involving materials authorized under the license when it sold its facilities located at 81 Angelica Street, St. Louis, Missouri, the only place where the licensee was authorized to use
. such materials under its license, and did not notify the Commission.
Collectively, the above violations have been categorized as a Severity Level III problem (Supplement VI). (Cumulative Civil Penalties - $15,000 - assessed equally between the violations). Pursuant to the provisions of 10 CFR 2.201, Combustion Engineering, Incorporated is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137 within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: : (1) admission or denial of the alleged violation; (2) the reasons for the < l violation if admitted; (3) the corrective steps that have been taken and the l l results achieved; (4) the corrective steps which will be taken to avoid further NUREG-0940 II.A-?d
L Notice of Viola' tion 2 violations; and (5) the date when full compliance will be achieved. Consideration may be given to extending the response time for good cause .shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
~
Within the same time as provided for the response required above under 10 CFR 2.201, Combustion Engineering, Incorporated may pay the civil penalties by letter addressed to the Director, Office of Ins p ction and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Fifteen Thousand Dollars (515,000) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Of rector, Office of Inspection and Enforcement. Should Combustion Engineering Incorporated fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should Combustion Engineering, Incorporated elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties. In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of Combustion Engineering, Incorporated is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties. Upon failure to pay any civil penalties due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant
.to Section 234c of the Act, 42 U.S.C. 2282.
FOR THE 1UCLEAR REGULATORY COMMISSION CLmA@A IJames G. KepplIr Regional Administrator Dated at Glen Ellyn, Illinois, this ao' day of June 1986. NitpEn_0940 II.A-25
4 ) t
/ July 22, 1986 Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, DC 20055 Re: Notice of Violation and Proposed Imposition of Civil Penalties dated June 30, 1986 Combustion Engineering, Inc.
Docket No. 030-05165 License No. 24-13998-01 Centlemen: In accordance with the provisions of 10 CFR 2.201 and 10 CFR 2.205 Combustion Engineering, Inc. (the " Company") hereby responds to the above-captioned hotice as follows: A. The Company admits the violation of 10 CFR 30.41(a) as alleged but requests a reduction of the. amount of the civil penalty to be assessed for this violation in view of the following mitigating factors, to wit:
- 1. The Extenuatine Circumstances Attendant to the Original Transfer on October 2. 1981 On October 2, 1981, the Company sold the business and assets of its former Glass Division, including the facility at 88 Angelica Street, St. Louis, Missouri, as a going and operating l concern to Hordis Brothers, Inc. ("Hordis"). The assets sold to Hordis included a Robertshaw Model 770-A5 density containing l licensed materials (the " subject source") which was an intrical part of the glass making equipment installed at the St. Louis plant. All employees of the St. Louis plant, including the individuals who used and directly supervised the use of the subject source were transferred and became Hordis employees at the time of the sale on October 2, 1981. The transfer to Hordis was efiected without any shut-down or interruption of production activities at the St. Louis plant, and the same individuals continued to use and supervise the use of the l subject source in conjunction with the ongoing operation of the l St. Louis plant which Hordis continued for some time after October 2, 1981. The violation lies in the Company's failure, l
by oversight, to assure that Hordis was properly licensed to receive the subject source at the time of the transfer in October 1981, however, given the circumstances of that Combusbon Ergneenng, Inc. 900 Long Ridge Road (203) 329-8771 Post Office Box 9308 Telex. 96-5950 Stamford, Connecbcut 06904 NUPEG-00ap II.A-26
1 transfer, and the' continuity of plant-level management and activities at the St. Louis facility, the Company had every reason to believe and expect that Hordis would remain in responsible possession and control of the subject source. The amount of the civil penalty which the NRC proposes to impose for this violation has been measured out not in terms of the violation itself and the circumstances under which it occurred, but on the basis of Hordis' subsequent actions in disposing of the subject source more than a year after the Company had transferred and relinquished possession and control of same to Hordis. The Company bwlieves that the ultimate penalty should be commensurate with the violation taking into account not only the subsequent events which actually occurred but also the extent which the Company could or should have reasonably foreseen or anticipated those events at the time of the violation. By the latter standard, an appropriate reduction in the amount of the proposed penalty would be justified under the facts of this case.
- 2. Promot Remedial Actions Undertaken by the ComotDZ Upon learning, on February 20, 1986, that the subject source had been abandoned by others, the Company immediately arranged for and completed the removal of same from the St. Louis site 4
on February 21, 1986. Ultimate disposition of the subject source to Texas Nuclear was completed on February 28, 1986, which the Company certified to the NRC on May 23, 1986. A copy of that certification is attached. From the time the Company first became aware of the situation, it has fully cooperated with and assisted the NRC in its investigation of this matter
- 3. No Previous Violations The Company has had considerable experience in the use and handling of nuclear materials over a period of more than 25 years. It currently holds 31 general or specific licenses from the NRC and Agreement States. The Company has never been cited for any similar violations in respect to any past or current activities involving nuclear materials. This $30.41(b) violation represents an isolated incident in the Company's long 4
and otherwise unblemished record of compliance in this area.
- 4. Corrective Measures Which the Comoany Has Taken to Prevent Violations of a Similar Kind from Occurrina in the Future Upon learning of this incident the Company reviewed and evaluated its existing radiation safety program and associated recordkeeping and control procedures as they relate to the receipt and/or transfer of source material in the broader context of acquisition and disposition of business entities, plants or facilities. An effective built-in mechanism to assure that the Company's management and counsel is alerted whenever a proposed sale or acquisition of a business entity, a
2 I NUREG-0940 II,A-?7
plant or facility involves a transfer of licensed materials _~ would have prevented the type of violation which occurred in connection with the sale of the Company's Glass Division to Hordis in 1981. To remedy ~this deficiency, the Company has installed such a mechanism to prevent similar violations from occurring in the future. Elements of this mechanism which have been implemented by the Company are as'follows: (a) The Company has designated its Corporate Health, Safety and Environmental Control Department (the " Department") to serve as a centra 1' repository for all general and specific licenses ' issued by the NRC or Agreement States to any
. facility of the Company.
(b) By April 7,1986, the Department had compiled a complete
-file of all such licenses by each facility of the Company.
(c) The Company's Legal Department has included provisions i requiring inquiry as to existence of NRC and Agreement State licenses or materials requiring such licenses in its check lists covering acquisitions and divestitures. (d) The Manager of each Company facility is required to notify the Department of any new license applications. (e) The Department will use the information: (i)~ to monitor license renewals, (ii) to notify management and the Company's legal department when a facility in which licensed materials are used is being sold or closed, and (iii)- for periodic health and safety audits of facilities and training of plant personnel. For the reasons cited above, the Company requests that'the penalty to be assessed for this severity level III violation be reduced to
$500.
B. The Company denies and claims error in respect to the 10 CFR t 30.36(b) violation as alleged. Section 30.36(b) provides that "Each license: shall notify the Commission immediately in writing under
$30.6 and request terisation of the licensee when the licensee i decides to terminate all activities involvina materials authorized
[ under the license."-[ emphasis added). The language is clear in that [. the licensee's duty to notify springs from its decision to terminate the activities in which the licensed materials are used. In the instant case, those' activities were transferred intact to Hordis as l a going enterprise. The decision ~as contemplated in 30.36(b) requires some conscious act or process of deciding on the part of the licensee. Since ownership, possession and control of all activities involving the licensed materials passed to Hordis upon the sale on October 2,1981, any decision to terminate those NIJREG-0940 II.A-28
activities after that date rested exclusively with Hordis and could . only have been made.by Hordis and not the Company. The transfer of the St. Louis Plant to Hordis on October 2, 1981 (in respect.of which the Company has admitted the 30.41(a) as stated. above) effectively eliminated all power and ability on.the part of the Company to maka the termination decision which is a necessary prerequisite to'a 30.36(b) violation. On this basis the Company requests dismissal of the 30.36(b) violation as charged. Combustion Engineering, Inc. By Y'" / ':l
! has 2. /$ H a b '. f [ .
Before me, the undersigned officer, personally appaared John P. Brett, known to me to be the Vice President of Combustion
-Engineering, Inc., and who acknowledged to me that being authorized so to do he executed the foregoing instrument on behalf of the said corporation as such Vice President.
IN WITNESS WHEREOF, I hereunto set my hand and seal. ik. . ((, . c ll n l w p W!!.!ON cc: Regional Administrator My Cv. r .s w e* * *-' d ** ** U.S. Nuclear Regulatory Commission Region _III 799 Roosevelt Road Glen Ellyn, IL 60137 R. L. ' Hoover 4 NilREG-0940 II.A-79
# %, UNITED STATES ! NUCLEAR REGULATORY COMMISSION wAswiwaTom.o, c.aoses %,*****/ OCT i c 1966 Docket No. 03005165 License No. 24-13998-01 EA 86-51 Combustion Engineering, Inc.
ATTN: Mr. Reynold L. Hoover Corporate Director Health, Safety and Environmental Control Windsor, CT 06095 Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTIES This refers to your letter dated July 22, 1986 in response to the Notice of Violation and Proposed Imposition of Civil Penalties sent to you by letter dated June 30, 1986. The Notice of Violation describes violations found during a special NRC safety inspection conducted during the period February 11 - March 6,1986 at facilities in St. Louis, Missouri that were formerly owned by C-E Glass, Incorporated, a Division of Combustion Engineering. The Notice of Violation described two violations. In your response you admitted one of the violations, denied the other, and gave reasons why you believed the proposed civil penalties should be mitigated. After careful consideration of your response, we have concluded for the reasons set forth in the enclosed Order and Appendix that the violations did occur as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties and that mitigation of the civil penalties is not warranted. Accordingly, we hereby serve the enclosed Order on Combustion Engineering, Incorporated imposing civil penalties in the amount of Fifteen Thousand Dollars ($15,000). The corrective actions described in your response will be reviewed during a subsequent inspection. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. The response directed by this letter and the enclosed Order are not subject to the clearance procedures of- the Office of Management and Budget, as required by the Paperwork Recuction Act of 1980, PL 96-511. Sincerely, g!
,~ %
Ja es M. Tay , irector fice of In pection and Enforcement
Enclosure:
Order Imposing Civil Monetary Penalties with Appendix N!! REG-0940 II.A-30 I
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) C-E GLASS. INCORPORATED ) Docket No. 030-05165 A Division of Combustion ) License No. 24-13998-01 Engineering, Incorporated ) EA 86-51 St. Louis, MG 63147 ) ORDER IMPOSING CIVIL MONETARY PENALTIES I C-E Glass, Incorporated, St. Louis, MO (*.he licensee) is the holder of License No. 24-13998-01 issued by the Nuclear Regulatory Commission (the Commission) which authorizes the licensee to use byproduct material in a source holder (gauge) for level measurement. II An NRC special safety inspection of the licensee's activities under the license was conducted February 11 through March 6,1986. Doring the inspection, the NRC staff determined that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Prcposed Imposition of Civil Penalties was serveo upon the licensee by letter dated June 30, 1986. The Notice stated the nature of the violations, the provisions of the Nuclear Regulatory Commission's requirements that the licensee had violated, and the cumulative amount of the proposed civil penalties. The base civil penalty was increased from 5500 to S15,000 because of the licensee's failure to maintain effective management control over licensed activities. As a result, members of the general public were unnecessarily exposed to radiation. A response dated July 22, 1986, to the Notice of Violation and Proposed Imposition of Civil Penalties was received from the licensee. i NilPEG-0940 II.A-31 1
III After consideration of the licensee's response and the statements of fact, explanation, and arguments for remission or mitigation of the proposed civil penalties contained therein, as set forth in the Appendix to this Order, the Director, Office of Inspection and Enforcement has determined that the violations occurred as stated and that the penalties proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalties should be imposed. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: The licensee pay civil penalties in the cumulative amount of Fifteen Thousand Dollars ($15,000) within thirty days of the date of this Order, by check, draft or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. V The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director, Office NUREG-0940 ll.A-32
. = .
of Inspection and Enforcement. A copy of the hearing request also shall be sent to the Assistant General Counsel for Enforcement, Office of the General Counsel, U.S. Nuclear Regulatory Comission, Washington, D.C. 20555. If 4 4 hearing is requested, the Comission will issue an Order designating the ticie and place of hearing. If the licensee fails to request a hearing within thirty days of the date of:this Order, the provisions of this Order shall be effective without further proceedings and, if payment has not been made by that. time, the matter may be referred to the Attorney General for col'lection. In the event the licensee' request a hearing as provided above, the issues to be considered at such a hearing shall be: (a) Whether the licensee violated NRC requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties, and (b) Whether, c'n the basis of such violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION a s M. Tay1 , Director fice of In pection and Enforcement Dated at Bethesda, Maryland this /cfAday of October 1966 NUREG-0940 II.A-33
4 APPENDIX EVALUATIONS AND CONCLUSIONS 4 2 In a letter dated July 22, 1986 the licensee responded to the Notice of e Violatior. and Proposed Imposition of Civil Penalties dated June 30, 1986. In its response,'the licensee denies one violation. The licensee admits that the other violation occurred as described in the Notice, but requests reduction of the civil penalties for this violation and provides reasons why it believes that mitigation of the penalties is appropriate. Provided below are (1) a restate-4 ment of each violation, (2) a summary of the licensee's response regarding each violation, (3) NRC's evaluation of the licensee's response, and (4) NRC's conclusion. Restatement of Violation A 10 CFR 30.41(a) provides that no licensee'may transfer byproduct material to any person or entity except as specifically authorized in Section 30.41(b). Contrary to the above, on October 2,1981, C-E Glass, Incorporated, the licensee, transferred a Robertshaw Model No. 770-A5 source holder (gauge) containing a nominal 1.2 curies cobalt-60 sealed source to Hordis Brothers, Incorporated, an entity not authorized to receive this byproduct material under terms of 10 CFR 30.41(b). Licensee's Response j The licensee admits that the violation occurred. However, the licensee requests e that the civil penalties proposed for this violation be reduced to $500 in view of extenuating circumstances and certain mitigating factors. The licensee explains : that although on October 2,1981 it sold its St. Louis' facility and assets including i the gauge containing the sealed source to Hordis Brothers, all of the St. Louis employees were transferred and became Hordis employees, and the transfer was effectea without interruption of activities.- The licensee states that although by oversight it failed to assure that Hordis was properly licensed to receive the gauge, given the circumstances of the transfer and continuity of plant management ano activities, it had every reason to believe that Hordis would remain in responsible possession and control of the gauge. The 'icensee claims that the amount of the penalty proposed by the NRC for this violation should not only reflect the subsequent actions of Hordis in disposing of the source, but the extent to which the licensee could reasonably have foreseen such an event. The licensee also claims that mitigation of the proposed civil penalty for this violation is appropriate based upon its prompt remedial actions which included inmediate removal of the source from the St. Louis site when it learned ) i' that the' source had been abandoned and its full cooperation with the NRC's ( investigation; the fact that it had never been previously cited for similar violations; and its corrective actions, which included developing an administrative mechanism to assure that the Company's management is alerted whenever a proposed sale or transfer of licenseo material will occur. NRC Evaluation 1 l The licensee admits that the violation occurred as stated in that licensed byproduct material was transferred to Hordis Brothers, Incorporated, an entity l NUREG-0940 II.A-34
Appendix that was not authorized to receive and use the material. The licensee has attempted to minimize the significance of this event by noting that when Horois Brothers, Incorporated purchased the C-E Glass facilities, the same individuals who were employed by C-E Glass continued to use the gauge and, , therefore, the licensee assumed they would continue to do so in a responsible manner. i The NRC regulates the possession and use of byproduct material to ensure that unauthorized individuals do not possess, use, or make decisions regarding the use of byproduct material. Even though the individuals at Hordis Brothers. Incorporated who used the gauge apparently understood how the device functicned, they did not demonstrate a knowledge of NRC regulatory requirements through applying for and being granted a license. The licensing process helps the NRC to ensure that byproduct material such as that contained in the gauge will be used in a safe manner. The NRC staff does not agree that a transferee of byproduct material can be expected to maintain responsible possession and control of such materials if that transferee has not demonstrated an understanding of the applicable regulatory requirements. The licensee's unauthorized transfer of the gauge to an unlicensed user resulted in a member of the public being exposed to radiation. The size of the civil penalty demonstrates the NRC's concern regarding this occurrence. With regard to the licensee's corrective actions, the NRC finds no basis for mitigation. Although the licensee removed the abandoned byproduct material from the St. Louis site and otherwise cooperated with the NRC, the staff concludes that these actions were no more than would be expected under the circumstances. Further, because the NRC expects licensees to maintain control over their licensed materials, the administrative mechanisms put into place to monitor licensed activities are also no more than those corrective actions which would be expected by the NRC. Therefore, no mitigation is wa rranted. Restatemeat of Violation B 10 CFR 30.34(f) (1981) [now codified as 10 CFR 30.36(b)] requires that each licensee notify the Coanission in writing when the licensee decides to terminate all activities involving materials authorized under the license. Contrary to the above, on October 2,1981, the licensee, C-E Glass. Incorporated teminated all activities involving materials authorized under the license when it sold its facilities located at 81 Angelica Street, St. Louis, Missouri, the only place where the licensee was authorized to use such materials under its license, and did not rotify the Commission.
# m2 S y A ...
Licensee's Response . The licensee denies and claims error in Violation 3, in that it claims that .. the language of $30.36(b) makes it clear that the licensee's duty to notify the Commission springs from a decision to teminate the activitiec in which Qc (Y r *v f the licensed materials are used. The licensee states that in the instant case, [.gf Q f L. y$,- %, j 3 y .
?.
NUREG-0940 II.A-35
Appendix those activities were transferred intact to Hordis Brothers, Incorporated as a going enterprise. The licensee claims that the decision contemplateo in
%30.36(b) requires some conscious act or process of deciding on the part of the licensee and that since cwnership, possession, and control of all activities involving the licensed materials passed to Hordis upon the sale of the licensee's facility on October 2,1981, any decision to tenninate those activities after that date rested exclusively with Hardis and could only have been made by Hordis and not the licensee.
NRC Evaluation In its response to Violation A, the licensee admitted it transferred licensed byproduct material to Hordis Brothers, Incorporated although Hordis was not licensed by the NRC to possess or use this material. C-E Glass now seeks to deny responsibility for its failure to notify the NRC by noting that the use of the gauge had not been terminated, only transferred. The NRC staff has concluded that such a rationale is without merit for the following reasons: (1) The license authorizing use of the RoDertshaw Model No. 770-A5 gauge containing a nominal 1.2 curie cobalt-60 sealed source was issued to C-E Glass not Hordis Brothers; (2) on October 2,1981, C-E Glass pennanently ard totally tU minated control over all activities authorized by the license when it sold its facility at 81 Angelica Street, St. Louis, Missouri (the only authorized place of use) and it was required to report this tennination of activities to the NRC; and (3) C-E Glass, in effect, abandoned the gauge when tt sold the facility and transferred possession in an unauthorized manner. Therefore, the NRC staff concludes that the violation occurred as stated. NRC Conclusion The NRC staff has concluded that all of the violations did occur as originally stated in the June 30, 1986 Notice of Violation and Proposed Imposition of Civil Penalties. These violations collectively demonstrated licensee management's inadequate control and oversight of the licensed program at the St. Louis, Missouri site. This failure resulted in a member of the public being unnecessarily exposed to radiation. The licensee's response does not provide a sufficient basis for withdrawal of any violation or for mitigation of the proposed civil - penalty. Therefore, the NRC staff has concluded that a $15,000 civil penalty should be imposed. NUREG-0940 II.A-36
UNITED STATES
/ja etcg}o,^ NUCLE AR REGULATORY COMMISSION O ,, REGION 11 j i 1.' j to1 MARIETTA STREET.N W f ATL ANT A. GEORGI A 30323
% .27.. # DEC 111986 Docket No. 030-09947 License No. 45-15877-01 EA 86-172 Eastern Virginia Medical Authority ATTN: R. Lester, M.D., Ph.D.
Dean and Vice President Academic Affairs 700 Olney Road Norfolk, VA 23510 Gentlerren:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NO. 45-15877-01/86-01) This refers to the Nuclear Pegulatory Commission (NRC) inspection conducted by Ms. C. Connell at the Eastern Virginia Medical Authority on August 27 and 28, 1986. During the inspection, several violations of NRC recuirements were identified. The violations were discussad bv Mr. J. P. Stohr, Director, Division of Radiation Safety and Safeguards, NRC, Pegion II, with you and your staff in an Enforcement Cnnferance held on September 25, 1986. A Confirmation of Action Letter was also sent to you on September 26, 1986. A copy of this letter is provided as an enclosure. Tha violations dascribed in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties involved failures to ensure that the Radiation Safety Officer and Radiation Safety Committee fulfilled their responsibilities . that adequate instrumentation was maintained, that required leak tests were perfnrmed, and that ash residues were analyzed prior to disposal. These violations demonstrate tha need for improvements in the administration and control of ycur radiation safety program to ersure the safe perfonnance of licensed activities and adherence to NRC requirements. To emahasize the need fer adeouate management centrol over the radiation safety program, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Two Thousand Five Hundred Dollars ($2,500) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procadure for NRC Enforcement Action," 10 CFR Part 2, Appandix C (1986) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity level III problem. The base civil penalty for a Severity Level III violation or problem is $2,500. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. i CERTIFIED MAIL RETUPN RECEIPT REQUESTED FUREG-0940 II.A-37
1 Eastern Virginia Medical Authority 2 DEC 1 i W You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taker and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will detemine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Roen. The responses directed by this letter and its enclosures are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Should you have any questions concerning this letter, please contact us. Sincerely,
, , ,h . W
'J. Nelson Grace Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalties
- 2. NRC Inspection Report
- 3. Confirmation of Action Letter Dated September 26, 1986 4
NUREG-0940 II.A-38
NOTICE OF VIOLATION AND PROPOSED IMPOSITI0fi'UF CIVIL PENALTIES Eastern Virginia Medical Authority Docket No. 030-09947 Norfolk, VA License No. 45-15877-01 EA 86-172
~
' During the Nuclear Regulatory Commfssion (NRC) inspection conducted on August 27 and 28, 1986, several violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforce-ment Actions " 10 CFR'Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below:
1 Violations Assessed A Civil Penalty A License Condition 22 requires the licensee to possess and use licensed material in accordance with statements, representations, and procedures contained in application dated August 20, 1984, and a letter dated Sctober 9, 1985. Section 14.D of the application dated August 20, 1984, describes the Radiation Safety Officer (RS0), outlines his responsibilities, and lists functions he is to perform for the Radiation Safety Committee. Contrary to the above, from December 7, 1985 until August 27, 1986 (the date of the inspection), the Radiation Safety Officer had not fulfilled the following responsibilities which were listed in Section 14.0 of the application dated August 20, 1984:
- 1. general surveillance over all activities involving radiation and radioactive material;
- 2. determination of compliance with rules and regulations and license conditions;
- 3. mor.itoring and maintaining absolute filters and other special filter systems associated with the use, storage, or disposal of radioactive material;
- 4. purchasing and transferring of all radioactive materials;
- 5. receiving, delivering and opening all shipments of radioactive material arriving at the institution; HilREG-0940 II.A-39
4 Notice of Violation 2
- 6. determining the need for and evaluation of bioassays;
- 7. performing leak tests on all sealed sources,
- 8. coordinating and submitting all-licensing applicaticns and amend-ments to the NRC;
- 9. maintaining an inventory.of radiation detection equipment;
- 10. serving as recorder for the Radiation Safety Committee'and keeping Radiation Safety Committee records;
- 11. furnishing an annual report to the Radiation Safety Committee on unusual or. abnormal incidents involving radiation and radioactive material; and 12, reporting at every quarterly meeting of the Radiation Safety Committee on unusual or abnormal incidents involving radiation and radioactive material.
