ML20214H980

Ro:On 870424,operator Personnel Blocked Open Two Torus to Drywell Vacuum Breaker Valves at Time When Primary Containment Integrity Was Required.Caused by Cognitive Personnel Error.Procedures Revised

ML20214H980
Person / Time
Site:	Oyster Creek
Issue date:	05/07/1987
From:	Fiedler P GENERAL PUBLIC UTILITIES CORP.
To:	Russell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
Shared Package
ML20214H949	List: IR 05000219/1987018 ML20214H945 ML20214H970 ML20214H980
References
NUDOCS 8705270573
Download: ML20214H980 (5)

Text

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$c9 971 O:o sene.s c e n a v :er Mr. Wfiliam Russell, Administrator May 7, 1937 Regfon !

U.S. Nuclear Regulatory Comf ssion 631 Park Avenue King of Prussia, PA 19406

Subject:

Oyster Creek Nuclear Generating Station Docket No. 50-219 Torus to Drywell Yacuum Breakers During a reactor shutdown on April 24, 1987, Operations personnel blocked open two (2) Torus to Drywell vacuum breaker valves at a time when Primary l Containment Integrity was required. This occurred as a result of a cognf ttve l error on the part of two key control recen individuals. The purpose of the action taken was to asstst N deinerting the containment in preparation for l entering and performing maintenance within containment. This action was in I

violation of Technical Spectfications, Section 3.5.A.5 which requires operability of the Torus to Orywell vacuum breakers when primary containte9t is required. One of the individuals involved in the decision to block open the vacuum breaker valves recognized his error approximately four (4) hours af ter blocking the valves open and imediate actions were taken to restore the valves to operable status. The NRC restdent inspector was nottfled of thf s occurrence and subsequently the required nottfication was made to the NR0 Operations Center. The latter nottf f cation, however, was not made in a tfrrely manner in accordance wtth 10 CFR 50.72 In rece;nition of the serious nature of this occurrence, CPUN upper level managemnt initiated an (mediate investigation of this event concurrent with the NRC Re)fon I fnspection.

Altnuugh this event was a cognitive error by on shif t personnel, investigations by GPUN and NRC Inspectors identifled problems associated with the Temporary Varf ation Program and the implementation of the associated ufety review process. GPUN had previously identf fle t problems with reve:t to the i. Liementation of the $dfety review process at the Oyster Creck Station, Oelcar Assurance (Quality Assurance Departmnt) had performed i review t a deterrit ne the implementation aco@acy and interface ef fect1. nes o' the Temporary Varf ation Program (Station Procedure 108). Subsequent to the revision to the safety review process in Septaber of 1986, the Nuclear Safety Assessmnt Ocpartnwnt had planneif a review to assess the effectiveness of stition Proced;re 130 (Conduct of Independent Safety Reviews and Raven f ble Technical Revivas by the Plant Review Group). This assessfnent was conducted in January 1987 Doth of these assessments identified required fmpenvemants 0705270573 070515 PDH ADOCK 05000219 o PDH

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. . 05'07<87 16:17 CPUN OCNGS LICEN NO.000 003 Mr. William Russell, Administrator US NRC Page 2 in implementation. At the time of this event, actions were in progross to correct these deficiencies (Plant Procedure 108 " Equipment Control had been significantly revised and is currently in the review stage; and needed changes to the training program and Station Procedure 130 had been identified).

Based on the above, GPUN upper level management has directed that, prior to restart from the current outage, the following shall be completed:

1 All personnel (Responsible Technical Reviewers and Independent Safety Reviewers) involved in the safety , review process for temporary variations will be retrained prior to performing any reviews.

2. The documentation for all current outstanding temporary variations will be reviewed and revised, if required, by the Temporary Yariation Task Force. Safety evaluations will be prepared where appropriate and for those that are identified as not requiring a safety evaluation, a documented justification for the determination will be provided.

3. Procedure No.108 (Equipment Control) will be changed as follows:

a. All future temporary variations will be reviewed prior to installation of a temporary variation by at least one qualified individual, who is not assigned to Control Room shift duties,

b. Procedure No.100 (l'quipment Control) will be revised to be compatible with Procedure 130 (Conduct of Independent safety Reviews and Responsible Technical Reviews by Plant Review Group).

c. Additional guidance will be placed in the 108 procedure to prohibit the use of a temporary variation when a procedure change is more appropriate,

d. The temporary variation fonn will be revised to explicitly require a technical review of the temporary verf ation packaga including the >rocudure 130 "Nucicar Safety Environmental Determination leview" (NSEDR) form, which identifies the safety significance, and the written Safety Evaluation (SC) when one is required.

4 Frxedure No.130 (conduct of Independent Cafety Revim and

? vicniible Technical Reviews by Plant Roview Group) will t>e chinyd

t. o.v'; i ' t tten justifl;ation f cr "W aWel given tu qu.istfons 3 through 6 on the NSEDR.

5. Procedure No. 312 (Reactor Containment Integrity and Atmosphere O ntrol) will be changed to preclude opening of roactor batiding to torus vacuun breaker valva's while primary conttin9ent integrity is required.

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. 05'07 87 16:18 CPUH CO65 LICEN NO.008 004 Mro William Russell, Administrator US NRC Page 3 I

6. Percef ved technical problems regarding torus to drywell vacuum breaker valve position indication, required maintenance, and degradation of the torus deinerting rate will be thoroughly investigated and resolved. (With regard to the torus to drywell vacuum breaker position indication concern, operability surveillance (procedure 604.4.006) was performed on all torus to drywell vacuum breakers on May 3,1987 which verified proper operation of the valves and their associated position alarms, A compartson was made between past and present torus deinerting rates. The results of the investigation show no appreciable

, increase in the time required to deinert the torus and, therefore, there is no basis for suspecting any degradation in the operation of any torus vent valves.)

GPUN has recognized a needed improvement in the review of temporary variations (TV) and TV associated safety reviews by procedurally responsible management personnel. It was found that better understanding was needed with i

regard to what was expected of them in their review of temporary variations and associated safety reviews, All management personnel procedurally responsible for reviews have been or will be retrained as to what is expected and what their responsibilities include. Examples