B. License Condition 22 requires the licensee to possess and use licensed material in accordance with statements, representations, and procedures contained in an application dated August 20, 1984, and a letter dated October 9, 1985. Item 3.e of Section 14 of the application dated August 20, 1984,. requires the Radiation Safety Committee, as the final authority in all matters pertaining to the establishment and administration of the Radiation Safety Program, to receive and review periodic reports from the Radiation Safety Officer. Contrary to the above, from December 7, 198' > til August 27, 1986, the Radiation Safety Committee did not adequately exercise its administra-tive responsibility over the Radiation Safety program in that it failed to ensure that the RSO prepared reports regarding licensed activities. C. License Condition 22 requires the licer,see to possess and use licensed material in accordance with statements, representations, and procedures contained in application dated August 20, 1984, and letter dated October 9, 1985. Section 10 of the application dated August 20, 1984, specifies the radiation detection instrumentation which is to be available for use by the Radiation Safety Officer and any isotope user. Contrary to the above, the Victoreen Thyac III, the Victoreen Panoramic 470A, and the Eberline E-520 survey meters and the multichannel analyzer with the 2 inch by 2 inch Nal crystal used for thyroid uptake bioassay, l NilREG-0940 II.A-40 l-
Notice of Violation 3 all of which were specified as available for use in Section 10 of the application dated August 20, 1984, were not available on August 27, 1986 (the date of the inspection). D. License Condition 15.A requires the licensee to test each gas chromato-graph detector containing Nickel 63 for leakage and/or contamination at intervals not to exceed six ronths. Contrary to the above, the licensee did not test the chromatograph de-tectors containing Nickel 63 for leakage or contamination between July 1985 and August 27, 1986, an interval exceeding six months. E. License Condition 18 requires the' licensee to survey ash residue following incineration of licensed material to determine that concen-trations do not exceed the limits specified for water in Appendix B, Table II, 10 CFR Part 20, prior to disposal as ordinary waste. Contrary to the above, the licensee disposed of ash residue as ordinary waste during the period from January 1986 until August 27, 1986, without performing surveys prior to its disposal to determine that concentrations of licensed material in the ash did not exceed the limits of Appendix B. Table II,10 CFR Part 20. F. 10 CFR 20.103(a)(3) requires that for purposes of determining compliance with the requirements of 10 CFR 20.103(a), the licensee shall use suitable measurements of concentrations of radioactive materials in air for de-tecting and evaluating airborne radioactivity in restricted areas and in addition, as appropriate, shall use measurements of radioactivity in the body, measurements of radioactivity excreted from the body, or any combination of such measurements as may be necessary for timely detection and assessment of individual intakes of radioactivity by exposed individuals. Contrary to the above, the licensee failed to use the results of the measurements listed in 10 CFR 20.103(a)(3) to determine compliance with-the requirements of 10 CFR 20.103(a) in that the results of thyroid bioassay counts taken from December 1985 until August 28, 1986, were not evaluated to determine the regulatory significance of the exposure. Collectively, the above violations have been assessed as a Severity Level III problem (Supplement VI). (Cumulative Civil Penalties - $2,500 - assessed equally among the violations.) II. Violation Not Assessed A Civil Penalty Licensee Condition 22 requires the licensee to possess and use licensed material in accordance with statements, representations, and procedures contained in application dated August 20, 1984, and letter dated October 9, 1985, i II.A-41 {NUREG-0940
Notice of Violation 4 Section 11 of the application dated August 20, 1984, specifies the calibra-tion frequency for the instruments listed in Section 10 to be at least annually. Contrary to the above, the 1.udlum Model 16 portable ratemeter/ analyzer had not been calibrated from June 13, 1985 to August 6, 1986, a period exceeding one year. This is a Severity Level IV violation (. Supplement VI). Pursuant to the provisions of 10 CFR 2.201, Eastern Virginia Medical Authority is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulate?y Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice a written statement or explanation including for each violation: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is rot received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Ccnsideration may be given to extendirg the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U..S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Eastern Virginia Medical Authority may pay the civil penalties by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Two Thousand Five Hundrea Dollars ($2,500) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Eastern Virginia Medical Authority fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should Eastern Virginia Medical Authority elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties. 1 i In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written
- answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Eastern Virginia Medical Authority's attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing civil penalties.
NUPEG-0940 II.A-47
Notice of Violation 5 Upon failure to pay the peralties due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION
\.
//J.NelsonGrace Regional Administrator Dated at Atlanta, Georgia, this //4 day of December 1986 NilREG-0940 II.A-43
ar EASTERN VIRGINTA MEOtCAL SCHOOL
;5 Post 0554ce Ocx seso
- NcapOL< VaG4A 23501
O,$
CFF<CE OF THE DE AN TEtspWNa tec4uas-seco December 17, 1986 Director Office of. Inspection and Fnforcemer.t U.S. Nuclear Regulatory Commission Washington, D.C. 20555
Reference:
Your notice of violation to me dated December 11, 1986. License # 45-15788-01
Dear Sir:
Enclosed please find a check of $2,500.00 made out to the Treasurer of the United States. I admit the following violations: A. Failure of the Radiation Safety Officer to fulfill the responsibilities listed in Section 14D of our license application. B. Failure of the Radiation Safety Committee to adequately exercise its administrative responsibilities over the Radiation Safety Program in that it failed to ensure that the Radiation Safety Officer prepared reports regarding licensed activities. C. Failure to have spsicified radiation detection instrumentation available for use by the Radiation Safety Officer and any isotope user. D. Failure to perform leak testing on a Nickel-63 source at intervals not to exceed six months. E. Failure to perform surveys that determined that concentrations in the ash did not exceed the limits of Appendix B, Table II, 10 CFR Part 20. F. Failure to evaluate the results of thyroid bioassay counts taken from December 1985 through August 28, 1986 to determine the regulatory significance of the exposure. G. Failure to calibrate the Ludlum Model 16 portable ratemeter/ analyzer at yearly intervals. f !. NUREG-0940 II.A-44 , i i
All violations except Item B are the result of the failure of Mr. Eric Raudenbush to carry out his responsibilities as Radiation Safety Officer. I was not aware of this failure on his part. The Radiation Safety Comittee was apparently not full aware of its responsibility and therefore had not adequately fulfilled it. The Committee is now fully aware of its responsibility. In addition, in October of-1986 Mr. John W. Cure, III, a consulting Certified Health Physicist, was appointed as a member of the Committee. See attachment for a copy of his resume. A new Radiation Safety Officer has been hired and will report for duty early in January 1987, at which time we will be in full compliance on all items. In the intarim Mr. . Cure has been on the staff at least ten hours per week since September 30, 1986. In addition, Dr. Donald Meyer,
- acting Radiation Safety Officer, has been available at least ten hours per week as agreed with your office.
Each violation is addressed as follows: Item A: Failure of the Radiation Safety Officer to fulfill his responsibilities. We are presently covering this position with a consulting Certified Health Physicist an interim Radiation Safety Officer on staff. We will be in full compliance when'the new Radiation Safety Officer arrives early in January 1987. Item B: Failure of the Radiation Safety Committee to ensure that the Radiation Safety Officer prepared reports regarding licensed activities. A comprehensive audit was conducted by Dr. Daniel J. Strom, Certified Health Physicist on September 26 and 27, 1986. This audit and the Annual Report of the Radiation Safety Committee Ju.ly 1, 1985 through June 30, 1986 constitute an Annual Report from the Radiation Safety Officer. The new Radiation Safety Officer will report unusual or abnormal incidents at the next quarterly meeting of the Radiation Safety Committee in February. Item C: Failure to have specified radiation detection equipment available for use by the Radiation Safety Officer and any isotope user. Victoreen Thyac III-Model 490, and Eberline E-520 GM counters were calibrated on September 4, 1986. The thyroid probe was operational September 28, 1986. The Victoreen Cutie Pie Model 470A was repaired and calibrated on October 8, 1986. Item 0: Failure to perform leak testing of Nickel-63 source. The source was leak tested on September 22, 1986. Item E: Failure to perform surveys to ensure that concentrations in ash did not exceed the limits of Appendix B. Table II, 10 CFR Part 20. Technicians calculated the concentration of radioactive material in the ash. A survey was made with a low level GM survey meter and no activity above background was measured. However, no assay of the ash was performed. On November 25, 1986, a scintillation counting system was assembled and calibrated. Assay performed on so:ne present waste drums have indicated that activities NUREG-0940 II.A-45
are below the levels of Appendix B, Table II,10 CFR Part 20. Item F: Failure to evaluate the results of thyroid bioassay counts and to determine regulatory significance of the exposures. Mr. Cure has been available since September 30, 1986. The new Radiation Safety Officer will be available early in
-1987.
Item G: Failure to calibrate the Ludium Model.16 ratemeter analyzer at yearly intervals. In the future it will be calibrated at annual intervals. We here at Eastern Virginia Medical Authority intend to operate responsively and safely under the conditions of our license. I believe this is apparent from our actions since the nforcement conference on Septem5er 15, 1986. 'Should you need any additional information please contact me. , Sincerely yours, g Am b Richard G. Lester, M.D., Dean EVMS, and Vice President of Academic Affairs EVMA copy to: Regional Administrator, Region II US Nuclear Regulatory Commission 101 Marietta Street, NW Suite 2900 Atlanta, GA 30323 RGL:akz i l l l NUREG-0940 II.A-46
/' 'g UNITED STATES 8 4 a NUCLEAR REGULATORY COMMISSION
-{ WAsmMGTON. O. C. 20045
%..... JUll 171986 Docket No. 30-02971 License No. 37-00897-01 EA 86-40 Mercy Hospital ATTN:.W. David Keating Vice President, Ancillary Services 25 Church Street P.O. Box 658
.Wilkes Barre, PA 18765 Gentlemen:
SUBJECT:
. 1) ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED
- 2) NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY During an NRC inspection of activities authorized by License No. 37-00897-01 conducted at Mercy Hospital on July 17, 1985, NRC inspectors attempted to ascer-tain the validity of an anonymous allegation received by the Region I office that a misadministration had occurred at the hospital in May 1985 ar.d was not reported to the NRC or the referring physician as required. The inspectors were unable to confirm that a misadministration had occurred. In fact, the Chief Nuclear Medicine Technician, who allegedly was responsible for the mis-administration when questiored, told the NRC inspectors that there had not been any misads:fnistrations at the hospital since June 1984.
Subseluently, an investigation of this matter was conducted by the NRC Office ofInvestigations(01). The synopsis of the report is enclosed. As a result of the investigation, the NRC has detennined that (1) a misadministration had in fact occurred at Mercy Hospital in May 1985, but was not reported to the NRC or the referring physician as required because.the Medical Director of Radiology, who is also the Radiation Safety Officer, told his staff not to report the incident; and (2) tL Chief Nuclear Medicine Technician willfully made a materia 1 false statement during the July 1985 inspection when questioned regarding the alleged misadministration. The deliberate failure by the Radiation Safety Officer to report the misadmin-istration, and the deliberate material false statement to the NRC by the Chief Nuclear Medicine Technician, each constitute a violation of NRC requirements. The violations which are described in detail in the enclosed Notice raise questions with regard to whether the hospital will comply with NRC requirements while these individuals have responsibility for the performance or supervision of licensed activities. Accordingly, I am issuing the enclosed Order requiring that you show cause why these two individuals should not be prohibited from serving in ary capacity involving the performance or supervision of any licensed activities. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-47
Mercy Hospital In addition, although the violations occurred because of the deliberate, irresponsible actions of the two individuals, the NRC also is concerned that hospital management did not aggressively pursue investigation of the alleged misadministration when informed of it during the NRC inspection, but rather awaited the initiation of the NRC investigation. Accordingly, I have decided to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Thousand Dollars ($5,000) to further emphasize the seriousness of the violations as well as the need for increased management control and oversight of licensed activities to prevent such actions in the future. The violations have been classified in the aggregate as a Severity Level I problem in accordance with the " General Statement of Policy and Procedures for NRC Enforcement Actions," 10 CFR Part 2. Appendix C. The severity level has been raised to Severity Level I because the failure to report the misadministration was willful and because a willful material false statement was made to NRC inspectors regarding the misadministration. The base civil penalty amount for a Severity Level I violation or problem is $5,000. The mitigation and escalation ft.ctors in the policy were considered and no adjustment to the base civil penalty was deemed appropriate. You are required to respond to' this letter as well as the enclosed Order and Notice, and you should follow the instructions specified therein when preparing your resp'onse. In your response, you should document the specific actions taken and planned to prevent recurrence. In particular, you should describe your plans for assuring that every individual involved in your NRC-licensed program is aware of the appropriate requirements, as well as the need for adherence to the terms of your license and NRC regulations. After reviewing your response to the Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Order and Notice are not subject to the clearance procedures of the Office of Management and Budget as required the Paperwork Reduction Act of 1980, PL 96-511. Sincerely,
,/
'W. /f '
mes M. Ta or, Director
- Office of nspection and Enforcement l
Enclosures:
- 1. Order to Show Cause Why License Should Not Be Modified
- 2. Notice of Violation and Proposed Imposition of Civil Penalty
- 3. Synopsis of 01 report i
cc w/encls: ! Dr. S. M. Imperiale, Mercy Hospital C. T. Carter, Mercy Hospital Comonwealth of Pennsylvania NUREG-0940 II.A-48 l 1
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) MERCY HOSPITAL Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 License No. 37-00897-01 EA 86-40 0RDER TO SHOW CAUSE WHY THE LICENSE SHOULO NOT BE M00!FIED I Mercy Hospital, Wilkes Barre, Pennsylvania (the licensee / hospital) is the holder of specific byproduct material License No. 37-00897-01(thelicense) issued by the Nuclear Regulatory Comission (the Comission or the NRC) pursuant to 10 CFR Parts 30 and 35. The license authorizes the use of
.radiopharmaceuticals to perform diagnostic and therapeutic procedures listed in Groups I-IV of Schedule A,10 CFR 35.100. The license was originally issued on July 25, 1956; was most recently renewed on June 17, 1985; arid is due to expire on June 30, 1990.
II During an NRC inspection at the licensee's facility on July 17, 1985, the NRC inspectors attempted to ascertain the validity of an anonymous allegation received by the NRC Region I office that a diagnostic misadministration by Ms. Carol T. Carter, the licensee's Chief Nuclear Medicine Technician, had occurred at the facility on May 8,1985 and was not reported to either the NRC or the patient's referring physician as required. In response to questions by the NRC inspectors during the July 1985 inspection, Ms. Carter told the NRC inspectors that the hospital had not had any misadministrations since June 1984. NUREG-0940 II.A 49
Subsequently, in an interview' conducted under oath with investigators from the NRC Office of Investigations (01) on August 7,1985 and in a sworn statement dated August 14, 1985 and provided to the investigators, Ms. Carter admitted
~ that (1) a misadministration had occurred on May 8,1985;(2) she deliberately was not truthful with NRC inspectors on July 17, 1985 when questioned regarding the misadministration; and (3) the reason for her actions was the fact that the Medical Director of Radiology, who is also the Radiation Safety Officer (R50),
had told her via a hospital radiologist not to report the misadministration. III On August 7,1985, the NRC OI investigators conducted an interview under oath with Dr. Salvatore M. Imperiale, the RSO. During the interview, Dr. Imperiale admitted that he was informed in May 1985 by Ms. Carter via a hospital radiologist that a diagnostic misadministration had occurred at the ho.pital and that he knew at the time that the misadministration was required to be reported to the NRC but Dr. Imperiale told his staff not to do anything because he did not think the incident was that serious. Dr. Imperiale also stated that he did not recall all the reasons behind his decision. Dr. Imperiale reiterated these statements in a sworn statement provided to the 01 investigators on August 15, 1985. NUREG-0940 II.A-50 1
IV
- The willful-violation of NRC requirements by Dr. Imperiale in deliberately not reporting the misadminstration to the NRC'and the patient's' referring physician as required and the willful actions of Ms. Carter, Chief Nuclear Medicine Technician, in not being truthful with the NRC inspectors, raise questions whether the licensee will comply with Commission requirements and the conditions of-the license while Dr. Imperiale and Ms. Carter have any responsiblity for the performance or supervision of licensed activities.
V Accordingly, pursuant to Secticns 81, 161b, and 186 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR 2.202 and Parts 30 and 35, IT IS HEREBY ORDERED THAT THE LICENSEE SHALL: Shcw cause, in a manner hereinafter provided, why License No. 37-00897-01
.should not be modified to prohibit Dr. Salvatore M. Imperiale and Ms. Carol T. Carter from serving in any capacity involving the performance or' supervision of any licensed activities.
4 NtfPEG-0940 II.A-51
VI
'The licensee may show cause, within 25 days of the date of issuance of this Order, as required by Section V above,-by. filing a written answer under oath or affirmation setting forth the matters of fact and law on which the licensee relies to demonstrate that prohibition of these two individuals from performance and supervision of licensed activities is not warranted. The licensee may answer, as provided in 10 CFR 2.202(a), by consenting to the entry of an order in i substantially the form proposed in this Order, in which case the license will
~be modified in the manner stated in Section V. If the. licensee fails to file 4 an answer within the specified time, the Director, Office of Inspection and Enforcement, may issue without further notice an Order modifying the license as described above.
VII The licensee or any other person adversely affected by this Order may request a hearing within 25 days after issuance of this Order. Any an',wer to this Order or any request for hearing shall be submitted to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Comission, Washington, I l . 0.C. 20555. Copies shall also be sent to the Executive Legal Director at the same address and to the Regional Administrator, U.S. Nuclear Regulatory l [ l l NUREG-0940 II.A-52 l .. _-- --_.__- -_-_ _ _ - _ _ - _ _ - - _ _
i Commission, Region I, 631 Park Avenue, King of Prussia, Pennsylvania 19406. If a hearing is requested, the Conunission will issue an order designating the time and place of any hearing. If a hearing is held, the issue to be considered at such hearing shall be: Whether, on the basis of the matters set forth in this Order, License No. 37-00897-01 should be modified in the manner set forth in Section V of this Order. FOR THE NUCLEAR REGULATORY COMMISSION
/
a s M. Taylo , Director fice of Inspection and Enforcement Dated at Bethesda, Maryland, this ay of June 1986. NUREG-0940 II.A-53
( i ; i r NOTICE OF VIOLATION AND PROPOSED IMPOSITIF0F CIVIL PENALTY Mercy Hospital' Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 License No. 37-00897-01 EA 86-40 17, 1985 and a subsequent As a result ofby investigation anthe NRCNRCinspection Office ofconducted on July (01), two violations of NRC Investigations requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1985), the Nuclear Regulatory Consnission
- proposes to impose a civil penalty for these violations pursuant to Section 234 of the Atomic Energy Act of 1954, 1 as amended. ("Act"), 42 U.S.C. 2282 PL 96-295 and 10 CFR 2.205. The particular !
violations and the associated civil penalty are set forth below: A. 10 CFR 35.43 requires that whenever a misadministration occurs involving a diagnostic procedure, the referring physician and the appropriate NRC regional office shall be notified in writing within 10 days after the end of,the calendar quarter in which the misadministration occurred. Ccatrary to the above, on May 8, 1985, the Chief Nuclear Medicine Technician performed a misadministration involving a diagnostic procedure by mistakenly injecting a chest X-ray patient with a compound containing the radioactive I isotope technetium-99m; however, the misadministration was not reported to I the NRC or the referring physician as of July 10, 1985. The Medical Director of Radiology, who is also the Radiation Safety Officer (RS0), directed his staff not to report the misadministration. I B. On July 17, 1985 the Chief Nuclear Medicine Technician of Mercy Hospital told NRC inspectors that no misadministrations had occurred at the hospital since June 1984. Contrary to Section 186 of the Atomic Energy Act of 1954, as amended, this statement constitutes a deliberate material false statement. The state-ment was false because the Chief Nuclear Medicine Technician had actually performed a diagnostic misadministration of a radioisotope on May 8,1985. The statement was material because, had the Chief Nuclear Medicine Technician truthfully answered the inspector's question, the NRC would have taken enforcement action in the fann of a Notice of Violation and would have reviewed the licensee's corrective actions to assure the May 8,1985 misadministration was reported and acceptable corrective action to prevent recurrence had been taken. The statement was deliberate in that the Chief Nuclear Medicine Technician knew that the statement was false when she made it and subsequently admitted this during an interview NUREG-0040 II.A-54
Notice of Violation 2 conducted under oath with an NRC investigator on August 7,1985, and in a - sworn statement dated August 14, 1985 that was provided to the investigators. Collectively, these violations have been categorized as a Severity Level I problem (Supplements VI and VII). Cumulative Civil Penalty - 55,000 assessed equally between the violations. Pursuant to the provisions of 10 CFR 2.201, Mercy Hospital is hereby required to submit to this office, with a copy to the-Regional Administrator, U.S. Nuclear Regulatory Comission, Region I, 631 Park Avenue, King of Prussia, PA 19406, within 30 days of the date of this Notice, a written statement or explanation in reply, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation, if admitted. (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and, (5) the date when full compliance will be achieved. If an adaquate reply is not received within the time specified in this Notice, the. Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good catis~e shown. Under the authority of Section 182 of the Act 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Mercy Hospital may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Five Thousand Dollars ($5000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Mercy Hospital fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Mercy Hospital elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2. Appendix C, should be addressed. Any written answer in acccrdance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 fFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Mercy Hospital's attention is directed to the other provisions of 10 CFR 20.205 regarding the procedure for imposing a civil penalty. NUREG-0940 II.A-55
Notice of Violation Upon failure to pay the civil penalty due, which has been subsequently deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE hUCLEAR REGULATORY COMISSION a es M. Taylor f irector 0 fice of Inspection and Enforcement Dated at Bethesda, Maryland thist Fday of June 1986 d 1 NUREG-0940 II.A-56
7 l ALDER COHEN & GRIGSBY A Paorssstowu,ConrosAnoN ATTORNEYS AT LAW Finn Froom eoo Ga ANT STassT PITTsscuou, Paxwsitvax1A toene Tatarnows (412) 094-4000 Tataxse easa Tatacortsa 001 0082 July 15, 1986 CERTIFIED MAIL RETURN RECEIPT REQUESTED Secretary U.S. Nuclear Regulatory Commission Washington, D.C. 20555 ATTENTION: Chief Docketing and Service Section RE: Mercy Hospital of Wilkes-Barre Docket No. 30-02971
Dear Secretary:
Please find enclosed for filing the original and two conformed copies of the Affidavit of Robert J. Moylan which was inadvertently omitted from Mercy Hospital's Answer to Order to Show Cause filed with the Commission in the above-captioned matter by letter dated July 14, 1986. As stated in Part IV(1) of its Answer to Order to Show Cause, Mercy Hospital has formally requested further adjustment of this issue--through a conference with the enforcement branch; a conference which normally would have been afforded Mercy Hospital prior to any NRC enforcement action pursuant to 10 CFR Part 2, App. C Section IV. As further stated in Part VII of its Answer, Mercy Hospital has formally requested a hearing on this issue pursuant to 10 CFR Section 2.202(b), contingent upon an NUREG-0940 II.A-57
AI. DER COHEN & GRIOSBY, P.C. Secretary, U.S. Nuclear Regulatory Commission July 15, 1986 Page two unsatisfactory resolution of the requested enforcement conference. Very truly yours, ALDER COHEN & GRIGSBY, P.C. By , Jodethan LJ Alder Robert M. Lucas Counsel for Licensee Mercy Hospital of Wilkes-Barre RML:pab Enclosure cc: ' Director, Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Dr. Salvatore M. Imperiale Ms. Carol T. Carter Executive Legal Director, U.S. Nuclear Regulatory Commission Regional Administrator U.S. Nuclear Regulatory Commission, Region I NUREG-0940 II.A-58 _ _ . - _ _ _ _ _ ~ _ _ ._ _, _ -, .m_ , , __
I UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes-Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 A E E I_ E A V I_ T COMMONWEALTH OF PENNSYLVANIA )
) ss:
COUNTY OF LUZERNE ) Before me, the undersigned authority, personally appeared Robert J. Moylan, who, being duly sworn according to law, deposed and said that he is the Executive Vice President of Mercy Hospital of Wilkes-Barre, and Licensee in the above-captioned action, that he has read the foregoing Answer To Order To Show Cause Why The License Should Not Be Modified, and that the averments contained in said Answer are true and correct to the best of his knowledge, information and belief. >
,~ ,
- ' s t e ( < ,' s : ! -; (a -.
Robert J. .Moylan. Sworn to and gilbscribed before me th.is //lt i day of July, 1986.
-4 .
h> L&:--* ., cA1 a _
-- Notary'Public My commission expires:
fGTARY PUGUC witme Gene, tmeme Camar, Pa w wnen taswee ouseer 12, les7 NUPEG-0940 II.A-59
ALDER COHEN & GRIGSBY A Paorasstowan, Coseosarson ATTORNEYS AT LAW Farra Floon eoo GaAarr Stanst Pittssunos. Pawusvt.vasta teene Ist.sesows (4ts) 304-4000 Tar.szso-oose Tsz.scoessa oot-oosa July 14, 1986 CERTIFIED MAIL i l Secretary, U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Attention: Chief, Docketing and Service Section RE: Mercy Hospital of Wilkes-Barre Docket No. 30-02971
Dear Secretary:
Please find enclosed for filing the original and two conformed copies of Mercy Hospital's Answer To Order To Show Cause and Reply To Notice Of Violation And Proposed Imposition Of Civil Penalty. Service of all future documents should be made on the undersigned counsel on behalf of Mercy Hospital. Sincerely, ALDER COHEN & GRIGSBY, P.C. By - J6dathan'L. Alder Robert M. Lucas Counsel for Licensee Mercy Hospital of Wilkes-Barre cc Secretary, U.S. Nuclear Regulatory Commission g/ Director, Of fice of Inspection and Enforcement U.S. Nuclear Regulatory Commission Dr. Salvatore M. Imperiale Ms. Carol T. Carter Executive Legal Director, U.S. Nuclear Regulatory Commission Regional Administrator,, U.S. Nuclear Regulatory Commission, Region I NUREG-0940 II.A-60
UNITED STATES NUCLEAR REGULATORY COMMISSION I In the Matter of )
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 t
ANSWER TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED 4 Jonathan L. Alder Robert M. Lucas ALDER COMEN & GRIGSBY, P.C. 600 Grant Street, Fifth Floor Pittsburgh, PA 15219 (412) 394-4900 Counsel for Mercy Hospital I NUREG-0940 II.A-61
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 ANSWER TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED Mercy Hospital by its counsel, Jonathan L. Alder, Alder Cohen & Grigsby, P.C., pursuant to 10 CFR $2.202 files the following Answer to the Commission's Order to Show Cause Why the License Should Not Be Modified.
I. The averments in Paragraph I are admitted. II. It is admitted that a routine annual on-site inspection was conducted by Ms. Judith A. Justra and Mr. John Miller of the NRC on July 17, 1985 at Mercy Hospital with respect to NRC License No. 37-00897-01. At no time prior to such investigation, or during the inspection did the said NRC officials advise the Hospital or its management and agents that the purpose of the inspection was other than the normal annual on-site inspection. The results and findings from this inspection and the Hospital's compliance with such report are set forth in the NRC's letter of August 9, 1985, the Hospital's NUPEG-0940 II.A-6?
response of August 23, 1985, and the NRC's confirmation of September 17, 1985. In none of those documents is there any reference to a misadministration. The only information concerning the NRC's interest in this incident provided to the Hospital was at the termination of the July 17, 1985 on-site inspection. Among other items, the inspectors advised David Keating, Administrative Vice-President of Ancillary Services of the Hospital, that they had found no evidence of a misadministration which they believed had occurred in the fall of 1984, for which they had-been looki r.;. The inspectors related to Mr. Keating that they had not found any evidence to either prove or disprove the allegation and; therefore, would not'make that segment of their investigation part of their report. The incident about which the NRC inspectors were asking involved two outpatients who were present at the i Hospital's Radiology Department at the same time on May 8, 1985. The essential facts may be summarized as follows: Patient Jones' was at the Hospital for a chest x-ray; Patient Smith was there for a liver scan. When the technician who was to perform the liver scan went to the waiting area and asked for Patient Smith, Patient Jones responded. Patient Jones was then told the procedure she was to undergo, and made no objection to a liver scan, despite the fact she was there for a i The two patients names have been obviously changed to assure confidentiality. NilREG-0940 II.A-63 l
chest x-ray. Since outpatients are ambulatory, alert and capable of responding when specifically called by name, they are not give identifying bands or tags, as are inpatients. Thus, it was as a result of a patient misidentifying herself and making no objection to the liver scan when told of it, that the error occurred. She also received her chest x-ray later when she returned to the waiting area, and was called by another technician who was to give the chest x-ray. i The initial error by the patient should have been detected by the technician who routinely has the patient sign a consent form. A review of that form would have shown a printed name " Patient Smith", but that it had been signed by " Patient Jones". This check was not performed or the difference in names not observed, presumably because Patient Jones had positvely identified herself as Patient Smith and acquiesced after being told she was to receive a liver scan. In accordance with the policies of the Hospital, the error was routinely reported to Dr. Imperiale, the Medical Director of the Department, and the Radiation Safety Officer under the license issued by the Nuclear Regulatory Commission to the Hospital. It was his obligation to report what the NRC characterizes as a " misadministration" as defined in 10 CFR S35.41. Dr. Imperiale determined that the matter was not serious enough to report and told the technician not to report I it. Following the July 17, 1985 interview with the NRC inspectors, Mr. Keating contacted the head of the department, l NUREG-0940 II.A-6a
Jesse Waselus, and advised him of the inspector's comments, since they had asked that he be excused from the exit interview with Mr. Keating. Mr. Keating indicated to Mr. Waselus that he wanted to know whether or not in fact there had been an incident which could be characterized as a misadministration and to let him know. The inspectors did not advise Mr. Keating that they had questioned Mr. Waselus concerning a specific patient who they believed to be involved in the alleged misadministration, nor did they advise Mr. Keating that they had asked questions' of Carol Carter, the Supervisor of Nuclear Medicine, concerning this matter. Neither of these employees were told specifically by the inspectors that they were investigating or seeking information about an alleged misadministration. ! However, as soon as Mr. Keating notified Mr. Waselus specifically what the NRC was looking for Mr. Waselus brought to Mr. Keating's attention the incident which had occurred on May 8, 1985 described above. Both he and Ms. Carter made a full and prompt report on the matter, so that when two other NRC investigators appeared at the Hospital a short time later, they were given a full and accurate account of the incident. Very simply, a minor misadministration had occurred, but was not taported to the NRC by Dr. Imperiale, but by August 7, 1985 at the latest, everyone knew about it, the NRC, as well as all relevant Hospital officials. Despite this, the NRC took no further action until its press Release, and Order to Show Cause and Notice of Violation f!! MEG-09dn II.A-65
were issued this past month. In the meantime, however, the Hospital took appropriate action to reprimand the technician who had committed the misadministration and to ensure that in the j future any such incident be reported up the chsin of command,
.regardless of the action or inaction of the Railiation Safety Officer, as more specifically set forth below, i
The Hospital, therefore admits the averments of Paragraph II of the Order that Ms. Carter did not tell the NRC inspectors on July 17, 1985 of the misadministration which occurred on May 8, 1985. i The Hospital is without sufficient.information or knowledge to admit or deny the remaining allegations of Paragraph II since it has no knowledge as to how the NRC was advised of the misadministration, and has never been furnished with a copy of Ms. Carter's affidavit by the NRC or Ms. Carter. Based upon belief, the Hospital avers the following: since Ms. Carter had advised Dr. Imperiale of the May 8, 1985 incident, and he had advised her that it need not be reported ! and that he would assume full responsibility for the matter, i Ms. Carter reported nothing to the NRC on July 17, 1985 or prior to that date. As the Radiation Safety Officer, it is Dr. Imperiale's obligation and responsibility to report any matters which may be classified as a misadministration under the regulations issued by the Nuclear Regulatory Commission. It is i not within.the scope of the job duties of Ms. Carter to report such matters directly to the NRC, nor did she violate the NRC's
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NUREG-0940 II.A-66
regulations by failing to report to incident. On all such matters, the responsbility rests with Dr. Imperiale, who as the Radiation Safety Officer and Medical Director, is in the best position both from a medical standpoint, and from his knowledge of the NRC's regulations, to make such determinations. As a consequence, when NRC inspectors questioned Ms. Carter about a misadministration that occurred in June of 1984, which Dr. Imperiale had reported to the NRC in accordance with it's regulations, and asked whether there had been any other misadministrations, Ms. Carter responded that there were none. She did so, apparently, because she believed she was bound by the decision of Dr. Imperiale with respect to the reportability a and nature of the incident, and since Dr. Imperiale was not present on July 17, 1985 to explain his decision to the NRC. Accordingly, based on the foregoing, it is denied that Ms. Carter deliberately was not truthful with the NRC inspectors on July 17, 1985 or that she adraitted to such deliberate untruthfulness in an affidavit given to the Office of Investigations of the NRC on August 7, 1985. III. Mercy Hospital is without sufficient information, knowledge or belief to form an answer to the allegations in paragraph III of the Order since they have never been furnished with a copy of the interview conducted with Dr. Salvatore M. Imperiale, or received a copy of any af fidavit or statement which he gave to the NRC investigators on or about that time. In further answer, the Hospital avers that it first became i l NUREG-0940 II.A-67
.. . - . _~ - . .- -_- _-.
aware after July 17, 1985 that a misadministration may have occurred,'and immediately directed it's employees, as did Dr. Imperiale, to divulge to the NRC investigators a full account of the May 8, 1985 incident. i i I i IV. Paragraph IV states a legal conclusion and requires no answer, but to the extent that it states facts, it is denied j that Ms. Carter was " willfully untruthfu1* with NRC inspectors or that Dr. Imperiale " deliberately" failed to report the misadministration, or that there is any justification for the ' conclusion that questions are raised concerning the Hospital's i future compliance with the Commission's requirements and the conditions of the license. I In further answer the Hospital sets forth the I following: i { 1. The Hospital agrees that Dr. Imperiale should j j have reported the May 8, 1985 misadministration to the NRC by July 10, 1985. Accordingly, no hearing is sought with respect I to the entry of an Order Modifying its license to remove Dr. Imperiale as Radiation Safety Officer. The Hospital has already removed Dr. Imperiale from such capacity and appointed a new Safety Officer. Even though the misadministration was of a minor nature, constituting only a Level Four severity under the NRC's General Statement o[ Policy and Procedure for NRC Enforcement Actions, (the " General Statement") 10 CFR Part 2, Appendiz C, Section V, which usually results in no penalty (carrying in any case, a maximum penalty of only $750 General [ l r NUREG-0940 II.A-68
i Statement, Section V(8)), the Hospital agrees that a license modification removing Dr. Imperiale as Radiation Safety Officer j
- - is appropriate. However, given the nature and circumstances of the misadministration, the absence of any other violations by the Hospital of the NRC's rules and regulations in the past, and Dr. Imperiale's acknowledgment of error of judgment in this one instance, the Hospital believes it is inappropriate to j remove Dr. Imperiale from all licensed activities, if other supervision satisfactory to the NRC is established.
4 Accordingly, while the Hospital will consent to an 4 i i order of the NRC with respect to a modification of its license ' limited as is described above with respect to Dr. Imperiale, it I respectfully requests that further adjustment of this issue be j had in accordance with the resolution procedures of the I j' Commission, particularly 10 CFR Section 2.203. j 2. With respect to the Proposed Order restricting l the employment of a specific technician in the department, the I Hospital sets forth the following: 1 (a) The NRC has no express authority to modify a 1
- license except with respect to those specifically licensed, as in the case of the Hospital and Dr. Imperiale. It has no express authority to modify a license to enlude a non-licensee, a
such as an employee, from employment as is shown by a J } comparison of General Statement, Section V(A), n.3, and Section V(C)(1) which provide only for the possibility of imposition of j a civil penalty against a non-license employee. The entire regulatory scheme is directed at licensees,
- l i
N!! REG-0940 II.A-69 i 1
- not specific employees. The licensees are the Hospital and Dr. Imperiale, and it is their conduct which is regulated. While the NRC may have authority to regulate
" management controls" through the license modification procedure, its asserted power to pick on specific employees is fraught with potential abuse and unfairness to the employee.
^
The potential unfairness is demonstrated by the fact that the NRC has issued a press release which accuses the technician in this case of deliberate falsehood, concealing a misadminstration, and stating that she had left her employment with the Hospital (which was not true), thus creating the impression through the pregnant vagueness of such an irrelevancy, that her departure was in some way re17.ted to the allegations against her. Thus condemned by the press release, the technician has no right of appeal. The facts, however, do not justify the NRC's response i in this case. As we have seen, a minor misadministration occurred resulting in a routine liver scan exposure to a i patient. The technician reported the error to the Radiation Safety Of ficer and Medical Director of the department who told her not to report it. If it was a misadministration, it was his responsibility to make that determination and to report it. ! Now,.we come to July 17, 1985. In a routine on-site inspection, the technician was asked if the department had had any misadministrations. The June, 1984 incident was mentioned and the records of the report of that incident, which Dr. Imperiale had reported to the NRC, were given to the l l ( N!JREG-0940 II.A-70
i I inspector. When asked if there were any other misadministrations, the technician responded in the negative. O'thers may have answered differently in the same circumstances, and the Hospital fully concurs with the NRC that this incident should have been promptly disclosed. While the Hospital does not condone her action, any , one may sympathise with the dilemma posed to this technician - l duty to the Hospital policies which required an incident report, and a duty to the NRC to whom she had no formal-responsibility, as against the determination of her professional superior, who was Medical Director of the department, as well as Radiation Safety Officer, having the , i specific authority to determine all such issues, who said the incident should not be reported. l The technician had the records in front of her 4 concerning a prior misadministration which was reported to the NRC by Dr. Imperiale and she was aware that Dr. Imperiale has
- said that the May 8, 1985 incident should not be reported - for i whatever reason. While the technician may have in her own mind privately disagreed with Dr. Imperiale, his decision was not to report it. On July 17, 1985 Dr. Imperiale was not present in
; the Department (the on-site inspections are not pre-scheduled). Who should know what is reportable, who has the legal responsibility to report, except Dr. Imperiale? One
] I can understand that she felt constrained to reflect Dr. i' Imperiale's stated position, and that is all she did when she responded degatively to the NRC officials. l
)
1 4 e i tillREG-0940 II.A-71 i
l- ' Mitigating any adverse impression'from her July 17, 1985 answer is the fact ~that when questioned directly about the issue, rather than obliquely as in the case of the NRC inspectors, the technician immediately disclosed the facts, i assembling immediately all available documentation. This was I furnished'to the NRC shortly thereafter, and at the direction 4 of Dr. Imperiale and the Hospital. While these events may not exactly constitute a 4 molehill, neither are they the mountain which the NRC created. The NRC has not proposed any change in " management controls" or procedures, to which it's authority to modify a license is confined. General Statement, Section V(C)(1). It proposes only that the Hospital terminate the employment of the i , technician in question from performing licensed nuclear i medicine procedures. i- ! However, the Hospital would point out that to the l extent the technician's failure was due to any question
- concerning the correct reporting procedure, it has taken the l
l following measures: i I l A. Clarified to the technician in question that she l had an obligation to report the incident not only to the i Radiation Safety Officer, but also to file an incident report in accordance with the Hospital's established Incident Report procedure. B. As a result of its own investigation and the NRC inspections of August 7, 1985 the Hospital took immediate steps to insure additional management reporting procedures to insure l NUREG-09A0 II.A-7?
that future misadministrations, if any, are reported in acccordance with 10 CFR $35.43. Employees of the department and Ms. Carter were specifically advised that in the future they were to follow the certain specific performance standards
! which were given them on September 20, 1985, which directs them to report all misadministrations in accordance with the Hospital's incident report procedure, and provides that appropriate personnel have the authority to report such misadministrations or any other matters directly to the NRC, and that there was to be no deviation from that policy. The policy also makes clear that if an employee believes his/her incident report has not been appropriately acted upon, they should take the matter to higher authority.
C. The technician in question, Ms. Carol Carter, has completed education in an additional area of espertise and accepted employment at another institution, terminating her employment effective July 7, 1986 with Mercy Hospital. V. Paragraph *V of the Order requires no answer since it i states a legal conclusion. However, the Hospital specifically denies that the NRC has any authority under Section 186 of The Atomic Energy Act to modify its license, or has any authority
; to specifically modify its license to effectively terminate or substantially alter the terms and conditions of employment of a specific employee. This is shown by General Statement, Section V(A), n.3 and Section V(C)(1), and by the absence of provisions in the Atomic Energy Act of 1954 concerning termination of NUREG-0040 II.A-73
employees that parallel the broad civil penalty powers af forded the NRC under Section 234 of the Act, 42 U.S.C.A. $2282(a). VI. Paragraph VI of the Order requires no response since it states a legal conclusion. In further answer, the Hospital makes the following written answer as contemplated by Paragraph VI of the Order; (1) Dr. Salvatore M. Imperiale is no longer the Radiation Safety Officer at Mercy Hospital, since his appointment has been terminated and a new Radiation Safety Officer appointed, (2) the Order should be modified to delete any restriction of the right of Ms. Carol T. Carter from serving in any capacity involving performance or supervision of I any licensed activities in view of the fact . 3 Carter did not make any " deliberately misleading" or faise scitements to the NRC investigators. She merely reflect 3d the conclusion of ! Dr. Salvatore M. Imperiale as the Rsciation Safety Officer of the Hospital that the May 8, 1985 incident should not be reported. It is to be noted that: (3) the nature of Ms. Carter's offense, if any, was not greater than a Level Two severity violation, and should appropriately be considered as merely a Level Three severity violation, because it did not involve significant information, General Statement, Supplement VII(C)(1) and (2), as more particularly set forth in; (b) Ms. Carter had no reason to believe that Dr. Imperiale would not 4 appropriately report those matters coming within the definition of misadministration under the NRC's rules and regulations as I l required by law, since Dr. Imperiale had done so in the past;
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l HilPEG-09B0 ti.A-74 __._r_ . . . . - _ . _ _ - _ . . . _ _ . - . - . _ - _ _ _ _ . - . , , , - . , , , - - - , , ,
(c) Ms. Carter correctly reported the questioned incident to Dr. Imperiale as the Radiation Safety Officer on two (2) separate occasions and was told by Dr. Imperiale that it should not be reported and that he would assume full responsibility for the matter; (d) When directly questioned concerning the incident
- by the Hospital and NRC investigators (and when they stated openly and frankly that they were investigating the possibility of a misadministration), Ms. Carter unhesitatingly disclosed a full and truthful account of the events that occurred; (e), Dr.
Imperiale was not present at the July 17, 1985 on-site inspection, and in his absence she assumed tht she should comply with Dr. Imperiale's position that the May 8, 1985 4 incident was not a misadministration reportable to the NRC, and thus she did so as part of her responsibilities to report to Dr. Imperiale and take his direction with respect to all safety matters, even though she may privately have questioned his
, decision in her own mind, (f) Dr. Imperiale had the i
responsibility to report directly such misadministrations to , the NRC, and it was within her responsibility to accept as i final the determination of the Radiation Safety Officer as to what is reportable and what is not reportable; and (g) Ms. Carter has not been involved in another violation of NRC rules or regulations. l l 4 In view of the fact that the misadministration was a de minimis matter, in light of the fact that Ms. Carter has j otherwise completely fu11 filed her responsibilities to the NRC, NUREG-0940 !!.A-75
and in light of the fact that she believed that she was acting correctly in behalf of Dr. Imperiale, Ms. Carter should not be restricted from performing supervised licensed activities, specially in view of the remedial action that has been taken by c the Hospital. The Proposed Crder is, in any case, mooted by the fact that Dr. Imperiale has been removed as and is no longer Radiation Safety Officer at the Hospital, and will not be so appointed again in the future, and that Ms. Carter is no longer employed at Mercy Hospital. For reasons entirely unrelated to any of the foregoing incidents, Ms. Carter took a leave of absence for educational reasons on January 5, 1986 and has l resigned her position with the Hospital following the completion of her educational studies. Ms. Carter leave espired on July 7, 1986 and Ms. Carter has not been employed by the Hospital since January 5, 1986. For all the foregoing reasons the Hospital respectfully requests that the Order be modified in the foregoing respects. In other respects, the Hospital consents j to the entry of an Order in substantially the form proposed in this Order by prohibiting Dr. Salvatore M. Imperiale from serving as Radiation Safety Officer. In further answer the i Hospital denies that the NRC has authority under Section 186 of ! The Atomic Energy Act to modify licenses and may only iswue modification orders "when some change in licensee eautoment, i procedures, or management controls is necessary." General Statement, Section V(C)(1). NllPEG 0940 II.A-76
VII. In the event the Commission does not modify it's Order as requested above, the Hospital respectfully requests a hearing be conducted in this matter for consideration of the foregoing denials, averments, new matter and legal argument set forth above, i Respectfully submitted, By ./4 d b [ L Jonathan L. Alder Robert M. Lucas ALDER COMEN & GRIGSBY, P.C. 600 Grant Street, Fifth Floor Pittsburgh, PA 15219 (412) 394-4900 Counsel for Mercy Hospital of Wilkes-Barre Dated: /Y /ff/ f i MIPEG-0940 It,A.77 l
CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Answer Of Mercy Hospital To Order To Show Cause Why The License Should Not Be Modified has been served upon all parties of record listed below by depositing same in the firts class mail, postage prepaid, this 14th day of July, 1986.
, w
*i I 1
Secretary, U. S. Nuclear Regulatory Commission, Washington, D. C. 20555 Attention: Chief, Docketing and Service Section i Director, Office of Inspection and Enforcement U. 5. Nuclear Regulatory Commission Washington, D. C. 20555 i Dr. Salvatore E. Imperiale Director of Nucleat Medicine Valley Radiology Associates, Inc. 451 Third Avenue l Kingston, Pennsylvania 18704 Ms. Carol Carter c/o A. Peter Kanjorski, Esquire ' 126 South Franklin Street Wilkes-Barre, Pennsylvania 18765 Executive Legal Director U. S. Nuclear" Regulatory Commission Washington, D.C. 20555 Regional Administrator l U. S. Nuclear Regulatory Commission, Region I i 631 Park Avenue King of Prussia, Pennsylvania 19406 , l 1 1 i NUREG-0940 li.A 78
l UNITED STATES NUCLEAR REGULATORY COfst!SSION In the Matter of ) .
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 REPLY TO NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Jonathan L. Alder Robert M. Lucas
( ALDER COMEN & GRIGSBY, P.C. 600 Grant Street, Fifth Floor Pittsburgh, PA 15219 (412) 394-4900 Counsel for Mercy Hospital i NilREG-0940 II A-79
UNITED STATES NUCLEAR REGULATORY COpetISSION In the Matter of )
)
MERCY NOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 REPLY OF MERCY HOSPITAL TO NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Mercy Hospital by its counsel, Jonathan Alder, Alder Cohen & Grigsby, P.C., pursuant to 10 CFR $$2.201 and 2.205 files the following reply to the foregoing Notice of Violation and Proposed Imposition of Civil Penalty.
I. Reply to Notice of Violation A. To the extent the averments of Paragraph A of the Notice contain legal conclusions they require no answer. As to the remaining averments of that Paragraph the Hospital avers that It is admitted that a routine annual on-site inspection was conducted by Ms. Judith A. Justra and Mr. John Miller of the NRC on July 17, 1985 at Mercy Hospital with respect to NRC License No. 17-00897-01. At no time prior to such l I investigation, or during the inspection did the said NRC l officials advise the Hospital or its management and agents that 1 l i l ff0 REG-00a0 II.A-80
e the purpose of the inspection was other than the normal annual on-site inspection. The results and findings from this inspection and the Hospital's compliance with such report are set forth in the NRC's letter of August 9, 1985, the Hospital's response of August 23, 1985, and the NRC's confirmation of September 17, 1985 which are made eshibits hereto and attached as Eshibits A, B, and C respectively. In none of those documents is there any reference to a misadministration. The only information concerning the NRC's interest in this incident provided to the Hospital was at the termination of the July 17, 1985 on-site inspection. Among other items, the inspectors advised David Keating, Administrative Vice-president of Ancillary Services of the Hospital, that they had found no evidence of a misadministration which they believed had occurred 1 in the fall of 1984, for which they had been looking. The inspectors related to Mr. Keating that they had not found any evidence to either prove or disprove the allegation and; therefore, would not make that segment of their investigation < part of their report. The incident about which the NRC inspectors were asking involved two outpatients who were present at the Hospital's , Radiology Department at the same time on May 8, 1985. The essential facts may be summarized as follows: patient Jones' The two patients names have been obviously changed to assure confidentiality. 2-l l i MIREG-0940 II.A-81 l
was at the Hospital for a chest E-ray; Patient Smith was there for a liver scan. When the technician who was to perform the liver scan went to the waiting area and asked for Patient Smith, Patient Jcnes responded. Patient Jones was then told the procedure she was to undergo, and made no objection to a liver scan, despite the fact she was there for a chest x-ray. Since outpatients are ambulatory, alert and capable of responding when specifically called by name, they are not give identifying bands or tags, as are inpatients. I Thus, it was as a result of a patient misidentifying herself and making no objection to the liver scan when told of
- it, that the error occurred. She also received her chest x-ray later when she toturned to the waiting area, and was called by another technician who was to give the chest x-ray.
The initial error by the patient should have been detected by the technician who routinely has the patient sign a l consent turm. A review of that form would have shown a printed name " Patient Smith", but that it had been signed by " Patient Jones". This check was not performed or the difference in 1 I names not observed, presumably because Patient Jones had positvely identified herself as Patient Smith.and acquiesced f after being told she was to receive a liver scan. In accordance with the policies of the Hospital, the l error was routinely reported to Dr. Imperiale, the Medical { Director of the Department, and the Radiation Safety Officer t under the license issued by the Nuclear Regulatory Commission 1 NUPEG.0940 !!.A-A2 i
to the' Hospital. It was his obligatioL to report what the NRC characterises as a " misadministration" as defined in 10 CFR
$35.41. Dr. Imperiale determined that the matter was not serious enough to report and told the technician not to report it.
Following the July 17, 1985 interview with the NRC inspectors, Mr. Keating contacted the head of the department, Jesse Waselus, and advised him of the inspector's comments, since they had asked that he be excused from the exit interview with Mr. Keating. Mr. Keating indicated to Mr. Waselus that he wanted to know whether or not in fact there had been an incident which could be characterized as a misadministratiin and to bn ... ':uw.- The inspectors did not advise Mr. Keating that they had questioned Mr. Waselus concerning a specific patient who they believed to be involved in the alleged misadministration, nor did they advise Mr. Keating that they had asked questions of ,*arol Carter, the Supervisor of Nuclear Medicine, concerning this matter. Neither of these employees were told specifically by the inspectors that they were investigating or seeking information about an alleged misadministration. However, as soon as Mr. Keating notified Mr. Waselus specifically what the NRC was looking for Mr. Wasalus brought to Mr. Keating's attention the incident which had occurred on May 8, 1985 described above. Both he and Ms. Carter made a full and prompt report on the matter, so that when two other 4 MIRfG-0"40 !!.A 83
NRC investigators appeared at the Nospital a short time later, they were given a full and accurate account of the incident. ' very simply, a minor misadministration had occurred, but was not reported to the NRC by Dr. Imperiale, but by August ! 7, 1985 at the latest, everyone knew about it, the NRC, as well as all relevant Hospital officials. Despite this, the NRC took no further action until its Press Release, and Order to Show Cause and Notice of Violatioa were issued this past month. In the meantime, however, the Hospital took appropriate action to reprimand the technician who had committed the misadministration and to ensure that in the future any such incident be repor'ted up the chain of command, regardless of the action or inaccion of the Radiation Safety i j officer, as more specifically set forth below. j sased upon belief, the Hospital avers the followingt i since Ms. Carter had advised Dr. Imperiale of the May 8, 1985 incident, and he had advised her that it need not be reported and that he would assume full responsibility for the matter, l ) I Ms. Carter reported nothing to the NRC on July 17, 1985 or prior to that date. As the Radiation Safety Officer, it is Dr. , Imperiale's ob1Leation and responsibility to report any matters ; which may be classified as a misadministration under the ' i regulations issued by the Nuclear Regulatory Commission. It is ! l not within the scope of the job duties of Ms. Carter to report such matters directly to the NRC, nor did she violate the NRC's
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,i n.a.no l nonen.co4n l
regulations by failing to report the incident. On all such , matters, the responsbility rests with Dr. Imperiale, who as the { Radiation Safety Officer and Medical Director, is in the best position both from a medical standpoint, and from his knowledge i of the NRC's regulations, to make such determinations. , As a consequence, when NRC inspectors questioned Ms. l Carter about a misadministration that occurred in June of 1944, which Dr. Imperiale had reported to the NRC in accordance with
- it's regulations, and asked whether there had been any other
; misadministrations, Ms. Carter responded that there were none.
She did so, apparently, because she believed she was bound by the decision of Dr. Imperiale with respect to the reportability and nature of the incident, and since Dr. Imperiale was not present on July 17, 1985 to esplain his decision to the NRC. Mercy Hospital is without sufficent information, knowledge or belief to formulate a further answer to allegations of this paragraph since the NRC has never until ) receipt of this Order fully advised the Hospital of the nature
- or results of the investigation conducted by the Office of !
l Investigations, has never furnished the Hospital with a copy of i the information developed by the NRC Office of. Investigations [ on the August 7, 1945 investigation and has never furnished the (
- Hospital with copies of the affidavits allegedly obtained by l
the Office of Investigations on or about August 7, 1985. i ! t l
- 8. Mercy Hospital is without sufficient information, '
) i nunm-nun n . A-ns l !
knowledge or belief to form an answer to the allegations in Paragraph a of the Notice concerning Dr.'Imperiale's alleged actions since it has never been furnished with a copy of tha interview conducted with Dr. Salvatore M. Imperiale, or received a copy of any affidavit or statement which he purportedly gave to the NRC investigators on or about that time. Based on the factual averments contained in Paragraph A of this Reply it is denied that Ms. Carter deliberately was not truthful with the NRC inspectors on July 17, 1985 or that she admitted to such deliberate untruthfulness in an affidavit given to the Office of Investigations of the NCR on August 7, 1985. In further answer, the Hospital avers that when it first became aware after July 17, 1985 that a misadministration may have occurred, it immediately directed its employees, as did Dr. Imperiale to divulge to the NRC investigators a full account of the May 8, 1985 incident. C. Furthermore, Mercy Hospital as a result of it's own investigation after July 17, 1935, and as a result of the NRC investigation of August 7, 1985 took immediate steps to insure that sufficient additional management reporting procedures and other procedures were adopted to insure that any future misadministration, if any, would be reported in accordance with j 10 CFR $35.43. Employees of the department and Ms. Carter were specifically advised that in the future they were to follow the certain specific performance standards which were given in i i flVPEG-0040 II.A-86
writing to them on September 20, 1985. They were specifically directed to report all misadministrations in accordance with the Hospital's incident report procedure which had been in effect prior to the alleged misadministrations, and appropriate personnel have the authority to report such misadministrations l or any other matters directly to the Nuclear Regulatory Commission and that there was to be no deviation from such a policy. A copy of that document is made part of this answer and is marked Exhibit D. l While reporting any misadministration to the Radiation Safety Officer should have been sufficient in and of itself to i comply with the Commission's requirements, and the Radiation Safety Officer should have reported such misadministration, to insure a double check and to insure this reporting is done in the future, therefore, all such incidents are to be reported to the Hospital through the Hospital normal incident reporting j procedure and appropriate personnel have the authority to j report any such incident directly to the NRC. A copy of the Hospital's incident report procedure is made Exhibit E and attached hereto. 1 Additionally, employees engaged in licensed activities, have been advised that they should report misadministrations directly to the NRC, where no action is taken by the appropriate Hospital official, a right which they l have had at all times. The Hospital has posted in the i Department both prior to the May 8, 1985 incident, and since, a l ; 1 l NUREG-0940 II.A-87 i i l.. ....... _ _-_ _ _- _--.- _ _ _ ~ . - - - - - - - - - - - - - - - - - - ---
poster issued by the NRC. This poster is in a position'to be seen by all employees and specifically advises them of the right to contact the NRC in confidence. The Radiology Department policy also specifically provides: -
"The technologist involved with the misadministration must fill out and [ sic] an incident report and have it forwarded to the Director of Safety and Security.
If an incident is reported to the RSO and if the RSO decides that it is not reportable to the NRC, then he/she must submit in writing to the Vice President of Clincial Operations why the incident is not being reported.
- If the technologist questions the response i of the Director, RSO and/or consulting physicist, he/she may notify the Vice President of Clinical Operations and/or the Chief of Surgery Any employee, who follows the I aforementioned chain of reporting an incident to achieve resolution, will not be fired, retaliated or discriminated against."
A copy of this policy is made Exhibit F and attached hereto. While in the case of the May 8, 1985 incident, the I i Hospital's incident reporting procedures were not followed, it is evident that the information provided to employees by the ! Hospital by means of the NRC poster was an effective check since i this was the procedure evidently used to notify the NRC. l l D. The Hospital avers that based on the above facts and circumstances as well as the above described corrective steps the Hospital has taken with regard to reporting procedures, full compliance with 10 CRF 35.43 has been achieved and shall continue to be achieved. 1 NUREG-0940 II.A-88 L _ _ ._ _ . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _
II. Reply to Proposed Imposition of Civil Penalty A. The Hospital incorporates Part I(A) of its Reply to
^
Notice of Violation as if more' fully set forth herein. B.. The Hospital incorporates Part I(B) of its Reply to Notice of Violation as if more fully set forth herein. 1
, C. The Hospital incorporates Part I(C) of its Reply to
, Notice of Violation ~as if more fully set forth herein. The i prompt corrective measures as described in Part I(C) and the Hospital's past exemplary record of compliance with NRC regulations entitles the Hospital to mitigation.of the Propcred 1 Civil Penalty pursuant to General Statement, Section V.(E) 1-3. i D. In further answer Mercy Hospital avers that the Commission is without statutory or regulatory authority to increase the civil penalty for violation of 10 CRF S35.42 since it is a Level four (4) violation. General Statement of Policy and , Procedure for NRC Enforcement Actions (the " General Statement"), 10 CRF Part 2, Appendix C Supplement VI D(3)'. i Under the General Statement, Section V(B) and Supplement VI the Commission has no authority to raise a Level four (4) violation to severity Level one (1) simply on the basis of the fact that a separate Level one (1) violation allegedly occurred. Accordingly, pursuant to the General Statement Section V(B), I i NilPEG-0940 II.A-89 l
there should be no civil fine imposed for the failure to report a misadministration as Level four (4) violations do not give rise to civil penalties unless the licensee had committed ~ similar previous violations -- which Mercy Hospital has not ,. done. At the most the base penalty permitted by that regulation for a Level four (4) violation which is limited to $750, may be , imposed. . The Hospital further avers that the alleged deliberate and misleading falso statement made by Carol Carter at most e constitutes a violation of severity Level two (2), and since the regulations clearly contemplate that where a false statement is
' made which does not involve significant information, even if 4
deliberate, there is only a severity Level three (3) violation. General Statement, Supplement VII C(1) and (2) states as follows:
"C. Severity II (sic] violations involving for example:
- 1. A MFS not amounting to a Severity I or II violation.
- 2. Deliberate falsification, or i falsification by or with the-knowledge of management, of records which the NRC requires to be kept that did ngt involve sianificant information."
f 10 CFR Part 2, Appendix C, Supplement VII(C)(1), (2) (1985) i (emphasis added). As the May 8, 1985 misadministration that occurred in this case involved an exposure to radiation brought on by Patient Jones' own knowing submission to the liver scan,
- Ms. Carter's statement thereabout did not involve significant
' information and should therefore be characterized as severity l l NUREG-0940 II.A-90
Level chree (3). ' Moreover the insignificant nature of this purported misadministration is to be weighed in the NRC's determination of the severity Level to be accorded the alleged material false statement, General Statement, Supplement VII, n.15, a consideration apparently not afforded by the NRC in this case. Thus, even if Ms. Carter's statement was material and false, any civil penalty imposed therefor should be at the lesser rate associated with a severity Level three (3) violation. In this case for the reasons advanced above, Carol Carter did not make a deliberately misleading false statement, but on the contrary was reflecting accurately the view of the Hospital's Radiation Safety Officer, which she felt she had an obligation to do as the Head of the Department in his absence
'i during the routine on site inspection of July 17, 1985. While it is true that Ms. Carter may have felt that the Radiation Safety Officer was wrong in his determination and for that reason felt that there had been a misadministration, she reasonably believed that she had an obligation to adhere to the determination of Dr. Imperiale as Radiation Safety Officer.
The alleged offense is further ameliorated by the fact that when directly confronted both by her department head immediately after July 17, 1985, and by NRC investigators on August 7, 1985, Ms. Carter promptly and fully and truthfully ( disclosed all that had happened on May 8, 1985. It is entirely i
,es.1 1. ehae had ehe inveseigaeors whe were ehere for a l
1 NDPEG-0940 II.A-91
routine on site inspection on July 17, 1985 asked directly the same questions that were asked by her department head later that day, and asked directly by the NRC investigators on August 7, 1985 they would have received a more direct answer than they received to their questions that were framed in such an oblique fashion. E. The Hospital further points out in support of it's reply and request for amelioration and mitigation of the proposed civil penalty that Dr. Imperiale has been replaced as Radiation Safety Officer, and that Ms. Carter is no longer employed by the Hospital. For the foregoing reasons, Mercy Hospital respectfully requests-that the Commission reduce the proposed civil penalty to an amount appropriate for a Level four (4) severity violation in the case of the failure to report a misadministration and a Level three (3) violation for the purported material false statement. In support of this request the Hospital respectfully points out that the Commission has no power or authority to increase a severity Level four (4) failure to report a misadministration to severity Level one (1), and points out that under the circumstances of this case as described fully above any failure by Ms. Carter to fully disclose the events of May 8, 1985 were made for the bona fide reason that Dr. Imperiale, the Radiation Safety Officer, had determined that those events were not reportable. As Ms. Carter was standing in Dr. Imperiale's shoes in NUREG-0940 II.A-92 i
his absence during the routine on-site inspection of July 17, 1985 she acted with no intention of deliberately misleading the I NRC investigators. In any case, under the NRC's General ' Statement the nature of this mistatement, rises only to a Level three (3) severity, particularly in light of the insignificant nature of the information concerning the misadministration which occurred and, based upon the fact that failure to report a a misadministration is only considered to be a Level four (4) severity violation in any case by the Commission. General Statement, Supplement VI and VII. Respectfully submitted, c #m . By MMi b Jonathan L. Alder Robert M. Lucas ALDER COHEN & GRIGSBY, P.C. 600 Grant Street, Fifth Floor Pittsburgh, PA 15219 (412) 394-4900 2 Counsel for Mercy Hospital of Wilkes-Barre Dated: // /fM (7 (7 NUREG-0940 II.A-93
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 hII1Dh11T COMMONWEALTH OF PENNSYLVANIA )
) ss:
COUNTY OF LUZERNE ) Before me, the undersigned authority, personally appeared Robert J. Moylan, who, being duly sworn according to law, deposed and said that he -is the Executive Vice President of Mercy Hospital of Wilkes Barre, the Licensee in the above-captioned action, that he has read the foregoing Reply To Notice Of Violation And Proposed Imposition Of Civil Penalty, and that the averments contained in said Reply are true and correct to the best of his knowledge, information and belief.
.41 6 l
l
'l Robert)J. Moyllan l
Sworn to and subscribed i before me this // fA, day of , Juh,1986. kna
\ Notary Public htihin l
My commission expires: ftJiANT rNDUG game.gern, Luzerne Coway, A W Casesnessen Espres Octaner 12,1W NUREG-0940 II.A-94
ALDER COHEN & GRIossy l I A Paoresstowat Conromarrow ATTORNEYS AT LAW Farrn FLooE eoo Gaawr Srazer Pirrset:nou, PewwsytvantA 15219 Tatzenows (412) 394-4eoo Tatzx so-ece2 Tatzcorren 301-3382 October 17, 1986 James M. Taylor, Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Re: In the matter of Mercy Hospital; Docket No. 30-02971; License No. 37-00897-01; EA 86-40
")ar Mr. Taylor:
Enclosed please find the original Supplemental Response of Mercy Hospital to the Order To Show Cause Why The License Should Not Be Modified, as well as Mercy Hospital's check payable to the Treasurer of the United States in the amount of
$5,000 in payment of the civil penalty imposed upon Mercy Hospital in the captioned matter.
Very truly yours, ALDER COHEN & GRIGSBY, P.C. By Jonathan L. Alder Robert M. Lucas Counsel for Mercy Hospital of Wilkes-Barre cc: Executive Legal Director, U.S. Nuclear Regulatory Commission (with copy of Supplemental Response) Dr. Thomas Murley, Regional Administrator, U.S. Nuclear Regulatory Commission, Region I (with copy of Supplemental Response) Robert J. Ross, Esq. (with copy of Supplemental Response) A. Peter Kanjorski (with copy of Supplemental Response) JLA:pab l
- NUREG-0940 -
II.A-95 l
UNITED STATES NUCLEAR' REGULATORY COMMISSION In the Matter of )
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 SUPPLEMENTAL RESPONSE TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED f
Jonathan L. Alder Robert M. Lucas ALDER COMEN & GRIGSBY, P.C. 600 Grant Street, Fifth Floor
- l. Pittsburgh, PA 15219 (412) 394-4900 Counsel for Mercy Hospital l
l l NUREG-0940 II.A-96
UNITED STATES NUCLEAR REGULATORY COMMISSION. In the Matter of )
)
MERCY HOSPITAL ) Docket No. 30-02971 Wilkes Barre, Pennsylvania 18765 ) License No. 37-00897-01
) EA 86-40 SUPPLEMENTAL RESPONSE TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED Mercy Hospital, by its counsel Alder Cohen & Grigsby, P.C., pursuant to 10 C.F.R. $2.202 files the following Supplemental Response to the Commission's Order to Show Cause Why the License Should not be Modified as follows:
Pursuant-to. agreements between the NRC and Mercy Hospital-achieved at an August 26, 1986 enforcement conference at the NRC Region I offices in King of Prussia, Pennsylvania and a September 17, 1986 telephone conference, Mercy Hospital hereby stipulates and agrees to the following: I. Misadministration Reporting As a corrective measure to avoid the possibilty of a future failure to report any therapy or diagnostic misadministra-tions, Mercy Hospital established a revised Procedure for Incident
?
NUREG-0940 II.A-97
Reporting in the Radiology Department, which assigns, inter alia, specific responsibility for reporting misadministrations to the NRC. A copy of this Procedure is attached hereto as Exhibit "A". II. Radiation Safety Officer As a further corrective measure, Dr. Salvatore Imperiale was removed as Radiation Safety Officer at Mercy Hospital effective July 15, 1986. Mercy Hospital's new RSO effective that l same day is Champak M. Dedhia, M.D..
~
i l III. Authorized Users. In a further attempt te avoid reoccurrence of a failure to report a misadministration, Mercy Hospital sought and this Commission approved an amendment of its NRC license limiting the authorized users listed thereon. A copy of the approved Amendment No. 24 is attached hereto as Exhibit "B". Dr. Salvatore Imperiale has been removed as an authorized user for a one-year probationary period by this amendment. Pursuant to a September 23, 1986 telephone conference between NRC Region I Attorney Jay Cateros and counsel for Mercy Hospital it is Mercy Hospital's understanding that during the one-year probationary period, Dr. Imperiale shall be permitted to perform all, activities involving licensed material under the supervision of one of the authorized user's listed on Amendment No. 24. Mercy Hospital avers that it has informed the authorized users listed of their responsibilities under this condition. NUREG-0940 II.A-98
It is the present intent of Mercy Hospital to seek amendment of its license at the end of the one-year probationary period in order to have Dr. Imperiale be reinstated to authorized
' user status.
IV. Communications with NRC To reemphasize Mercy Hospital's commitment to maintaining forthright and truthful communications with the NRC, the Mercy Hospital Administration, by memorandum dated September 29, 1986, issued a statement to all employees that forthright and truthful communications with the NRC are expected of them as a requirement of their employment with the Hospital. A copy of this Memorandum is attached hereto as Exhibit "C". Mercy Hospital avers that it will hold a meeFing with employees to explain and discuss this statement. V. Identification of Outpatients On September 5, 1986 Mercy Hospital filed its Misadministration Report concerning the May 8, 1985 misadministration which is the subject of this Commission's Order to Show Cause. In that report, two corrective measures were listed to aid in correct identification of outpatients. Additionally, it should be emphasized that Mercy Hospital has changed its consent form to provide for both a printed and written signature by the outpatient and has revised its consent form procedure to include that technologists must receive verbal confirmation from the outpatient of the NUREG-0940 II.A-99
outpatients' printed name prior to submitting the patient to a nuclear medicine scan. Copies of-the Consent Form and Consent Form Procedure are attached hereto as Exhibits "D" and "E" respectively. IV. Conclusion. Based on the within-listed corrective measures and the. additional reasons and authorities stated in Mercy Hospital's Answer, Mercy Hospital respectfully requests that this Commission lift its Order to Show Cause Why the License Should Not be Modified for good cause shown. Respectfully submitted, ALDER COMEN & GRIGSBY, P.C. Jona'than L. ' Alder Robert M. Lucas 600 Grant Street, Fifth Floor Pittsburgh, PA 15219 (412) 394-4900 Counsel for Mercy Hospital of Wilkes-Barre Dated: October [hf,1986 NUREG-0940 II.A-100 t l- .- -. - ._. __ __ _ .
.- . .- - + .~. , _ , - . - -- . - _ ~ . . . . - _ , -
UNITED STAf f S
, NUCLE AR REGULATORY COMMISSION g - v. , s/ utGios r.
- W [, . n SW AN M A/A OHtyt %94f f ties:
4
.....~ AduNGroN. It 2 As femi SEP 2 61%6 Pocket No. 30-28758 License No. 35-23188-01 L EA 86-138 NOW Logging Perforating, Inc.
Attn: Jim Dixon, Vice President P. 0. Box 128 Enid, Oklahoma 73702 Gentlemen: 3
SUBJECT:
NOTICE OF VIOLATION 'J ' PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NO. 30-28758/86-01) This refers to the routine, unannounced inspection conducted by the NRC in your office in Enid, Oklahoma, on June 20, 1986. Violations identified during the inspection by L. T. Ricketson of the NRC vere Jiscussed with you and members of your staff at the conclusion of the inspection.' This also refers to the enforcement conference held in Oklahoma City en July 18, 1986 with you and members of the Region IV staff to discuss the violations identified during the 4 inspection. The violations described in the enclosed Nos; ice of Violation and Proposed Imposition of Civil Penalties (Notice) occurred during the period of September 9. j 1985 to June 20, 1986 and involved failure to survey, to provide an operable survey meter, to conduct leak tests, to provide personnel monitoring devices and to properly store licensed material. These violations are of significant l concern to the NRC because they collectively demonstrate a very serious breakdown in management oversight and control of your radiation protection program. Although this inspection was the first.since your license was granted on July 31, 1985, the number of violations indicate that you have operated in careless dis-regard for the requirement of your license and that significantly increased atten-l tion to NRC regulatory requirements is necessary. 4 To emphasize the importance of complying with NRC requirements. I have been authorized, af ter consultation with the Director, Of fice of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of EiEht Hundred Dollars (8800) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations described in the
- enclosed Notice have been categorized in the aggregate as a Severity Level II f CERTIFIED MAIL RETURN RECEIPT REQUESTED h
j i i l i W EG-0940 II.A-101
SEPc
- x'? Legging . Pe rrorat ti.g . Inc. problem because they inoicate careless disregard for NRC requirements. The base value of a civil penalty for a Severity Level II violation or prebitm is f800. The escalation and eltigation f actors in the Enforcement Policy were considered and no adjustment was deemed appropriate.
You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is recessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10. Code of Federal Regulations, a copy of this letter and its enc 1ceure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980 PL 96-511. Sincerely, CRic;Nr. SCC O' ROBERI D. i&,?.i:N Robert D. Martin Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalties . cc: Oklahoma Radiation Control PreFran Director l l NUREG-0940 II.A-102
i MOTICE OF VIUI.ATION PROPOSEl' !!'POSITIC F CIVIL PENALTIES hot.' f ogging, Pertorating. Inc. Docket ho. 30-2875P Enid,' Oklahoma License No. 35-23188-01 EA 86-138 4 During an NRC inspection conducted at your office in Enid. Oklahoma on June 20, 1986, violations of NRC requirements were identified. In accordance with the "Ceceral Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1986), the Nuclear Regulatory Commission proposes to impose civil pennities pursuant- to Section 234 of the Atomic Energy Act of 1954, as amended ("Act"), 42 U.S.C. 2282, FL 96-295, and 10 CFR 2.205. The particular-violations and associated civil penalties are set forth below:
- 1. License Condition 18 requires that licensed material be used in accordance with statements, representations, and procedures contained in the license application, dated June 18, 1985.
i a. Part II, Section A(1) of the procedures submitted with the license application requires that a TLD badge be assigned by name and number to each employee working with radioactive materials. Contrary to the above, at the time of frspection, personnel working with radioactive material had never been provided TLD badFes.
- b. Part III.- Section A(1) of the procedures submitted with the license I application requires that radioactive sources be secured in a i storage pit at all times when not in use.
l
- - Contrary to the above, at the time of the inspection, the NRC inspector found an americium-241 source in a transport container
; stored in the garage area of the licensee's shop.
- c. Part III, Section B of the procedures submitted with the license ,
application requires that a radiation survey meter to be carried on 4 each vehicle used for transportation of radioactive materials and one ! l or more operable radiation survey meters be kept at the base ' facility ,
! as a spare and for emergency use. ,
, Contrary to the above, at the time of the inspection, the inspector noted and the licensee confirmed that no survey instruments had ever i been provided.. j d.- Part II, Section B(1) of the procedures submitted with the license , application requires that a job site survey must be made before and
- af ter each operation using radioactive materials. ,
1 r J t 4 I i Nt'dEG-0940 II.A-103
. . .. ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ . . . . _ _ _ _ _ _ _ ~ - _ _ _ _
Contrary to the above, at the tice of the inspection, tl:e licensee's. representatives stated that since the licensee bed no surve) tretrument, no job site surveys hed been performed before end af ter operations using radioactive materials.
- e. Part III. Section A(4) of the procedures submitted with the license application requires that monthly storage bunker surveys will be made by the Radiation Safety Officer and records of the surveys will be - ,
kept in the survey files. Contrary to the above, at the time of the inspection, the licensee's representatives confirmed that no surveys, by measurement or calcula-tien, had ever been perforned for the source storar,e area.
- f. Part IV. Section I of the procedures submitted with the license application requires that a vehicle survey be made and recorded af ter use at a job site and before transport back to the storage area.
. Contrary to the above, at the time of the inspection.
Licensee's representatives stated that since the licensee had no survey instruments, no vehicle surveys had ever been made,
- g. Part I. Section D of the procedures submitted with the license application outlines the required personnel training for individuals using radioactive materials. Step 3 of this section requires that records be kept showing fulfilleent of training requirements.
Contrary to the above, at the time of the inspection, the NRC inspector found that there were no training records for individuals using radioactive materials.
- h. Part IV. Section C of the procedures submitted with the license application requires that prior to leaving the facility for the job site, the source will be logged cut on the source utilizetion log.
This icg will be kept in the radiation files for review by regulatory agencies. Contrary to the above, at the time of the inspection, the licensee had not maintained a utilization log.
- 1. Part VII. Section B of the procedures submitted with the license application requires that a program of inspection and maintenance for sealed sources be conducted at intervals not to exceed six months.
Pecords are to be maintained for a period of two years for inspection. Contrary to the above, at the time of the inspection. records for the inspection and maintenance of sealed sources were not available.
- 2. License Condition 13.A(1) requires that each sealed source containing Itcensed material shall be tested for leakage and/or contamination at intervals not to exceed six months.
NUREG-0940 II.A-104 l
-,m = m<--- -
e ,-,--m - u-
s-7 Contraty to the above, the 3.0 curie amerletic "41 source. Ferf al Nunber 71-1-883B, had not been tested for leakage during the period September 9,1985, the date of receipt, until June 70, 1986, the date of inspection.
- 3. 10 CFR 20,203(e)(1) requires, in part, that each area or room in which ifcensed material is used or stored shall be conspicuously posted with a sign or signs bearing the radiation caution symbol and the words "rAUTION (or DANGER) RADI0 ACTIVE MATERIAI,(S) ."
Contrary to the above, at the time of the inspection, the areas used to store the radioactive source were not posted at the time of the inspection. 4 License Condition 16 requires that the licersee shall conduct a physical inventory every six months to account for all sealed sources received and possessed under the license. The records shall be maintained for two years from the date of inventory for inspection by the Commission. Contrary to the above, at the tine of the inspection, records of inventory were not available for inspection.
- 5. 10 CFR 71.5(a) requires, in part, that each licensee who transports licensed material outside the confines of its plant or other place of use,
, or who delivers any licensed material to a carrier for transport shall licensee comply with applicable requirements of the regulations appropriate to the mode of transport, of the Department of Transportation , in 49 CFR Parts 170-189. ! 49 CFR 172.200(a) requires that each person who offers a hasardous material for transportation shall describe the hazardous material on the shipping papers in the manner required by subpart C of Part 172.
Centrary to the above, shipping papers had not been provided for the 3.0 curie americium-241 source when transported on the public highways of the state of Oklahoma during the period of September 5, 1985, to Jur.e 20, 1986. 4
- 6. 10 CFR 19.!!(a) and (b) require that each licensee shall poet current
. copies of specified regulations, the license and incorporated documents.
l and the operating procedures applicable to licensed activities or if the above is not practical, then the licensee may post a notice specifying where such documentu may be examined. Contrary to the above, at the time of the innpection, neither the documents nor a notice were posted. I
- 7. 10 CFR 19.ll(c) requires that Form NRC-3, " Notice to Employees " shall be posted by each licensee.
l l NUREG-0940 II.A-105 1
- , .-----,c e- ,,, . . - - - -. , - - - - _ _ - - - - - - - , - , , - - , - - - - - _-r_ . - - + - -- - - -
.. - - - . ~ . - _ ~ - - . ..- - _ - - - _-
4 Centrary to the above, f orm NFC-1 wrn tmt pested at the tire rsi ir.spection. [ These violations have teen categorized in the APgregate as a Severity Level Il problem (Supplements IV, V, and VI), Cumulative Civil Penalties - 8800 assessed equally among the violations. Pursuant to the provinions of 10 CFR 2.201, NOW Logging. Perforating. Inc. . is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region IV, 611 Ryan Plaza Drive Suite 1000, Arlington, Texas 76011, within 30 days of the date of this Notice a written statement or explanation. l including for each alleged violation: (1) admission or denial of the alleged violation (2) the reasons for the violation if admitted. (3) the corrective i steps that have been taken and the results achieved (4) the corrective steps
)
which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the l time specified in this Notice, the Director Office of Inspection and Fnforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, ; j 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under l 10 CFR 2.201, NOW Logging, Perforating. Inc., may pay the civil penalties ' j by letter addressed to the Director Of fice of Inspection and Enforcement. with a check, draf t, or money order payable to the Treasurer of the United ' l States in the cumulative amount of Eight Hundred Dollars ($800) or may
- . protest imposition of the civil penalties in whole or in part by a written 3
answer addressed to the Director, Office of Inspection and Enforcement. Should ! NOW Logging, Perforating Inc., fail to answer within the time specified, the
- Director, Of fice of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should NOW Logging, Perforating,
' Inc., elect to file an answer in accordance with 10 CFR 2.205 protesting the
- civil penalties, such answer may (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be l imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties.
i In requesting mitigation of the proposed penalties, the five factors addressed j in Section V.B of 10 CFR Part 2. Appendix C should be addressed. Any writtet I answer in accordance with 10 CFR 2.205 should be set forth separately from the I statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate NUREG-0040 II.A-106
parts of the 10 CFR 2.201 reply by epcitic reference (e.e. citing pne and paragraph m.chers) to avola repetitice. NOW Logging, Perfortting. inc.'s attention is directed to the other provielens of 10 CFP 2.205 reperding the procedure for imposing civil penalties. Upon failure to pay any civil penalties due.which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless com' promised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act. 42 U.S.C. 2282. FOR THE JUCLEAR REGULATORY COMMISSION
/
g < b f l~b Ws Robert D. Partin Regional Adninistrator Dated at Arlington Texas, this 1 N ay of September 1986. i l, h l NtlREG-0940 II.A-107
I'pG- c, @- ji 'dOF %1 MThe "Now" Companyq ,
, , a i
OCT 2 91986 I i Northern Oklahoma Wireline I 5720 N. Highway 81 -- Enid, Oklahoma 73701 (405) 233-0669 Oct. 22, 1986 Gentlemen, In response to your letter dated Sep.26,1986 of wich a copy is attached we hereby respond to the questi ms asked, i
- 1. We Admit to the alleged violations, f
- 2. Those individuals that were employed by us failed to perform the duties that were required of them.
3 A Copy of all stepe that have been taken is attached.
- 4. Our c apany is no longer in business and we will not be using theRadioactive Source.
5 Full compliance was achived on Sept. 8,1986. erely, In A. on 2"- Vice President l l 1 i l NUREG-0940 II.A-108
1 MThe "Now" Northern Oklahoma Wireline Companyq 5720 N. Highway 81 Enid, Oklahoma 73701 (405) 233-0669 september 8, 1986 puelear Regulatory e-4== ion 611 Ryan Flasa - Seite 1000 Arlington, Tm 76011 Attention: Richard L. Bengart Dear Mr. Sangart This letter is in regards to assuerlag the 14 violations listed in your letter dated July.10, 1984.
- 1. We have film badges from Radiaties Detection Co.
- 2. We have survey meter from Culf 5ecular, Ime.
- 3. We have not been out os job but have the proper forme to conduet en site surveys.
4 Pit has been constructed and posted as per instrweted.
- 5. We have the forme and they are up to date.
- 6. We have the forme and they will be filed when we use the source.
- 7. We have leak test kits from Radiation Deteettas Co.
- 8. Perseasel reeorde are up to date.
- 9. Isventary of sealed sourse reeerds are up to date.
- 10. We have forms to work pp when va see the soarea.
- 11. Balder, teels, & Sontainere are la good candities and paper work is in order.
- 12. We have shipping papers in our files.
- 13. All documente have been posted.
- 14. Form NRC - 3 has been posted.
NUREG-0940 II.A-109
l l pThe "Now" Companyg s - Northern Oklahoma Wireline 5720 N. Highway 81 f ' Enid, Oklahoma 73701 (405) 233 0669 2 ( Us will be esittag for year reply by roterm mail. Stacerely, I l Jim A. Dison Vice-President JADad11 i l l i flVREG-0940 II.A-110
E
- UNITED STATES
/ga es%qk, '
NUCLEAR R EGULATOR Y ' COMMISSION [ '
,e I REGloN lli "a j 799noostyst?noAo j at ~ <tova.itu~ois win May 30, 1986 Docket No. 030-13889 License No. 21-18576-01 EA 86-79 Progressive Engineering Consultants of Grand Rapids, Incorporated ATTN: Ray Fix, Vice President and Secretary Grand Rapids, MI 49505 Gentlemen:
t
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED imp 0SITION OF CIVIL PENALTIES [ INSPECTION REPORT 030-13889/86001(ORSS)] This refers to the routine safety inspection conducted during the period March 13 - April 7, 1986 at your facility in Grand Rapids, Michigan. The results of the inspection were discussed on April 15, 1986 during an enforce-ment conference in the Region III office between you and C. Marschall of your staff and J. A. Hind and other members of the NRC staff. As a result of the inspection, it appears that a number of violations of NRC requirements have occurred. These include (1) unauthorized users of licensed material, (2) unauthorized transfer of material, (3) failure of the Radiation Protection Officer to perform duties as required (4) failure to provide film badges to users of licensed material, (5) failure to perform leak tests of licensed material, (6) failure to adhere to Department of Transportation requirements, (7) failure to notify the Commission of changes to the license, and (8) failure to post documents and notices. These violations are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties. The violations collectively demonstrate that adequate control and oversight of the radiation safety program at your facility has not been exercised. To emphasize the seriousness of these violations and the need to ensure implementation of adequate management control over the radiation safety program, I have been authorized, after consultation with the Director. Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Five Hundred Dollars (5500) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), tne violations have been categorized in the aggregate as a Severity Level III croblem. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-111
Progressive Engineering Consultants 2 May 30, 1986 You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10 Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Re:m. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Act of 1980, PL 96-511. Sincerely, Q A-
. % g IeY ifJamesG.Kepp Regional Administrator
Enclosure:
Notice of Violation ! and Proposed Imposition of Civil Penalties I NUREG-0940 II.A-112
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Progressive Engineering Consultants Docket No. 030-13889 of Grand Rapids, Incorporated License No. 21-18576-01 Grand Rapids, MI 49505 EA 86-79 During the period March 13 - April 7, 1986 an NRC safety inspection was con-ducted which identified several violations of NRC requirements. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1984, as amended ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and the associated civil penalties are set forth below. A. License Condition No. 12 requires that licensed material shall be used by, or under the supervision and in the physical presence of, individuals who have attended the Device Manufacturer's Training Course for gauge users and who have been designated by the licensee's Radiation Protection Officer. Contrary to the above, since August 1984, the licensee has allowed individuals to use licensed material contained in moisture / density gauges who were not under the supervision and in the physical presence of an authorized gauge user and who had not attende,d the Device Manufacturer's Training Course.
- 8. 10 CFR 30.41(a) requires that no licensee shall transfer byproduct material except as authorized pursuant to this section. 10 CFR 30.41(b)(5) requires that byproduct material may be transferred to any person authorized to receive such byproduct material under terms of a specific license or a general Itcense or their equivalents issued by the Atomic Energy Commission, the Commission or an Agreement State or otherwise authorized pursuant to 10 CFR 30.41.
Contrary to the above, in January 1986, the licensee transferred byproduct material (a Troxler/ moisture density gauge) to an individual who was not authorized to receive byproduct material under the terms of a specific license or a general license or their equivalents issued by the Atomic Energy Commission, the Commission or an Agreement State or otherwise authorized pursuant to 10 CFR 30.41. C. License Condition No. 18 requires that the duties of the Radiation Protection Officer shall include those items listed in Item No. 5 of the NRC guide entitled, "A Guide for Preparation of Byproduct Material Applications for the Use of Sealed Sources in Portable and Semiportable Gauging Devices." Item No. 5(') requires that the Radiation Protection Officer will periodically review the terms and conditions of the license for compliance with NRC regulations, requirements, and license conditions. i Nt0EG-0940 II,A.113
Notice of Violation 2 May 30, 1986 Contrary to the above, as of the March 13, 1986 inspection the Radiation Protection Officer failed to perform any periodic review of the terms and conditions of the license for compliance with NRC regulations, requirements, and license conditions. D. '10 CFR 20.201(b) requires that the licensee make such surveys as may be necessary for. compliance with all sections of Part 20 and are reasonable i under the circumstances to evaluate the extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the prcduction, use, release, disposal, or presence of radioactive materials or other sou-ces of radiation under a specific set of conditions. Contrary to the above, since August 1985, the licensee did not make surveys or evaluations nor did the licensee provide personnel monitoring devices (film badges) to determine whether exposures to individuals using moisture density gauges would be within the occupational dose
-limits of 10 CFR 20.101(a).
E. License Condition No. 13 requires that each sealed source containing licensed material, other than hydrogen-3. with a half-life greater than thirty days and in any form other than gas shall be tested for leakage and/or contamination at intervals not to exceed six months. Contrary to the above, the licensee failed to perform sealed source leak tests every six months as required on a sealed source containing licensed i material other than hydrogen-3, with a half-life greater than thirty days and in a form other than gas. Specifically, the licensee performed leak tests only in December 1978, November 1984, and April 1986 on a sealed source (Serial Number NG-601) containing americium-241 and cesium-137. F. 10 CFR 71.5(a) requires that each licensee who transports licensed material j outside of the confines of its plant or other place of use shall comply 2 with the applicable regulations of the Department of Transportation in 49 CFR Parts 170-189. i (1) 49 CFR 172.101(a) references the Hazardous Materials Table which
- specifies requirements pertaining to the packaging, labeling, and
' transportation of hazardous materials. ,
Column 5(b) of that table specifies that radioactive material special ! form, not otherwise specified, shall be packaged according to 49 CFR 173.415 and 173.416. Those regulations authorize 0.0.T. ; j Specification 7A packages for shipment if they do not contain
; quantities exceeding 3A . The Ag limit for special form cesium-137 is 30 curies.
i l NUREG-0940 II.A-11A
Notice of Violation 3 May 30, 1986 Contrary to the above, from August 1984 until the date of the inspection, radioactive material consisting of moisture density gauges containing cesium-137 not in excess of A y limits were transported outside the confines of the licensee's facility without being' packaged in a 0.0.T. Specification 7A package as specified in the Hazardous. Materials Table. (2) 49 CFR 177.817(a) requires that a carrier may not transport a hazardous material unless it is accompanied by a shipping paper that is prepared in accordance with 49 CFR 172.201, 172.202, and 172.203. Contrary to the above, from August 1984 until +.he date of the inspection, the licensee shipped hazardous material (moisture density gauges containing cesium-137 and americium-241) to various temporary job sites without shipping papers prepared in accordance with 49 CFR 172.201, 172.202 and 172.203. G. License Condition No.10 requires that licensed materiai shall be used only at the licensee's facilities located at 2920 Fuller Ave., N.E., Grand . Rapids, Michigan and at temporary job sites of the licensee located throughout the State of Michigan. Contrary to the above, in April 1985, the licensee moved its permanent facility where it was authorjzed to use and store licensed material from 2920 Fuller Ave. , N.E., Grand Rapids, Michigan to 2942 Fuller Ave., N.E. , Grand Rapids, Michigan and had not sought an amendment to its license to authorize this change. H. 10 CFR 19.11(a) and (c) require that current copies of Part 19, Part 20, the license, license conditions, documents incorporated into the license by reference, license amendments and operating procedures, as well as Form NRC-3, " Notice of Employees," be posted. 10 CFR 19.11(b). requires that the licensee may post a notice describing the documents and their location if posting of the documents is not practicable. Contrary to the above, on March 13, 1986, neither the documents required by 10 CFR 19.11(a) and (c) nor a notice describing these documents and their location were posted. Collectively, these violations have been categorized in the aggregate as a Severity Level III problem (Supplements IV, V and VI). (Cumulative Civil Penalties - 5500.00 assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Progressive Engineering Censultants of Grand Papids, Incorporated is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, i Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or dental of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the NUREG-0040 II.A-II5
E Notice of Violition 4 May 30, 1986 4 results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be. achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Saction 182 of the Act,-42 U.S.C. 2232, this response shall be submitted under wth or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Progressive Engineering Consultants of Grand Rapids, Incorporated may pay the civil penalties by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the i Treasurer of the United States in the cumulative amount of Five Hundred Dollars (5500.00) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Progressive Engineering Consultants of Grand Rapids, Incorporated fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amount proposed above. Should Progressive Engineering Consultants of Grand Rapids, Incorporated elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed.in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show othef reasons why the penalty should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties. In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explantation in reply pursuant to 10 CFR 2.201 but may incorporate ; i parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Progressive Engineering Consultants of Grand Rapids, Incorporated's attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing civil penalties. t Upon failure to pay any civil penalties due which has been subsequently determined l in accordance with the applicable provisions of 10 CFR 2.205, this matter may be j referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION
% :y W^Ir' ^ ^W hamesG.Keppl Regional Administrator Dated at Glen Ellyn IL.
this M ay of May 1966. l l { NUREG-0940 II,A-116 l
TC a E Oesige KSV Architectural Build Olvis6en Evls6en 2942 Fuffer Avenue. NE Grand Rapids. MI 49505 616 361 2664 June 24, 1986 a00 556-s5s0 Mr. James G. Keppler Regional Administrator U.S. Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137
Dear Mr. Keppler:
In regards to your letter dated May 30, 1986 which reviewed the alleged violations detected by the routine safety inspection on March 13, 1986, I submit the following response. A. License Condition No.12 requires that licensed material shall be used by, or under the supervision and in the physical presence of, individuals who have attended the Device Manufacturer's Training Course for gauge users and who have been designated by the licensee's Radiation Protection Officer. Being unaware of the precise wording of Condition.No.12,,it appears that Condition No.12 was violated. The individuals using the gauges were instructed by myself on the proper use of the gauge to obtain required readings, minimize personal risk and what to do in case of emergencies. Future gauge users will be instructed through the manufacturer's training ' course. All persons now using the gauges hold Troxler Laboratories <
~ ,/
Certificates.
- 8. 10 CFR 30.41(a) requires that no licensee shall transfer by-product material except as authorized pursuant to this section. 10 CFR 30.41(b)(5) requires that by-product material may be transferred to any person authorized to receive such by-product material under terms of a specific license or a general license or their equivalents issued bi The Atomic Energy Connission, the Commission or an Agreement State ~ br otherwise authorized pursuant to 10 CFR 30.41.
A Troxler moisture / density gauge was loaned to a fellow professional who unit late 1985 owned and operated his own materials testing corporation which was licensed to use several of these gauges. The individual , actually operating the gauge was at that time certified by the Tromler Laboratories. The gauge has been returned and in the future .. cur certified people will be the only persons using our gauges. C. License Condition No. 18 requires that the duties of the Radiation Protection Officer shall include those items listed in Item No. 5 of the NRC guide entitled, "A Guide for Preparation of by-product Material . Progressive Engineerint Censultants al Grand hopid Inc NUREG-0940 II.A-117
Applications for the Use of Sealed Sources in Protable and Semiportable
-Gauging Devices." Item No. 5(f) requires,that the Radiation Protection Officer will periodically review the terms and conditions of the license for compliance with NRC regulations, requirements and license conditions.
The periodic review of the . license conditions were waived by the Radiation Protection officer, partially due to the fact that the position of Radiation Protection Officer was changed three times in four years and the total L inactivity of the gauges until late 1984 Under the new radiation' protection officer there will be an event calendar initiated to prompt the proper sequence of events. Also, we will presently be asking- ! RAD Services to assist us in all departments that involve the nuclear l gauges (July,1986). D. 10 CFR 20.201(b) requires that the licensee make such survey as may be necessary for compliance with all sections of Part 20 and are reasonable; under the circumstances to evaluate the extent of radiation hazards that' may be present. As defined in 10 CFR 20.201(a), " survey" means an ! evaluation of the radiation hazards incident to the production, use, i release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions. We had not been wearing film badges- prior to the time of the safety inspection.- However, at the time of our " Device Manufacturer's Training-Course" we were infonned that such monitoring devices were not necessary. We-.are now associated with the Landauer Corp. and have badges for all employees that use the gauges plus one that is being kept in the soils lab where the gauges are stored. We plan to continue with the Landauer service and intent to add any newly certified operators of the gauges to the list of employees in the Landauer program. E. License Condition No. _13 requires that each sealed source contained 4 licensed material, other than hydrogen-3, with a half-life greater than thirty days and in any form other than gas shall be tested for leakage
- and/or contamination at intervals not to exceed six months.
The results of only a few leak tests could be produced at the time of the inspection. The leak tests were not performed during the time of , complete inactivity of the gauges (1978 to 1984) and 1 series of tests were missed while the gauges were in use. The results of the remaining test in question (1 each for the calendar year 1985) could not be produced due to improper filing of the leak test-reports. It is believed that a proper filing system and an . event calendar will prevent a reoccurrence of this violation. RAD Services will assist us in updating our filing system and should be available for consultation in July,1986. I F. 10 CFR 71.5(a) requires that each licensee who transports licensed material outside of the confines of its plant or other place of use shall contply with the applicable regulations of the Department of Transportation in 49 CFR Parts 170-189. I l l MUREG-0940 II.A-118
. ,= . _
l 1 (1) 49 CFR 172.101(a)' references the Hazardous Materials Table 'which specifies; requirements pertaining to the packaging, labeling and transportation of hazardous materials. Column 5(b) 'of that -table specifies that radioactive material . special form, not otherwise specified, shall be packaged according to 49 CFR 173.415 and 173.416. Those regulations authorize D.O.T. Specification 7A packages for shipment if they do not , contain quantities exceeding A 7
. .The Ag limit for special form cesium-137 s is 30 curies. -
,. (2)' 49 CFR1177.817(a) requires that a lcarrier may not transpod a hazardous material unless it is accompanied by a shipping paper that is prepared in accordance with 49 CFR'172.201, 172.202 and 172.203.
' At the time of the inspection, one Troxler gauge was being shipped in its original (approved) card board and foam. shipping ~ container which was i
-somewhat deteriorated and only one soiltest shipping container was on-hand for the two soiltest gauges. The fate of the missing soil test shipping container is unknown at this timt. However, one soil test gauge is presently in need of repair, and we will ask Campbell Pacific to send us a container to ship the gauge back to them for repairs. Also in May.
this year, an additional Troxler Shipping container was purchased and is in use. These shipping containers will be maintained to provide one for each unit. The malfunctioning soil test gauge.is expected to be shipped to Ca:npbell Pt.cific some ' time' in July or August. At this time the
~
company will-have one ship;iing container per gauge. Only the soil test gauges were' shipped without proper shipping papers and l the shipping papers for the Troxler gauges could not be produced at the time of the inspection. .Peor filing and someone being unaware of the requirements of 49 CFR 172.201, 172.202 and 172.203 are-the prime reasons for this violation. . The entire nuclear gauge division of the company is under the jurisdiction of ,one person and will remain that way. With the aid of consuling provided by RAD Services, sometime in July,1986, it is believed that all violation will be a thing of the past. G. License Condition No.10 requires that licensed material shall be used only at the licensee's facilities located at 2920 Fuller Avenue, N.E., Grand Rapids, Michigan and at temporary job sites of the licensee located throughout the State of Michigan. The address was changed without amending the license. This was caused by
~
a simple move within the same office complex and an oversite of the
' Radiation Protection Officer. Our license is in the process of being , amended to bring us into full compliance with the current NRC Rules and with the aid of RAD Services consultations the license will be kept current.
l l
'NUREG-0940 II.A-119
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H. 10 CFR 19.11(a) and (c) require that current copies of Part 19. Part 20, the license, license conditions, documents incorporated into the license
-by reference, license amendments and operating procedures, as well as Form NRC-3, " Notice of Employees " be posted.
10 CFR 19.11(b) requires that the license may post a notice describing the documents and their location if posting of the documents is not practicable. Being unaware of the requirements of 10 CFR 19.11(a), (b), and (c), no notices were posted at the time of the inspection. All notices have now been posted and with the consultation services to be provided by RAD Services, it is expected that there will be no further violation of any NRC regulation. In reviewing the violations noted above I feel that the initiation of an event calendar and employing RAD Services as consultants will provide the ) improvement necessary to put our Nuclear Gauge Department on the proper Course. Thank you for all your help in past months and if there are any further problems, please call. Very 'truly yours. PROGRESSIVE ARCHITECTS / ENGINEERS / PLANNERS Ch Chris Marschall Radiation Protection Officer CM/ag 8510-01X , l l l l l l l l l l l l l l NUREG-0940 II.A-120
I TC a t Desige KSV Architectural ! Bull 8 Olvtsien 8vislee j no p os$ 5 616 361-2664 July 1, 1986 800 556-5560 Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Comission Washington D.C. 20555 Re: Nuclear License Pennit No. 21-18576-01 Docket No. 030-13889
Dear Director:
We are transmitting herewith a copy of our June 24, 1986 letter to the Regional Administrator responding to the Notice of Violation letter dated May 30, 1986. The letter was advertently sent directly to the Regional Administrator rather than to your office as directed in the May 30th correspondence. As indicated in the itached letter, we have promptly taken action to correct all the cited violations, and feel we are presently in full compliance with the requirements of our permit. This is the first tiJne we have been cited as being in violation of our pennit. In some instances, there were extenuating circumstances which resulted in the violation. For example, our employees were not wearing film badges because we were told at the training course provided by the manufacturer of the device that such monitoring devices were not required. In light of the above factors and our prompt correction of violations upon notice, we feel the proposed $500.00 fine should be remitted or at least mitigated. Thank you for your consideration of this request. Very truly yours. PROGRESSIVE ARCHITECTS / ENGINEERS / PLANNERS Sy A Raymond F. Fix, P.E. Vice President RFF/ag 8510-01X Enclosure cc: Mr. James G. Keppler, Regional Administrator
'JUL 3 1986 Progressive Engineering l Censultants of Grand Rapids lac NilREG-094n II.A-121 l __ - _ _
.- / g UMTeO STATES
! 'i NUCLEAR REGULATORY COMMISSION wasunsatose.o.c.acess 2~
)
s NOV 0 51986
- Docket No.- 030-13889
; License No. 21-18576-01 i EA 86-79 Progressive Engineering Consultants f of Grand Rapids,-Incorporated ATTN: Ray Fix, Vice President and Secretary '
i Grand Rapids, MI 49505 Gentlemen: -
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTIES 1-j This refers to your letters dated June 24 and July 1,1986 in response to the i Notice of Violation and Proposed Imposition of Civil Penalties sent to you by . J' our letter dated May 30, 1986. The Notice of Violation describes violations ! identified during a routine safety inspection conducted at your Grand Rapids,
, Michigan facility during the period March 13 through April 7, .1986. ,To emphasize the need to ensure implementation of adequate management control-c over the radiation safety program, a civil penalty of $500 was proposed.
! In your response you admitted the facts in all _of the violations, as set-forth in the Notice of Violation, but requested mitigation of the civil { penalties for several reasons. After careful consideration of your responses j-- and your request for mitigation of the proposed civil penalties, we have ; r concluded for the reasons set forth in the enclosed Order and Appendix that . the violations did occur as originally stated and that mitigation of the!
- penalties is not warranted. Accordingly, we hereby serve the enclosed Order on Progressive Engineering Consultants of Grand Rapids, Incorporated in the
- amount of Five Hundred Dollars ($500). We will review the effectiveness of your corrective actions during a subsequent inspection.
i In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. i I CERTIFIED MAIL RETURN RECEIPT REQUESTED i i I i NUREG-0940 II.A-122 i:
. y -.m., --=..---w- ,r.,. , - - - , _--..e-.-m,~..--,ww..--re.w.-w, -,.,.r.,e.,,,----m.-%w.,,-we,eur-- w -- - .- .e .,.,---,,m,---,i- .--..-i
Progressive Engineering Consultants The response directed by this letter and the enclosed Order are not subject to-the clearance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, s- l me V. Taylo Director Office of Ins ction and Enforcement
Enclosure:
Order Imposing b- "/ Civil Monetary Penalties
, with Appendix i
I i , NilREG-0940 II.A-173
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
) Docket No. 030-13889 PROGRESSIVE ENGINEERING CONSULTANTS ) License No. 21-18576-01 0F GRAND RAPIDS, INCORPORATED ) EA 86-79 2942 Fuller Avenue, NE )
Grand Rapids, MI 49505 ) ORDER IMPOSING CIVIL MONETARY PENALTIES I Progressive Engineering Consultants of Grand Rapids, Incorporated (the licensee) is the holder of License No. 21-18576-01 issued by the Nuclear Regulatory Commission (the Commission). The license authorizes the licensee to operate its facility in accordance with the conditions specified therein. II A routine NRC safety inspection of the licensee's activities was conducted during the period March 13 through April 7,1986. The results of this inspection indicated that the licensee had not conducted its activities in full compliance with Commission requirements. A wr'itten Notice of Violation and Proposed Imposition of Civil Penalties was served upon the licensee by letter dated May 30, 1986. The Notice states the nature of the violations, the provisions of the Nuclear Regulatory Commission's requirements that the licensee had violated, and the amount of civil penalties proposed for the violations. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalties with two letters dated June 24 and July 1,1986, respectively. l l I NilREG-0940 II.A-17A
III 4 After consideration of the licensee's responses and statements of fact, explanation,' and arguments regarding remission or mitigation contained therein, as set forth in the Appendix to this Order, the Director, Office of Inspection and Enforcement, has determined that the violations occurred as stated and that the penalties proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalties should be . imposed. IV in view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205, IT IS HEREBY
\
ORDERED THAT: The licensee pay civil penalties in the amount of Five Hundred Dollars ($500) within thirty days of the date of this Order, by check, draft, or money order, payably to the Treasurer of the United Stated and mailed to the Director, Office of Inspection and Enforcement, USNRC, Washington, D.C. 20555. V The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director Office of Inspection and Enforcement, USNRC, Washington, D.C. 20555. A copy of the NUREG-0940 II.A-125
hearing request also shall be sent to the Assistant General Counsel for Enforcement, Office of the General Counsel, USNRC, Washington, D.C. 20555 and to the Regional Administrator, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. If a hearing is requested, the Comission will issue an Order designating the time and place of hearing. If the licensee fails to request a hearing within thirty days of the date of this Order, the provisions of this , Order shall be effective without further proceedings and, if payment has not
~ been made by that time, the matter may be referred to the Attorney General for collection.
In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee violated the Comission's requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties referenced in Section II above; and (b) whether on the basis of such violations this Order should be sustained. FOR THE NUCLEAR REGULATORY C0W.ISSION
- /
w ts M. Tay1 Director [OficeofInspectionandEnforcement Dated at Bethesda, Maryland '- this $ day of November 1986 NUREG-0940 II.A-126
._. - ~.
4 Appendix Evaluation and Conclusion By letters dated June 24 and July 1,1986, the licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalties dated May 30, 1986. In its response, the licensee admits the violations occurred as described in the Notice, but requests mitigation of the civil penalties based upon extenuating circumstances which were responsible for some of the violations, its prompt corrective actions, and the fact that this is its first enforcement action. Provided below are (1) a restatement of each violation, (2) a summary of the licensee's response regarding each violation, (3) NRC's evaluation of the licensee's response, and (4) NRC's conclusion. Restatement of Violation A License Condition No.12 requires that ifcensed material shall be used by, or under the supervision and in the physical presence of, individuals who have attended the Device Manufacturer's Trainino Course for gauge users and who have been designated by the licensee's Radiation Protection Officer. Contrary to the above, since August 1984, the licensee has allowed individuals to use licensed material contained in moisture / density gauges who were not under the supervision and in the physical presence of an authorized gauge user and who had not attended the Device Manufacturer's Training Course. Licensee's Response The licensee admits that the violation occurred, but states that the reason for the violation was that the licensee was unaware of the precise wording of License No. 12. The licensee indicates that individuals who used the ' applicable gauges had been instructed on the proper use of the gauge, and states that, in the future, gauge users will be trained by attending the gauge manufacturer's training course. NRC Evaluation The NRC staff expects the licensee to be familiar with the conditions and requirements of its byproduct material license, and requires, as a minimum, that the users of licensed material attend the Device Manufacturer's Training Course, or be under the supervision and in the physical presence of an individual who has attended the course. The licensee's commitment to have all gauge users attend the manufacturer's training course constitutes the minimum corrective action necessary to bring it into compliance with the byproduct material license. The violation occurred as stated, and mitigation of the civil penalty based on prompt and extensive corrective action is not warranted. i ! NilREG-0940 II.A-127
Appendix Restatement of Violation B 10 CFR 30.41(a) requires that no licensee shall transfer byproduct material except as authorized pursuant to this section. 10 CFR 30.41(b)(5) requires that byproduct material may be transferred to any person authorized to receive such byproduct material under terms of a specific license or a general license or their equivalents issued by the Atomic Energy Commission, the Comission or an Agreement State or otherwise authorized pursuant to 10 CFR 30.41. Contrary to the above, in January 1986, the licensee transferred byproduct material (a Troxler moisture / density gauge) to an individual who was not authorized to receive byproduct material under the terms of a specific license or a general license or their equivalents issued by the Atomic Energy Comission, the Comission or an Agreement State or otherwise authorized pursuant to 10 CFR 30.41. Licensee's Response The licensee admits that the violation occurred, but states that the Troxler moisture / density gauge was transferred to an individual who, until late 1985, was licensed to possess and use the Troxler gauge and who had attended the Troxler training course on gauge use. The licensee's corrective actions consisted of recovering the cauge and assuring that only certified individuals employed by the licensee will use the gauges in the future. NRC Evaluation The licensee admits the violation in that, at the time of the transfer of the gauge, the individual did not possess a license from the Comission or an Agreement State to possess and use the gauge. This represents noncompliance with 10 CFR 30.41(b)(5) because transfer of the gauge to the individual was unauthorized. Further, the gauge was not returned until several weeks after the violation was brought to the attention of the licensee by the NRC inspector. The NRC staff does not consider the circumstances surrounding the licensee's recovery of the gauge to constitute prompt or extensive corrective actions. The licensee's actions were the minimal corrective actions required to preclude similar violations in the future. Therefore, mitigation of any of the civil penalty associated with Violation B is not warranted. Restatement of Violation C License Condition No.18 requires that the duties of the Radiation Protection Officer shall include those items listed in item No. 5 of the NRC guide entitled, "A Guide for Preparation of Byproduct Material Applications for the Use of Sealed Sources in Portable and Semiportable Gauging Devices." ItemNo.5(f) requires that the Radiation Protection Officer will periodically review the terms and conditions of the license for compliance with NRC regulations, requirements, and license conditions. NUREG-0940 !!.A-128
Appendix Contrary to the above, as of the March 13, 1986 inspection. the Radiation Protection Officer failed to perform any periodic review of the terms and conditions of the license for compliance with NRC regulations, requirements, and ifcense conditions. Licensee's Response The licensee admits that the periodic review of the Itcensed program by the Radiation Protection Officer was not performed. The licensee explains that the reviews were waived partially because of the numerous personnel changes in the Radiation Protection Officer position and the total inactivity of the gauges until late 1984. Corrective actions described by the licensee include the initiation of an events calendar which will help the Radiatinn Protection Officer identify the frequency for performance of certain required duties. Also, tha licensee stated that it would be asking RAD Services, Inc., a consulting finn, to assist in all departments that involve the nuclear gauges. NRC Evaluation The NRC staff does not consider numerous personnel changes in the Radiation Protection Officer position under any circumstances to be justification for failing to comply with NRC requirements. As long as licensed material is possessed by a licensee, the NRC staff expects the licensee to operate in accordance with the requirements of its license. The NRC staff also does not consider the licensee's corrective actions associated with this violation to be particularly prompt. While the N,1C staff agrees that the services of RAD Services, Inc. will add another audit mechanism to assure the radiation protection program is administered as required, the implementation of this audit mechanism did not occur until mid - August 1986, four months after the violations were identified. Although the licensee's corrective actions should prevent recurrence of the violation, the actions cannot be considered prompt in responding to NRC identified problems. The violation occurred as' stated, and mitigation of any of the civil penalty associated with Violation C is not wa rranted. Restatement of Violation 0 10CFR20.201(b)requiresthatthelicenseemakesuchsurveysasmaybenecessary for compliance with all sections of Part 20 and are reasonable under the cir-cumstances to evaluate the extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions. NUREG-0940 II.A-129
Appendix Contrary to the atove, since August 1985, the licensee did not make surveys or evaluations nor did the licensee provide personnel monitoring devices (film badoes) to determine whether exposures to individuals using moisture / density gauges would be within the occupational dose limits of 10 CFR 20.101(a). Licensee's Response The licensee aenits that the violation occurred, but explains the reason that users of the moisture / density gauges were not provided film badoes is that it was told by Troxler (gauge manufacturer) that film badges were not required. The licensee's corrective action is to obtain film badges for the gauges users and to assure that any new users of the gauges receive film badges. NRC Evaluation The NRC staff expects the licensee to be familiar with NRC requirements and the conditions of its license. Had the licensee been familiar with the license and with the requirements of 10 CFR 20.201(a) and (b), the licensee would have been aware of the requirement for personnel monitoring devices since the license to possess and use the Troxler gauge is issued by the NRC and not the gauge manufacturer. Because the licensee admits the violation, and because its corrective actions consist only of those measures required to bring itself into compliance with the requirements of the license, mitigation of any of the civil penalty associated with Violation D is not warranted. Restatement of Violation E License Condition No.13 requires that each sealed source containing licensed material, other than hydrogen-3, with a half-life greater than 30 days, and in any form other than gas, shall be tested for leakage and/or contamination at intervals not to exceed six months. Contrary to the above, the licensee failed to perform sealed source leak tests every six months as required on a sealed source containing licensed material other than hydrogen-3, with a half-life greater than 30 days and in a fonn other than gas. Specifically, the licensee performed leak tests only in December 1978, November 1984, and April 1986 on a sealed source (Serial Number NG-601) containing americium-241 and cesium-137. l l NUREG-0940 II.A-130 l
3 l l Appendix l Licensee's Response The licensee admits that leak tests of the americium-241 and cesium-137 sources were not performed every six months as required. The licensee states that a series of tests was missed while the gauges were in use. The licensee also attributes this violation to the improper filing cf leak test reports in some cases and the fact that the gauges were not used for several years durino which time leak tests were not performed. Corrective action by the licensee cdnsisted of the implementation of a proper filing system, an events calendar, and con-tracting the consultation services of RAD Services, Inc. NRC Evaluation Af ter careful consideration of the licensee's assertion that the sources were stored and thereby not used during the 1978-1984 time frame, the NRC staff concludes that License Condition No.13.A(3) provides an exemption from leak testing when the sources are being stored. Should the licensee produce the misfiled leak test reports for calendar year 1985, this will demonstrate no violation occurred for that time period. However, because the licensee admits that one series of leak tests was entirely missed, a violation of NRC require-ments still occurred. Regarding the licensee's corrective action, the creation of an events calendar and implementation of a proper filing system by the licensee is no more than would be necessary to bring the licensee into compitance. Further, the hiring of a consultant, RAD Services, Inc., did not occur until approximately four months after the violations were identified to the licensee at the April 15, 1986 enfurcement conference. Therefore, these corrective actions are neither prompt nor extensive, and mitigation of any of the civil penalty amount associated with Violation E is not warranted. Restatement of Violation F 10 CFR 71.5(a) required that each licensee who transports licensed material outside the confines of its plant or other place of use shall comply with the applicable regulations of the Department of Transportation in 49 CFR Parts 170-189. (1) 49 CFR 172.101(a) references the Hazardous Materials Table which specifies requirements pertaining to the packaging, labelino, and transportation of hazardous materials. Column 5(b) of that table specifies that radioactive material special form, not otherwise specified, shall be packaged according to 49 CFR 173.415 and 173.416. Those regulations authorize 00T Specification 7A packages for shipment if they do not contain quantities exceedingg A . Theg A limit for special form cesium-137 is 30 curies. Contrary to the above, from August 1984 until the date of the inspection, radioactive material consisting of moisture density gauges containing cesium-137 not in excess of A limits was transported outside the confines of the licensee's facility wilhout being packages in a 00T Specificatinn 7A package as specified in the Hazardous Materials Table. NilREG-0940 II.A-131
- - --. . - ~ - _ - _ . . _
i [ Appendia (2) 49 CFR 177.817(a) requires that a carrier may not transport a hazareous
- material unless it is accompanied by a shipping paper that is prepared in i accordance with 49 CFR 172.201. 172.202 and 172.203. ,
4
! Contrary to the above. from August 1984 until the date of the inspection.
1 the licensee shipped hazardous material (moisture / density gauges containing i cesium-137 and inaccordance papers prepared americiump 241) with to 49various CFR 172.201.temporary 1 [/2.202 and 172.203.ob sites withou , i ! Licensee's Response s l The licensee admits the violation. The licensee asserts that the reason for
- shipping the gauges without proper shipping containers was due to an inadequate i number of approved shipping containers. The licensee's corrective action is ,
4 to obtain additional approved shipping containers to there will te one available '
! for each unit. The licensee states that shipping papers were not provided i each time the gauges were shipped because individuals were unaware of the i requirements of 49 CFR 172.201. 172.202 and 172.203 and a poor filing system was in place. Corrective action consists of appointing one individual to di mct the nuclear gauge division of the company and the acquisition of
- i consultino services from RAD Services. Inc.
a NRC Evaluation 3 The NRC staff expects the licensee to familiarize itself with the requirements of the license upon receipt, and lack of awareness of the requirements is not , an eacuse for noncompliance. Although the licensee's corrective actions are expected to bring the licensee into compitance, none of the actions described by the licensee are considered prompt or extensive by the NRC staff. The violation occurmd as stated, and mitigation of any of the civil penalty amount associated with Violation F is not warranted. . Restatement of Violation G , i License Condition No.10 requims that licensed material shall he used only at , 4 the licensee's facility located at 2920 Fuller Ave. M.E., Grand Rapids. Nichigan ; and at temporary job sites of the licensee located throughout the State of Michigan. 4 l Contrary to the above in April 1985, the licensee moved its permanent facility. where it was authorized to use and store licensee material, from 2920 Fuller l Ave.. Grand Rapids. Michigan to 2942 Fuller Avenue, N.E., Grand Rapids, Michigan i j and had not sought an amendment to its license to authorize this change. ;
- i'
{ Licensee's Responte 1 The licensee admits the address was changed without notifyino the NRC of the ! l change. The licensee states that the violation involved a simple move within ! the same office comples, and msulted from an oversight of the Radiation l Protection Officer. The Itcensee's corrective action consists of amending the > j license to reflect the change of address and contracting the services of AAD Services. Inc. to aid in maintaining compliance with the license requi mments. 4 5 NUREG-0940 11.A-132 1
. _ _ _ . _ ~ _ __. _ _ _ _ _ _ _._- _ _ ,_
l
. Appendix NRC Evalue'. ion Although the change of address consisted only of a move across the street, this would not negate the twquirement that the licensee seek an amendment to its license to authorize this change. Any address change, no matter what the circumstances, requires a license amendment to reflect the change. Although the change in address may not have been considered significant by the licensee, the NRC must assess the qualifications of facilities in order to determine the appropriateness of the facility. The licensee's failure to notify the NRC of this move denied the NRC an opportunity to review the new facility's qualifications.
The NRC staff considers the licensee's corrective actions the necessary actions required to bring the licensee into compliance with this requirement. Therefore .
'its actions were neither unusually prompt nor extensive, and mitigation of any civil penalty amount associated with Violation E is not warranted.
Restatement of Violation H 10 CFR 19.11(a) and (c) require that current copies of Part 19. Part 20, the license, license conditions, or documents incorporated into the license by reference, license amendments and operating procedures, as well as Form NRC-3,
" Notice of Employees " be posted.
10 CFR 19.11(b) requires that the licensee may post a notice describing the documents and their location if posting of the documents is not practicable. Contrary to the above, on March 13, 1986, neither the documents required by 10 CFR 19.11(a) and (c) nor a notice describing the documents and their locations were posted. l.icensee aessonse The licensee states that it was unaware of the requirements of 10 CFR 19.11(a), (b), and (c). The licensee's corrective action consisted of posting the required documents and notices and acquiring the consultation services of RAD Services, Inc. NRC Evaluation The NRC expects the licensee to be familiar with the requirements of its by-product material license. If licensee management had become familiar with the Itcense requirements, it would have been aware of the requirements of 10CFR19.11(a),(b),and(c). Further, the consultant did not conduct its first site audit until the week of August 10, 1986, actions not considered prompt by the NRC staff. Therefore, since the licensee's corrective actions were neither prompt nor exter.31ve and are considered the minimum actions necessary to comply with the requirements of 19.11(a), (b), and (c), mitigation of any of the civil penalty amount associated with Violation H is not warranted, t i l OPEG-0940 ft.A-133 l i l
Appendix NRC Conclusion The NRC staff has concluded that all of the violations did occur as originally stated in the May 30, 1086 Notice of Violation and Proposed Imposition of Civil Penalties. The NRC does not agree that extenuating circumstances resulted in violations of license requirements, but has concluded that the violations occurred as a result of the licensee's failure to exercise adequate control and oversight over its radiation safety program and its failure to familiarize itself with the requirements of its license and NRC regulations. The NRC does not consider any of the licensee's corrective actions unusually prompt or extensive, as these corrective actions were the minimum actions which the NRC would expect a licensee to undertake in order to bring it into compliance. Because this is the licensee's first inspection, there is no prior inspection history or history of prior performance, thus no basis exists for reduction of the base civil penalty for prior good performance in the area of concern. Therefore, since the licensee has not provided a sufficient basis for mitigation of the civil penalties, the NRC staff has concluded that civil penalties in the amount of $500 be imposed. j 1 5 NilREG-0940 II,A-134
s
**o ,a megg'o,~, UNITED STATES
! o NUCLEAR REGULATORY COMMISSION
; e WAsNessoTom. o. c. 2oses
%.....) JtM 171986 Docket No. 030-15110 License No. 37-18452-01 EA 86-41 i Valley Radiology Associates, Inc.
ATTN: Salvatore M. Imperiale, M.D. Director of Nuclear Medicine 451 Third Avenue Kingston, Pennsylvania Gentlemen:
SUBJECT:
ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED During a recent NRC inspection and investigation at Mercy Hospital in Wilkes Barre, Pennsylvania, the NRC determined that Dr. Salvatore M. Imperiale, while performing the duties of the Radiation Safety Officer at Mercy Hospital, willfully violated.an NRC requirement in not reporting a misadministration to the NRC and to the referring physician, as required. Since Dr. Imperiale is also listed on your license as an authorized user of licensed radioactive material I have serious questions whether Valley Radiology Associates will comply with NRC requirements while Dr. Imperiale has any responsibility for the performance or supervision of licensed activities. Accordingly, I am issuing the enclosed Order to Show Cause Why The License Should Not Be Modified to prohibit Dr. Imperiale from any involvement in the performance or supervision of licensed activities. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10. Code of Federal Regulations, a copy of this letter and the enclosed Order will be placed in the NRC Public Document Room. The response directed by the enclosed Order is not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980. PL 96-511. Sincerely. l s . Taylo
%- trector fice of Insp' ction and Enforcement
Enclosure:
Order to Show Cause Why the License Should Not Be Modified CERTIFIED MAIL RETURN RECEIPT REQUESTED l NUREG-0940 II.A-135
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of VALLEY RADIOLOGY ASSOCIATES, INC. Docket No. 30-15110 Kingston, Pennsylvania License No. 37-18452-01
) EA 86-41 ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED I
Valley Radiology Associates. Inc., Kingston, Pennsylvania (the licensee) is the holder of specific byproduct material License No. 37-18452-01(thelicense) issued by the Nuclear Regulatory Commission (the Commission or NRC) pursuant to 10 CFR Parts 30 and 35. The license authorizes the use of radiopharmaceuticals to perform diagnostic procedures listed in Groups I-III of Schedule A,10 CFR Part 35:100, and also to perform in vitro studies. The license was originally issued on June 4,1979, 'was most recently renewed on November 30, 1984, and is due to expire on December 31, 1989. Dr. Salvatore E. Imperiale is listed on the license as an authorized user of licensed material. II As a result of an NRC inspection and investigation at Mercy Hospital in Wilkes Barre, Pennsylvania, where Dr. Imperiale is also employed as the Medical Director of Radiology and the Radiation Safety Officer, the NRC determined that Dr. Imperiale knew that a diagnostic misadministration had occurred at the hospital in May 1985 and knew that the incident should have been reported to the NRC, but told his staff not to do anything regarding the reporting of the misadministration because he did not think the incident was that serious. i 1 NUREG-0940 II.A-136 (
1 Dr. Imperiale admitted this in an interview conducted under oath with an NRC investigator on August 7, 1985 and in a sworn statement dated August 15, 1985, provided to the NRC investigators. During the interview. Dr. Imperiale also stated that he did not recall all his reasons for his decision. III The willful violation of NRC requirements by Dr. Imperiale, while performing ifcensed activities at Mercy Hospital, raises serious questions whether the licensee will comply with Commission requirements while Dr. Imperiale has any responstbility for the performance or supervision of licensed activities. IV i Accordingly, pursuant to Sections 81,161b, and 186 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR 2.202 and Parts 30 and 35, IT IS HEREBY ORDERED THAT THE LICENSEE SHALL: Show cause, in a manner herein after provided, why License No. 37-18452-01 should not be modified to prohibit Dr. Salvatore M. Imperiale from serving in any capacity involving the performance or supervision of licensed activities. l NllREG-0940 II.A-137
.V The licensee may show cause, within 25 days of the date of issuance of this Order, as required by Section IV above, by filing a written answer under oath or affirma-tion setting forth the matters of fact and law on which the licensee relies to demonstrate that prohibition of this individual from performance or supervision of licensed activities is not warranted. The licensee may answer, as provided in 10 CFR 2.202(d), by consenting to the entry of an order in substantially the form proposed in this Order. If the licensee fails to file an answer within the specified time, the Director, Office of Inspection and Enforcement, may issue without further notice an Order modifying the license as described above.
VI The licensee or any other person adversely affected by this Order may request a hearing within 25 days after issuance of this Order. Any answer to this Order or any request for hearing shall be submitted to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. Copies also shall be sent to the Executive Legal Director at the same address and to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 631 Park Avenue, King of Prussia, Pennsylvania 19406. If a hearing is requested, the Commission will issue an order designating the time and place of any hearing. If a hearing is held, the issue to be considered at such hearing shall be: f l NUREG-0940 II.A-138 l
Whether, on the basis of the atters set forth in this Order License No. , 37-18452-01 should be modified in the anner set forth in Section IV of - this Order. 4 FOR THE NUCLEAR REGULATORY Com!SSION _ / W/ Ja s M. Taylor irector fice of Inspection and Enforcement Dated a Bethesda, Maryland, this/ ay of June 1986 I l I t f NUREG-0940 II.A-139
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) VALLEY RADIOLOGY ASSOCI ATES, INC. ) Docket No. 30-15110 Kingston, Pennsylvania ) License No. 37-18452-01
) EA 86-41 ANSWER TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED valley Radiology Associates, Inc. by its counsel, Robert J. Ross, Doub and Muntaing, .Charteced, pursuant to 10 C.F.R. $2.202 files the following answer to the Commission's Order To Show Cause Why The License Should Not Be Modified.
I. Answer to Order to Show Cause The allegations contained in Paragraph I of the Order are admitted. , The allegations contained in Paragraph II of the Order are admitted, with the following explanation. An NRC inspection and investigation by Ms. Judith A. Justra and Mr. John Miller occurred on July 17, 1985, at Mercy Hospital with respect to NRC Materials License No. 37-00897-01. As a result of this inspection and inves-tigation, the NRC determined that a diagnostic misadministration occurred at the hospital on May 8, 1985. The misadministration ! involved a chest x-ray patient who was mistaken for a liver scan patient and injected with TC-99mS-C. The hospital's Chief Nuclear Medicine Technician, Ms. Carol Theresa Carter, performed the misad-ministration. 'is. Carter has since lef t her position at Mercy Hospital and is no longer employed by the hospital. NUPEG-0940 II.A-140
Page 2 In accordance with Mercy 5tospital policy, the diagnostic misadministration was reported to Dr. Salvatore M. Imperiale, the hospital's Medical Director of Radiology and Radiation Safety Officer. Dr. Imperiale decided that the matter was not serious enough to report to NRC and told the technician not to report it. When the NRC conducted its inspection and investigation at the hospital July 17, 1985, Ms. Justra asked Ms. Carter if there had been any misadministrations at the hospital subsequent to a misadministration that had occurred in June, 1984, and had been reported to NRC. Ms. Carter said that there had not been any subsequent misadministrations. She did so, apparently, to protect Dr. Imperiale, although Dr. Imperiato had not instructed her to misrepresent the truth to the investigators. Subsequently, in August, 1995, NRC investigators inter-viewed Ms. Carter and others concerning the misadministration. 9 hen Dr. Imperiale was informed that these interviews were scheluled, he told Ms. Carter and the others to "tell them the truth," which she did. Dr. Importale himself was interviewed on August 7, 1985, at which time, and later in a sworn statement, ho admitted the fore-going facts. At no time did Dr. Imperiale instruct Ms. Carter or any other member of the staf f at fiercy llospital to withhold or nis-1 represent the truth to NRC investigators. Furthermore, Dr. Importale took no action to impede the NRC inspection and investiga-tion into whether a diagnostic misadministration had occurred. 1 NUREG-0040 !!.A-ld!
Page 3 The alle14tions contained in Paragraph III of the Order are denied insofar as they suggest that the licensee, Valley Radiology Associates, Inc. (Valley Radiology), will not comply with NRC requirements while Dr. Imperiale is engaging in the performance or supervision of licensed activities. Therefore, in accordance with Paragraph IV of the Order, the licensee avers the following to show cause why Materials License No. 37-18452-01 should not be
.nodified to prohibit Dr. Imperiate from serving in any capacity involving the pectoriaance or supervision of Licensed activities:
- 1. Valley Radiology has not committed any prior violations of NRC reporting requirements.
Furthermore, Mercy Hospital has not com.nitted any prior violations of NRC reporting require.nonta. In fact, a .nisadministration that occurred in June, 1984, was reported promptly in strict compliance with NRC regulations.
- 2. Dr. Imperiale did not instruct Ms. Carter or any other member of the Mercy Hospital staf f to withhold or misrepresent the truth regarding the misadministration to NRC investigatora. Furthermore, Dr. I.nperiale took no action to impede the NRC's inspection and investigation into the diagnostic misadministration.
NilRFG 0040 ll.A-142
Page 4
- 3. Dr. Imperiale is no longer the Radiation Safety Of ficer at valley Radiology, nor is he any longer the Radiation Safety Officer at Mercy Mospital. In addition, Ms. Carter is no longer employed by the hospital.
- 4. Valley Radiology has prepared written procedures whereby all persons authorized to conduct licensed activities will be instructed semi-annually on NRC rules and practices, including the necessity to report any misadministrations or other incidents as required by NRC regulations. Valley Radiology employees will be further instructed on the impor-tance of strict adherence to NRC requirements and complete cooperation with NRC personnel. Valley l Radiology will also certify to NRC that each author-ized user and Radiation Safety Of ficer has read NRC's requiations related to reporting of medical misadmin-
! istrations and understands the contents of those l regulations. A copy of these procedures is attached I as Appendix 1.
- Mercy Itospital has instituted similar procedures to l
l ensure that all personnel in the Radiology Department l l will report further misadministrations, if any, in accordance with the incident report procedures. Appropriate personnel have the authority to report l l NtlREG-0940 II.A-143
Page 5 misadministrations or any other incidents directly to the NRC. If an eAployee believes that his/her incident report has not been acted upon, they are instructed to take the matter to a higher authority.
- 5. The ratsadministration that occurred on May 8, 1985, was a ininor incident involving a diagnostic procedure, not a therapeutic procedure. The radiation dose involved in the liver scan procedure was extresnely low involving virtually no risk to the patient. Thus, although Dr. Imperiale made an error in judgment in deciding initially not to report the incident, he.was justified in considering the matter
; a minor incident.
- 6. Dr. Imperiale is willing to subinit to a reasonable probationary ter.n during which he would perform licensed activities under . Valley Radiology's license only with the permission and under the supervision of the new Radiation Safety Officer at Valley Radiology. In addition, Dr. Imperiale would perform licensed activities at Mercy Hospital only with the i
permission and under the supervision of the new Radiation Safety of ficer. ( i 4 NttREG-0940 II.A-144
J ?. fA 7' Page 6' 'm d P
- 7. Amending - Valley Radiology's license to ' prohibit Dr.
Imperiale from conducting or supervising licensed activities would interfere with Valley Radiology's' and Mercy Hospital's ability to provide nuclear medical services to the public.- There is a'lisited number of physicians qualified to administer nuclear medical services in the area of Kingston and.
, <~'
) Wilkes-Barre, Pennsylvania. .
- 8. Public awareness of this matter will ensure that ,
, Valley Radiology will henceforth comply with NRC requirements. This matter has received great , notoriety in the area of Kingston, Pennsylvania, / where Valley Radiology is located, and Wilkes-Barre, -
~~ !
Pennsylvania, where Mercy Hospital is located. ." Newspaper accounts from The Times Leader of Wilkes-Barre are attached as Appendix 2. The public awareness of this matter in the area where Valley Radiology carries on its practice will ensure that . Dr. Imperiale and others at Valley Radiology and . . , , , j-i Mercy Hospital will in the future scrupulously comply , with NRC regulations. . l In view of the foregoing factors, Valley Radiology , t
, respectfully submits that its license should not be modified to . . -
prohibit Dr. Imperiale from serving in any capacity involving the ' 4 4 4 Il i NUREG-0940 II.A.145
. _ _ _ _ _ _ . _ _ . _ . _ _ _ . . . . . _ _ - - _ . _ . ___ ~- _ _ _ _ . _ __
Page 7 performance.or supervision'of licensed activities. l Valley Radiology agrees that1Dr. -Imperiale should no longer , serve as the Radiation : Safety Of ficer at Valley Radiology or at Mercy Hospital. However, Dr. Imperiale's error-of judgment;should not prevent him from continuing to perform licensed activities.under a plan of supervision acceptable to the NRC. .In order to formulate such-a plan, Valley Radiology intends .to meet with of ficials f rom the NRC's l Of fice of Inspection and Enforcement in a conference to discuss the violation, its significance. and causes, the licensee's corrective actions, and mitigating circumstances. Request That Violation Be Reduced From Severity Level I to j II. Severity Level IV In another docket before the NRC that' is related to this docket, the Notice of Violation and Proposed Imposition of Civil Penalty, Docket'No,' 30-02971, in the Matter of Mercy Hospital, classifies the May 8, 1985, misadministration as a Severity Level I problem. The incident was so classified because the statement of Ms. Carter to NRC investigators denying that a misadministration had occurred allegedly constituted a material false statement-in-violation of NRC regulations. Valley Radiology submits that the misadministration should properly be classified as a Severity Level IV violation under NRC's regulations at 10 C.F.R. Part 2. Severity Level IV includes "[flailure to report medical diagnostic misadministrations," which is precisely what occurred on May 8, 1985, at Mercy Hospital. NilREG-0940 II.A-146
I-Page 8 It is admitted that Dr. Imperiale'was wrong to tell Ms. Carter not to report the incident, and that Ms. Carter was wrong initially to deny to the NRC: investigators on July 17, 1935, that a misadministration had occurred. However, Dr. Imperiale did not tell "Ms. Carter to withhold the truth about the incident from the NRC
~
inspectors. Rather, Ms. Carter misrepresented the truth in an e f f ort t.o. protect Dr. Impcriale for not reporting the misadministra-t
; tion. .If Dr. Imperiale had, known that NRC inspectors would question Ms. Carter about the misadministration, he would have told her to tell the truth. Indeed, Dr. Imperiale did just this when he learned that Ms. Carter and others were to be interviewed by NRC investigators subsequent to the hospital inspection.
The foregoing scenario reveals two errors in judgment by Dr. Imperiale and Ms. Carter, but it does not constitute a matter serious enough to be classified as Severity Level I. Severity Level I includes violations involving radiation levels, contamination 1evels or releases thIt exceed' ten times the limits specified in the license,' and nuclear criticality accidents. 10 C . F. R. Part 2, App.
, C, Supp. VI. These violations are f ar more serious than the minor diagnostic misadministration that. occurred on May. 8, 1985, at Mercy Flospital.
Therefore, Valley Radiology respectf ully submits that the violation should be reduced from Severity Level I to Severity Level IV,'in keeping with 10 C.F.R. Part 2, Appendix C of NRC's regula-tions.
-s
<s Nt! REG-09a0 II . A-14 7 1
\
p g. [g , , J - -
Page 9 III. Request for Hearing and Enforcement Conference Pursuant to 10 C.F.R. $2.202(b), Valley Radiology respectfully requests a hearing in this matter. This request is contingent upon the outcome of an enforcement conference, which is hereby requested to be held between the licensee and NRC officials from the Office of Inspection and Enforcement pursuant to the spirit of the General Policy and Procedure for NRC Enforcement Actions set , 1 forth at 10 C.F.R., Part 2, Appendix C (IV-Enforcement Conf er-ences). The licensee makes this request in order to preserve its right to a hearing in the event that the conference does not yield a satisfactory resolution of this matter. Respectfully submitted, , i
/
By biWU -
?
Robert ys foss Doub and Muntzing, Chartered 1875 Eye Street, N.W., Suite 775 Washington, D.C. 20006 (202) 467-6460 J l Counsel for Valley Radiology l Associates, Inc. Dated: Q/d yM L' cy <
- -NUREG-0940 II.A-148
-UNITED STATES NUCLEAR REGULATORY COMMISSION In-the Matter of .
.)-
VALLEY RADIOLOGY ASSOCIATES, INC. ) Docket No. 30-15110 Kingston, Pennsylvania ) License No. 37-18452-01
) EA 86-41 AFFIDAVIT COMMONWEALTM OF PENNSYLVANIA )
COUNTY OF LUZERNE ) Before me, the undersigned authority, personally appeared Salvatore E. Imperiale, who, being duly sworn according to law, deposed and said that he is a practicing radiologist and listed on the above captioned license as an authorized user of 1-icensed materials, that he has read the foregoing Answer..to the Order to Show Cause, and that the information and assertions' contained in the j Answer are true and correct to the best of his knowledge, information and belief. Salvatore E/. Imperiale Sworn to and subscribjd before me this J g M day of July,'1986.
. .1 y ar p ublic I[g$t c!E .i'E*VW'
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y,.g.e t.;eres k'4Mt II. I, l NUREG-0940 II.A-149
CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Answer of Valley Radiology Associates, Inc., To Order To Show Cause Why The License Should Not Be Modified 'has been served upon all parties of record listed below by depositing same in the first class mail, postage prepaid, this 24th day of July, 1986. f_b b y- - Secretary, U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Attention: Chief, Docketing and Service Section Director, Office of Inspection aNd Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Jonathan L. Alder, Esquire Alder Cohen and Grigsby, P.C. 600 Grant Street, Fifth Floor Pittsburgh, Pennsylvania 15219 Ms. Carol Carter c/o A. Peter Kanjorski, Esquire 126 South Franklin Street Wilkes-Barre, Pennsylvania 18765 General Counsel U.S. Nuclear Regulatory Commission . Washington, D.C. 20555 Regional Administrator U.S. Nuclear Regulatory Commission, Region I 631 Park Avenue King of Prussia, Pennsylvania 19406 i l NUREG-0440 II.A-150 l
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
)
VALLEY RADIOLOGY ASSOCIATES, INC.). Docket No. 30-15110 Kingston, Pennsylvania ) License No. 37-18452-01
) EA 86-41 SUPPLEMENTAL RESPONSE TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED Robert J. Ross James R. Shoemaker Doub and Mantzing, Chartered 1875 Eye Street, N.W. Suite 775 Washington, D.C. 20006 (202) 467-6460 Counsel for_ Valley Radiology Associates, Inc.
a NUREG-0940 II.A-151
UNITED STATES NUCLEAR REGULATORY COMMISSION In.the Matter of ) Docket No. 30-15110 VALLEY RADIOLOGY: ASSOCIATES, INC.) License No. 37-18452-01 Kingston, Pennsylvania ) EA 86-41
)
SUPPLEMENTAL RESPONSE TO THE ORDER TO SHOW CAUSE WHY THE LICENSE SHOULD NOT BE MODIFIED Valley Radiology Associates, Inc., by its counsel, Rober t J. Ross, Doub and Muntzing, Chartered, pursuant to 10 C.F.R. S2.202 files the following Supplemental Response To The Order To Show Cause Why The License Should Not Be Modified. Supplemental Response Pursuant to agreements reached between Valley Radiology Associates, Inc. and the United States Nuclear Regulatory Commission resulting from an enforcement conference held August 26, 1986, at King of Prussia, Pennsylvania and a telephone conference held September 17, 1986, Valley Radiology Associates Inc. hereby stipulates and agrees to the following:
- 1. SALVATORE M. IMPERIALE, M.D. will be removed as i Radiation Safety Of ficer under Nuclear Regulatory Commission License No. 37-18452-01.
I
- 2. SALVATORE M. IMPERIALE, M.D. will be removed as an authorized user under Nuclear Regulatory Commission
,- License No. 37-18452-01 for a one (1) year l probationary period. During this one (1) year probationary period, Salvatore M. Imperiale, M.D. l i I l NUREG-0940 II.A-152
will be permitted to perform activities involving licensed material under the supervision of en authorized . user. Any and all authorized users will be informed of their responsibilities regarding Salvatore Imperiale, M.D. as a result of this condition. Respectfully Submitted
,- a fl. -
- l. .* ' h-e /, '
.L-~,
Robert J. /Ross ' Doub and Muntzing, Chartered 1875 Eye Street, N.W. Suite 775 .
~4a s h ing ton, D.C. 20006 (202) 467-6460 Dated I I * . " '[ -
Counsel for Valley Radiology T
~ Associates, Inc.
5 NUREG-0940 II.A-153
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 30-15110 VALLEY RADIOLOGY ASSOCIATES, INC.) License No. 37-18452-01 Kingston, Pennsylvania ) EA 86-41
)
AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF LUZERNE ) Before me, the undersigned authority, personally appeared Salvatore E. Imperiale, who, being duly sworn according to law, deposed and said that he is a practicing radiologist and listed on the above captioned license as an authorized user of licensed materials, that he has read the foregoing Supplemental Response to the Order to Show Cause, and that the information and assertions contained in the Supplemental Response are true and correct to the best of his knowledge, information and belief. w rp ,1
,$d' -
Salvatore #). Imperiale Sworn to and subscribed before me this g 4 day of S p ber, 1986. L- Ym Notary Public W g, ewm cutc. m *
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pg psas oc.w n, ts# NtIREG-0940 I1.A-154
CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Supplemental Response of Valley Radiology Associates, Inc., To Order To Show Cause Why The License Should Not Be Modified has been served upon all parties of record listed below by depositing same in the first class mall, postage prepaid, this 3rd day of October, 1986. . O 1
~
si - - Nfc A
, James R. Qhdemaker
/
L Director, Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 James Lieberman, Esquire Assistant General Counsel for Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Mr. Jay M. Gutierrez U.S. Nuclear Regulatory Commission, Region I 631 Park Avenue King of Prussia, Pennsylvania 19406 Jonathan L. Alder, Esquire Alder, Cohen and Grigsby, P.C. 600 Grant Street, Fifth Floor Pittsburgh, Pennsylvania 15219 H. Peter Kanjorski, Esquire 126 South Franklin Street Wilkes-Barre, Pennsylvania 18765 NtJREG-0940 II.A-155
II.B. FIATERIAL LICENSEES, SEVERITY LEVEL III VIOLATIONS, NO CIVIL PENALTY NUREG-0940
Y 1_ ' 49 UNITED STATES
%, NUCLEAR REGULATORY COMMIS$10N q f 7, REGION I --
E e 431 PAsen AvgNUE " ( ..... name or Psiussia. PsNNSVLVANI A 19466 _ DEC 0 81986 { 2 Docket Nos. 030-24300; 040-08917 License Nos. 20-12836-01; SUB-1485 EA 86-182 q j Amersham Corporation i " i ATTN: Mr. Victor Becker " l Operations Manager 40 North Avenue 4 Burlington, Massachusetts 01803 _; Gentlemen: I 5 i
SUBJECT:
NOTICE OF VIOLATION d (Inspection Nc. 86-01) j i This refers to the Nuclear Regulatory Commission (NRC) inspection conducted on November 5, 1986 of activities authorized by NRC License Nos. 20-12836-01 and 5U8-1485. The report of the inspection is enclosed. The inspection was _- conducted to review the circumstances associated with a violation of NRC requirements involving the transportation of a pt d r.ge containing licensed a material with a radiation level on a portion of the surface of the package - in excess of the regulatory limit. This violation was reported to the NRC 9 by the recipient of the package. 9~' The violation is classified at Severity level III in accordance with the 5
- " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, (1986). Although a civil penalty is normally con- -
sidered for a Severity Level III violation, a civil penalty will not be I proposed in this case because of (1) your unusually prompt and extensive cor- ' rective actions, and (2) your prior good enforcement history, as evidenced by ; the fact that no violations were identified during the previous four inspections. - Nonetheless, we emphasize that similar violations in the future may result in 1 additional enforcement actions, g= You are required to respond to the enclosed Notice and, in preparing your y response, you should follow the instructions specified in the Notice. In - your response, you should document the actions taken or planned to prevent ;; recurrence. After reviewing your response to the Notice, including your pro- , posed corrective actions and the results of future inspections, the NRC will e determine whether further enforcement action is necessary to ensure compliance ; ! with NRC regulatory requirements. ; 9 In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title - 10, Code of Federal Regulations, a copy of this letter and the enclosure will _f be placed in the NRC Public Document Room. - as fillPEG-0940 11.B-1
Amersham Corporation 2 The responses directed by this letter and the enclosed Notice are not subject to the cleprance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely,
% N. A T mas E. Murley egional Administrator
Enclosures:
- 1. Notice of Violation
- 2. Inspection Report 86-01 cc:
Public Document Room (POR) Nuclear Safety Information Center (NSIC) Commonwealth of Massachusetts NUREG-0940 11.8-2
NOTICE OF VIGLATION Amersham Corporation Docket Nos. 030-29300; 040-08917 Burlington, Massachusetts 01803 License Nos. 20-12836-01; SUB-1485 EA 86-182 On November 5, 1986, a special NRC inspection was conducted at the licensee's facility in Burlington, Massachusetts to review the circumstances associated with the shipment of a package which, upon receipt at its destination, had measured radiation levels on the surface of the package in excess of the regulatory limit. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation is set forth below: 10 CFR 71.47 requires, in part, that a package, unless transported in an exclusive use vehicle, be designad and prepared for shipment so that the radiation level does not exceed 200 millirem per hour at any point on the external surface of the package. Contrary to the above, on October 20, 1986, a package containing a Model 850 source change with 209 curries of iridium-192 was shipped via a common carrier vehicle (not designated as exclusive use) to Newport News Shipbuilding in Newport News, Virginia, and upon arrival at its destina-tion, the measured dose rate at a point on the surface of the package was approximately 280 millirem per hour. This is a Severity Level III violation (Supplement V). Pursuant to the provisions of 10 CFR 2.201, Amersham Corporation is hereby required to submit to this office, within thirty days of the date of the letter which transmitted this Notice, a written statement or explanation in reply addressing the alleged violation, including: (1) admission or denial of the alleged violation: (2) the reasons for the violation if admitted; (3) the cor-rective steps that have been taken and the results achieved; (4) the corrective steps which will be taken to avoid further violations; and (5) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending this response time. Dated a King of Prussia, Pennsylvania this 2 ay of December 1986 NUREG-09an IT,p_3
l UNITED STATES
/pa nesg'o, NUCLEAR REGULATORY COMMIS$10N 8 e 'k nEcioN lit 5
o, f 799 ROOSEVELT ROAD GLEN ELLVN. ILLINOIS 60137
% . . . . . ' 'g DEC 3 01986 Docket No. 030-04891 License No. 21-10459-01 EA 86-178 National Steel Corporation Great Lakes Steel Division ATTN: Mr. James Howell Vice President and General Manager 101 Tecumseh Road Encorse, MI 48229 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 030-04891/86001 (DRSS)) This refers to the inspection conducted during the period October 7-17, 1986 at your facility in Encorse, Michigan. The inspection was in response to a phone call to the NRC from an individual concerned about his possible exposure while handling a radioactive moisture / density gauge on October 2, 1986. The circumstances surrounding this event were discussed with you during an enforcement conference on November 4, 1986. The results of the inspection showed that on October 1, 1986, an electrical field engineer instructed an electrical foreman to examine and repair a moisture / density gauge in which the source rod could not be fully inserted into the gauge housing. On October 2, 1986, the foreman and an electrician, who had not been instructed as to the nature of the gauge, unbolted the gauge and manipulated the source rod. The employees were not authorized by the license to perform such activities. Exposures to the individual were estimated at less than 50 millirems to the hands and whole body. It appears the event resulted from inadequate control and oversight of your radiation safety program. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations described in the enclosed Notice have been classified in the aggregate as a Severity Level III problem. Normally, a civil penalty is considered for a Severity Level III violation or problem. However, after consultation with the Director, Office of Inspection and Enforcement, I have decided that a civil penalty will not be proposed in this case because of your prior good performance in the general area of concern and your unusually prompt and extensive corrective actions in response to this event. Your corrective actions consisted of: (1) a prompt investigation involving senior management into the causes of the event; (2) retraining plant personnel as to the limits of the license; (3) issuance of a company safety bulletin; (4) reissuance of the relevant safety procedures; and (5) prompt assignment of an authorized acting Radiation Protection Officer until the new Radiation Protection Officer receives authorization. NUREG-0940 II.B-4
National Steel Corporation 2 DEC 3 01986 You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, O
$0k d) M
( James G. Keppler Regional Administrator
Enclosure:
Notice of Violation NIJREG-0940 II.B-5
NOTICE OF VIOLATION National Steel Corporation Docket No. 030-04891 Encorse, Michigan License No. 21-10459-01 EA 86-178 An NRC inspection conducted during the period October 7-17, 1986, identified violations of NRC requirements. The violations involved: (1) the unauthorized relocation and repair of gauges containing licensed material; (2) inadequate labelling of gauges; (3) lack of safety training for individuals involved in the use or maintenance of gauges, and (4) failure to amend the license to reflect the individual designated as Radiation Protection Officer. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violations are listed below:
- 1. Violations Involved In The Event
- a. License Condition No.15 requires that relocation or repair of devices containing licensed material be performed only by the device manufacturer or by other specifically authorized persons.
Contrary to the above, licensee employees, who did not work for the device manufacturer and were not specifically authorized, relocated two devices containing licensed material in August 1986, and repaired one device containing licensed material on October 2, 1986.
- b. License Condition No. 19 requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the application dated April 27, 1985.
The referenced application dated April 27, 1985, states that the Radiation Protection Officer will arrange for the safety training of personnel involved in the use and maintenance of all radiation sources. Contrary to the above, as of October 2, 1986, the Radiation Protection Officer had not arranged for the safety training of personnel who repaired a gauge containing a licensed radiation source.
- c. 10 CFR 20.203(f) requires that each container of licensed material bear a durable, clearly visible label bearing the radiation caution symbol and the words " Caution, Radioactive Material" or " Danger, Radioactive Material."
Contrary to the above, on October 2, 1986, two gauges containing licensed material had labels which were not durable and clearly / visible because the labels were damaged and worn. Collectively, these violations have been categorized as a Severity Level III problem (Supplements IV and VI). NUREG-0940 11.B-6
Notice of Violation 2 DEC 3 01986 II. Violation Not Involved In The Event License Condition No. 19 requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in a letter dated April 24, 1985. The referenced letter dated April 24, 1985, names the individual designated by the licensee to be the Radiation Protection Officer. Contrary to the above, from June until October,1986, an individual other than the individual designated in the licensee's April 24, 1985 letter, acted as Radiation Protection Officer. This is a Severity Level V violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, National Steel Corporation is hereby required to submit to this Office within 30 days of the letter transmitting the Notice, a written statement or explanation in reply, including for each violation: (1) the reason for the violation if admitted; (2) the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. FOR THE NUCLEAR REGULATORY COMMISSION d &+(A \ James G. Keppler Regional Administrator Glen Ellyn, DatedagdayofDecember1986. this M_ NUREG-0940 II.P 7
UNITED STATES
# ,o,, ! 3 ,, p, NUCLEAR REGULATORY COMMISSION REGION 1
- j a 631 PARK AVENUE o,
KING OF PRUS$1A. PENNSYLVANIA 19406
% . . . . . ,o#
October 7, 1986 Docket No. 030-05985 License No. 37-00276-25 EA 86-123 PTL Inspectorate, Inc. ATTN: M. Ruyan, President 850 Poplar Street Pittsburgh, Pennsylvania 15220 I' Gentlemen:
Subject:
NOTICE OF VI0i.ATION This refers to two NRC inspections of activities authorized by License No. 37-00276-25. The inspections were conducted on March 4-5, 1986 at your facility in Milwaukee, Wisconsin, and on April 21, 22, 24, 25 and 29, and May 13, 1986 at your facility in Pittsburgh, Pennsylvania, and at two field sites. The two inspection reports were forwarded to you on June 16, 1986. During the inspections, violations of NRC requirements were identified. On June 26, 1986, an enforcement conference was conducted with you and members of your staff during which the violations, their causes, and your corrective actions were discussed. The violations are described in the enclosed Notice and include: use of an uncertified radiographer; failure to perform required surveys; failure to main-tain direct surveillance of a high radiation area; and failure by radiographers to follow emergency procedures and notify supervision when source disconnects were identified. The violations are of concern to the NRC because the failure to adhere to requirements during the performance of radiography can create a potential hazard to workers and the public. The violations have been classified in the aggregate as a Severity Level III problem in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986). Although a civil penalty is normally considered for a Severity Level Ill violation or problem, I have decided that a civil penalty should not be issued in this case for two reasons. First, the majority of the violations identified during the two recent inspections actually occurred in early 1985, prior to the criminal prosecution of PTL by the Department of Justice in February 1986 and the issuance of a $58,000 civil penalty by the NRC on April 7,1986 for other PTL violations of NRC requirements. Second, your corrective actions involving (a) the creation of the position of a Corporate Liaison Manager who has no responsibility for production and whose sole purpose is to ensure radiation safety, and (b) improvements made by the individual appointed to that position, including the establishment of a structured disciplinary policy to assure individuals are held accountable for their actions, if properly implemented, should preclude recurrence of future violations. NUREG-0940 11.8-8
PTL Inspectorate, Inc. 2 You are required to respond to this letter and should follow the instructions specifled in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. NRC intends to maintain close observation of your performance and, if problems continue to persist which indicate an inability of corporate management to assure that personnel adhere to NRC requirements, the NRC will not hesitate to take escalated enforcement action. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice", a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, S+t'=la-- 544 T omas E. Murley egional Administrator
Enclosure:
Notice of Violation cc w/ encl: Commonwealth of Pennsylvania State of Tennessee State of Washington State of Utah State of Wisconsin NilREG-0940 II.B-9
t NOTICE OF VIOLATION PTL Inspectorate, Inc. Docket No. 30-05985 r Pittsburgh, Pennsylvania 15220 License No. 37-00276-25
- EA 86-123 On March 4 and 5, April 21, 22, 24, 25 and 29, and May 13, 1986, NRC inspec-tions were conducted at the licensee's facilities in Pittsburgh, Pennsylvania and Milwaukee, Wisconsin, and also at two field sites. During the inspections, l violations of NRC requirements were identified. In accordance with the
" General Statement of Policy and Procedure for NRC Enforcement Actions,"
10 CFR Part 2, Appendix C (Enforcement Policy) (1986), the violations are set forth below: { A. 10 CFR 34.41 requires that during each radiographic operation, the radio- [ grapher or radiographer's assistant maintain direct surveillance of the operation to protect against unauthorized entry into a high radiation aret, unless the area is locked or equipped with an alarm system as descisued in 10 CFR 20.203(C)(2). t Contrary to the above, on January 31,.1985, at a field site in Buchanan, j West Virginia, radiographic operations resulted in a high radiation area that was neither locked nor equipped with an a'larm system, and for I { approximately two minutes during these operations, direct surveillance of the area was not maintained. Specifically, the radiographers went to a [ truck to obtain additional shielding because of a disconnected source, and they were unable to provide direct surveillance of the area from that
! location.
- B. 10 CFR 34.43(b) requires that a physical radiation survey be made after each radiographic exposure to determine that the sealed source has been I returned to its shielded position. The entire circumference of the s
radiographic exposure device must be surveyed and, if the device has a
' source guide tube, the survey nust include the entire length of the guide y
tube. [ Contrary to the above, on two separate occasions after a radiographic L exposure at different field sites, radiographers did not perform surveys i that were adequate to determine that the sealed source had returned to its shielded position. Specifically, i
- 1. On April 4, 1985, the survey performed by a radiographer from the Pittsburgh, Pennsylvania district office, who was performing radio-graphy at a field site in Newell, West Virginia, was inadequate to I verify that the sealed source had returned to its shielded position 5
in that the source guide tube was not adequately surveyed. At the { time, the source was in fact approximately 6 inches out of the source e guide tube; and 4 2 6 s E E K fiUREG-0940 II.B-10 =
. - . . . . . . , . . . . , . - - m. c - . . > ,
2
- 2. on December 16, 1985, a radiographer from the Milwaukee, Wisconsin district office, who was performing radiography at a field site in Duluth, Minnesota, approached the guide tube after completion of a four minute radiographic exposure without first performing a survey j of the guide tube.
C. 10 CFR 34.22(a) requires that, during radiography operations, the sealed source assembly be secured in the shielded position each time the source [ is returned to that position. i Contrary to the above, on April 4, 1985, at a fie.ld site in Newell, West i Virginia, a radiographic exposure device was not secured (locked) in the shielded position following return of the source to that position at the { completion of a radiographic exposure. D. 10 CFR 20.201(b) requires that each licensee make such surveys as may be necessary to comply with all sections of Part 20. As defined in 10 CFR i 20.201(a), " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions. Contrary to the above, as of April 24, 1986, a survey was not performed to f assure compliance with 10 CFR 20.101, which limits the radiation exposure to the whole body and extremities of individuals in a restricted area. Specifically, a survey was not performed to evaluate personnel exposures (1) to a construction site foreman and crane operator who entered a restricted area at a field site in Buchanan, West Virginia, on January 31, 1985, and (2) to the extremities of two radiographers involved in source recovery operations on the same date. E. 10 CFR 34.33(a) requires that individuals acting as radiographers shall wear pocket dostmeters at all times during radiographic operations, and pocket dosimeters shall be recharged at the beginning of each shift. Contrary to the above, on January 31, 1985, a pocket dosimeter worn by an individual performing radiography operations at a field site in Buchanan, West Virginia, was not recharged at the beginning of the shift. F. Condition 17 of License No. 37-00276-35 requires that licensed material be possessed and used in accordance with statements, representations and procedures contained in an application dated February 6,1980 and letter dated August 12, 1985 with enclosed Radiation Safety Procedures dated August 12, 1985.
- 1. Page 28-D of the application dated February 6, 1980, requires that radiographic personnel telephone their Radiation Safety Officer or responsible supervisor approved by the Radiation Safety Officer in the event of an accident involving radiographic equipment. Item 13.2 of the Radiation Safety Procedures dated August 12, 1985, requires l
i ] i I N pf q N!! PEG-0940 II.B-11 g
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I 3 k E that radiographic personnel promptly notify the Radiation Safety i Officer or Assistant Radiation Safety Officer in the event of a
- malfunction involving radiographic equipment.
E I Contrary to the above,
- a. on January 31, 1985, radiographic personnel performing radio-graphic operations at a field site in Buchanan, West Virginia did not notify their Radiation Safety Officer or responsible supervisor after they had determined that a source had been
; sheared off the drive cable; and
! b. On December 16, 1985, a radiographer performing radiographic S operations at a field site in Duluth, Minnesota did not notify " his Radiation Safety Officer after identifying a malfunction of radiographic equipment involving a source that was disconnected e b from the drive cable.
- 2. Page 28-0 of the application dated February 6, 1980, requires that radiographers never attempt to retrieve a loose source without the
, assistance of the Radiation Safety Officer. Item 13.2 of the Radia- [ tion Safety Procedures dated August 12, 1985, requires that under no ' g ~~.. circumstances should radiographic personnel attempt a source " retrieval or recovery without the consent and direction of the Radiation Safety Officer, Radiation Safety Coordinator, or Assistant E Radiation Safety Coordinator. . 7 Contrary to the above,
- a. on January 31, 1985, at a field site in Buchanan, West Virginia,
[ two radiographers retrieved a loose source without the assis-( tance of the Radiation Safety Officer; and e I b. on December 16, 1985, at a field site in Duluth, Minnesota, a
~
radiographer retrieved a loose source without the consent and i direction of either the Radiation Safety Officer, Radiation Safety Coordinator, or Assistant Radiation Safety Coordinator. i [
- 3. Item 4.3 of the Radiation Safety Procedure dated August 12, 1985, f requires that radiographers with prior experience satisfactorily i4 complete a 50 question test with a minimum grade of 80'.' in order j to be authorized as a radiographer.
F f Contrary to the above, an individual from the Pittsburgh,
! Pennsylvania district office who was previously qualified as a radio-i grapher with the licensee, left the company in May, 1984, and s although he was retrained upon being rehired, performed the duties of ? a radiographer on October 21-24, 1985 without having taken and passed an exam to be reauthorized as a radiographer.
p . g t t - - b W . E g NUREG-0940 II.B-12 v g_
i i E I 4 I ( 4. Item 8.1.2.a of the Radiation Safety Procedure dated August 12, 1985, [ requires that, during radiographic exposures, the radiographer keep p all access to the "High Radiation Area" and the surrounding restricted area under constant surveillance. 6: T Contrary to the above, on April 25, 1986, during radiographic exposures, a radiographer did not maintain constant surveillance of the access to a portion of the restricted area adjacent to a welding f shop in West Elizabeth, Pennsylvania.
- 5. Item 7.1.1.e of the Radiation Safety Procedure dated August 12, 1985, requires that a radiographer establish the restricted area boundary based on survey meter readings of less than 2 mR/ hour at the
, boundary, or on survey meter readings and calculations using exposure i time.
k" Contrary to the above, on April 25, 1986, at a field site in West y Elizabeth, Pennsylvania, a radiographer established a restricted area boundary and neither survey meter readings nor calculations were used to establish the boundary. Therefore, there was no assurance that any individual in the unrestricted area could not be exposed to more than 2 millirems in one hour. { G. 10 CFR 71.5(a) requires that no licensee deliver any licensed material to a carrier for transport without complying with the applicable requirements of the regulations appropriate to the mode of transport of the Department of Transportation in 49 CFR Parts 170-189. 49 CFR 172.403 requires that a package with a transport index greater than one must be labeled with a Yellow III label. 49 CFR 172.203(d) requires that the description on a shipping paper accompanying a shipment of radioactive material include the category of label and the transport index, for a package bearing a Yellow II or III label. Contrary to the above,
- 1. the description on shipping papers accompanying shipments made on February 17-21, 1986 did not include either the correct transport index or the correct category of label in that the associated packages were labeled as a Yellow II even though transport indexes were stated to be 5.0; and
- 2. a shipping paper dated February 26, 1986 did not indicate a transport index for a package labelled as Yellow III.
The violations have been categorized in the aggregate as a Severity Level III problem (Supplenent IV or VI). NUREG-0940 11.B-13
5 l l Pursuant to the provisions of 10 CFR 2.201, PTL Inspectorate. Inc. is hereby required to submit to this office within 30 days of the date of this Notice, a written statement or explanation, including for each alleged viola-tion: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. Consideration may be given to extending the response time for good cause shown. Dated at King of Prussia, Pennsylvania, this -) Nay of October 1986. i NilREG-0040 11.B-14
.. . . , _ ,_ . .m . . . _.
November 24, 1986 Docket No. 030-01389 License No. 12-00963-02 7 EA 86-169 ' St. Francis Hospital ATTN: Mr. Kenneth Schreiner l Vice President L 355 Ridge Avenue E Evanston, IL 60202 i [ Gentlemen: L [
Subject:
NOTICE OF VIOLATION [NRC INSPECTION REPORT NO. 030-01389/86001(DRSS)] p This refers to the special safety inspection conducted by the Nuclear Regulatory ' Commission (NRC) during the period September 4 through 15, 1986, at St. Francis Hospital, Evanston, Illinois. The inspection was conducted in response to your ( September 3, 1986 report that ten iridium-192 sources had been lost after being 7 removed from a patient on August 30, 1986. The circumstances surrounding the ii event were discussed during an Enforcement Conference held on September 26, 1986. 3 During the inspection two violations of NRC requirements were identified k which involved failure to perform a survey to assure that all implants had E been removed prior to a patient's release and failure to perform a survey E to assure that no sources remained in the room before another patient was i admitted to that room. The failure to perform these surveys led to the loss 7 of one iridium-192 ribbon containing ten sources. The template-needle device i containing the ribbons was removed from the patient on August 30, 1986. One
- ribbon was discovered missing on September 2, 1986 while the Radiation Safety Officer (RS0) was performing a source count. The NRC was informed of the lost t
ribbon on September 3,1986 by the RSO who determined that the iridium-192 h sources had most likely been disposed of in the trash. l' { 5 In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violations 1 described in the enclosed Notice have been classified in the aggregate as a k Severity Level III problem. Normally, a civil penalty is considered for a l Severity Level III problem. However, af ter consultation with the Director, Office of Inspection ard Enforcement, I have decided that a civil penalty p will not be proposed in this case because of your prior good performance in g the area of concern and your prompt and extensive corrective actions which $ involved numerous surveys at the hospital and at the patient's home to locate y the lost sources, w y F e R Q D [M. . E ' LQN
.M NUREG-0940 II.P-15
[ih l,ff
St. Francis Hospital 2 November 24, 1986 You are required to respond to this letter and should follow .he instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Managexent and Budget as required
.by the Paperwork Reduction Act of 1980, PL 96-511.
Sincerely, C.Ith .1 s h..-d bY
.,-p,- -
James G. Keppler Regional Administrator
Enclosures:
- 1. Notice of Violation
- 2. Inspection Report No. 030-01389/86001(DRSS)
NUREG-0940 II.B-16
I e g NOTICE OF VIOLATION i ! St. Francis Hospital Docket No. 030-01389 L 355 Ridge Avenue License No. 12-00963-02 -
- Evanston, IL 60202 EA 86-169 -
h During the Nuclear Regulatory Commission (NRC) inspection conducted during the - period September 4-15, 1986, violations of NRC requirements were identified. ' b The violations involved failure to perform surveys which resulted in the loss k of ten iridium-192 sources. In accordance with the " General Statement of Policy _. k and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), ; [ the violations are listed below A. License Condition No.16 requires patients containing iridium-192 implants [ to remain hospitalized until a survey made with an appropriate radiation detection instrument indicates that all implants have been removed. Contrary to the above, on August 31, 1986, a patient who had undergone b- iridium-192 implant therapy was released from the hospital and a survey L to assure that all implants had been removed was not performed prior to the patient's release. ' b B. License Condition No. 23 requires that licensed material be possessed k and used in accordance with statements, representations, and procedures y contained in the application dated April 1, 1985. Item 20.13 of the application dated April 1,1985 requires that a survey be performed that shows there are no radioactive sources remaining in the room before another patient can be admitted to that room. Contrary to the above, on August 31, 1986, a patient was admitted to a room where radioactive sources had been used and the licensee failed to perform a survey prior to admitting the patient to show that there were no sources remaining in the room. This is a Severity Level III problem (Supplement IV). Pursuant to the provisions of 10 CFR 2.201, St. Francis Hospital is hereby required to submit to this Office within 30 days of the date of the letter transmitting this Notice, a written statement or explanation in reply, including - for each violation: (1) the reason for the violation if admitted, (2) the corrective steps which have been taken and the results achieved, (3) the kr corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, 1 consideration will be given to extending the response time. D k C% +_S/[d
# James G. Keppler Regional Administrator Dated this 2at[ day of November 1986 i
~ py..
NUREG-0940 II.B-17 35J;, 24
b b ~ N. UNITED STATES [pa aeou 'e, T NUCLEAR REGULATORY COMMISslON - { [ . ,g< f h nEcios m 5 . j j 799 ROOSEVELT RO AD cLEN ELLYN, ILUNol5 60137 f e ...* DEC 1 1 1986 __ E L ( Docket No. 030-13378 _ License No. 24-15235-03 j EA 86-177 Veterans Administration s g Harry S. Truman Memorial Veterans Hospital . 1 y ATTN: Mr. J. L. Kurzejeski g Hospital Director i 800 Hospital Drive Columbia, MO 65201 - Gentlemen:
SUBJECT:
NOTICE OF VIOLATION [NRC INSPECTION REPORT NO. 030-13378/86001(DRSS)1 O L m This refers to the inspection conducted on September 18, 1986, at your b facility in Columbia, Missouri. The inspection was in response to a _ i, diagnostic misadministration reported to the NRC by the licensee via letter r h dated April 10, 1986. The circumstances surrounding the event were discussed h during a telephone Enforcement Conference on September 25, 1986. it The results of the inspection showed that a nuclear medicine technologist i f performed a diagnostic procedure using licensed material on a family member
; without the knowledge or under the supervision of the authorized user named in
[ the license. It appears that the technologist violated hospital procedures and that hospital management was unaware of and did not approve such actions. 1 I In accordance with the " General Statement of Policy and Procedure for NRC I Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), - 2 the violation described in the enclosed Notice has been classified at a Severity i Level III. Normally, a civil penaltj is considered for a Severity Level III violation. However, after consultation with the Director, Office of Inspection s_ - [ and Enforcement, I have decided that a civil penalty will not be proposed in r - this case because of your good prior performance in the general area of concern. 2 We noted your extensive investigation into this matter to determine the root -
# cause of the violation and implementation of corrective actions to prevent J recurrence.
~
^
You are required to respond to this letter and should follow the instructions _ specified in the enclosed Notice when preparing your response. In your if" response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this _ i Notice, including your proposed corrective actions, the NRC will determine - - whether further NRC enforcement action is necessary to ensure compliance with i NRC regulatory requirements. 5 In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, O Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. M NUREG-0940 II.B-18
,y. - -
-jp' i! .
t, . g y e i
. Harry S. Truman Memorial /.
3_ }[i 7 2 DEC 1 1 1986 Veterans Hospital
,, ,. P
( The responses directed by this letter and the enclosed Notice are not subject to .the clearance procedures of the Office of Management and Budget as required
., by the. Paperwork Reduction Act of 1980, PL 96-511.
,, Sincerely, I , ,
{' " Qn No_;g !=r . > James G. Keppler (' Regional Administrator
Enclosure:
- 1. Notice of Violation
- 2. Inspection Report No. 030-13378/86001(DRSS) t e
(, , V > t , (\ l 4. t a NUREG-0940 II.B-19 me m -_ - -- m__m .. , _ .
NOTICE OF VIOLATION Harry S. Truman Memorial Veterans Hospital Docket No. 030-13378 Columbia, MO License No. 24-15235-03 EA 86-177 During an NRC inspection conducted on September 18,~1986, a violation of NRC requirements was identified. The violation involved an unauthorized individual performing a diagnostic procedure using licensed material on a family member without the knowledge or under the supervision of the authorized user named in the license. In accordance with the General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation is listed below. License Condition No. 12 states that the licensed material shall be used by, or under the supervision of, individuals designated by the Radiation Safety Committee. Contrary to the above, on February 7,1986, licensed material was used by an individual who was neither designated by the Radiation Safety Committee nor was under the supervision of individuals designated by the Radiation Safety Committee. This is a Severity Level III violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, Harry S. Truman Memorial Veteran Hospital is hereby required to submit to this Office within 30 days of the day of the letter transmitting this Notice, a written statement or explanation in reply, including for each violation: (1) the reason for the violation if admitted, (2) the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. m5sG Ke Regional Administrator Dated at Glen Ellyn, this
- NayofDecember1986 NUREG-0940 II.B-20
ja s U800TED STATES m ase ,q#* l
+ . NUCLEAR REGULATORY COMMisslON !
[ 'e( k ftEGION til
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f cLEN ELLym. eLumoss sot 3r October 1, 1986 Docket No. 030-02271 License No. 24-00167-11 EA 86-125 Washington University School of Medicine ATTN: Samuel B. Guze, M.D. Vice Chancellor for Medical Affairs Skinker and Lindell Blvd. St. Louis, MO 63108 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 030-02271/86001) This ref.ers to the special safety inspection conducted on May 12 and June 2, 1986, at'your facility in St. Louis, Missouri. The inspection was in response to information provided to the NRC by Washington University School of Medicine officials on March 28, 1986, relating to deliberate falsification of survey records by a researcher. The results of the inspection were discussed on June 17, 1986 during a telephone enforcement conference between Messrs. R. Hickok anc J. Eichling of your staff and Mr. D. Sreniawski and other members of the NRC sta'ff. The inspection showed, among other things, that from August 1985 through January 1986 a licensee researcher submitted required weekly survey results even though the surveys had only been performed once a month. The researcher admitted that all survey results other than the monthly survey had been falsified. It was also confirmed that the licensee's January 28, 1986 audit identified predated survey results for the period February to March 18, 1986 when surveys had not been performed. The violation which is described in the enclosed Notice of Violation is classified as a Severity Level III violation in accordance with the "Ge.1eral Statement of Policy and Procedures for Enforcement Actions," (Enforcement Policy), 10 CFR Part 2, Appendix C (1986). The NRC places great emphasis on the integrity and credibility of individuals performing licensed activities and the accuracy of the records of such activities. However, your prior per-formance under your license has been good and you identified this violation through your audit program and reported the violation to the NRC. You also took extensive corrective actions once the violation was identified. These actions included requiring increased supervision of the graduate student's activities, prohibiting the student from conducting any license support activities such as surveys, and writing a letter of reprimand to the researcher in charge, who may not have fully understood the significance of the incident. NUREG-0940 11.B-21
Washington University School 2 October 1, 1986 of Medicine We also understand that-the graduate student has signed a sworn statement indicating that he recognizes the seriousness of his actions and will comply with all license requirements in the future. Accordingly, although a civil penalty is normally considered for a Severity Level III violation, we have decided, after consultation with the Director, Office of Inspection and Enforcement, not to propose a civil penalty in this case. .Nonetheless, we emphasize that any similar violation in the future may result in additional enforcement action. You are required to respond to this letter, and should follow the instructions specified in the enclosed Notice when preparing your response. In your. response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. -A*ter reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine-whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-5111. Sincerely, [h 4E [JamesG.Keppler J Regional Administrator
Enclosures:
- 1. Notice of Violation
- 2. Inspection Report l
No. 030-02271/86001(DRSS) t NUREG-0940 II.B-22
NOTICE OF VIOLATION Washington University School Docket No. 030-02271 of Medicine License No. 24-00167-11 St. Louis, M0 EA 86-125 During an NRC special safety inspection conducted on May 12 and June 2, 1986 a violation of NRC requirements was identified. The violation involved a deliberate falsification of survey records by a licensee researcher. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation is listed below: License Condition No. 23 requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the documents listed under this condition, one of which is a letter dated October 5, 1979. Section 14.2.1 of the " Instructions Regarding Laboratory Surveys" contained in the October 5, 1979 letter requires that laboratory areas where only small quantities of radioactive material are used and in possession (less than 100 microcuries of the commonly used radionuclides) will be surveyed monthly. Section 14.2.3 requires that all other laboratory areas will be surveyed weekly. Section 14.4 requires that a permanent record will be kept of all survey results.
- Contrary to the above, during the period August 1985 through January 1986, weekly survey results were submitted by a licensee researcher for laboratory 8828, which contained more than 100 microcuries of commonly-used radionuclides, although weekly surveys had not been performed. The surveys were conducted on a monthly basis. The researcher admitted to submitting falsified survey records for the weeks when surveys were not performed. In addition, during a January 28, 1986 licensee audit, falsified weekly survey results from February to March 18, 1986 were found predated when surveys had not been performed.
This is a Severity Level III violation (Supplement VII). Pursuant to the provisions of 10 CFR 2.201, Washington University School of Medicine is hereby required to submit to this Office within 30 days of the date of the letter transmitting this Notice, a written statement or explantation in reply, including for each violation: '(1) the reason for the violations if admitted, (2) the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further i violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. l Dated af Glen Ellyn, Illinois this / - day ofg M Q 1986 i NUREG-0040 II.B-23
g,*aM = v s. NvCL An..vuromy < - i m voa r NuM.. ,A.~ ., T,0c. m., No. ., e,, IE" E' BIBUOGRAPHIC DATA SHEET NUREG-0940
. NirRuCriON O rR. REv.R.. Vol. 5 No. 4
- 2. TITLE 4 ND SutfiTLE 3 LEAVE SLANK Enf:rcement Actions: Significant Actions Resolved Quarterly Progress Report (October - December 1986) a oArn auOar mMPLarEo MONTR YEAR
. ,.o r,,OR,,, January I 1987 IE Enforcement Staff a oA'< apoan55u'o MONr . EAR February l1987 7 Pt J ORuiNG ORGANIZATION NAME AND MAILING ADDRESS flachele Ceepf 8 PROJECTIT ASK/.ORK uNai NUMSER Office of Inspection and Enforcement U.S. Nuclear Regulatory Commission ' "N oa oa ANr NuMasa Washington, DC 20555 10 8PON50ReNG ORGANIZATION NAME AND M AeLiNG ADDRESS flac4mple Ce8tt Ils TYPE OP REPORT Samm as 7 above Technical b PERIOD COVERED (saceswe eNes 12 SUPPLEMENTARY NOT.S 13 ASSTs;ACT (200 weres se esses This compilation summarizes significant enforcement actions that have been resolved during one quarterly period (October - December 1986) and includes c pics of letters, Notices, and Orders sent by the Nuclear Regulatory Comission to licensees with respect to these enforcement actions and the licensee's responses. It is anticipated that the information in this publication will b2 widely disseminated to managers and employees engaged in activities licensed by thm NRC, in the interest of promoting public health and safety as well as comon defense and security. . DOCvME Nr AN At, .. . . R E v.ORoro..CR ,roR.
i . A.,A .gr , Tcchnical Specifications, Radiographers, Quality Assurance, Radiation Safety Program, Safety Evaluations Unlimited is 8.CumiryCLA$5sFICArlON
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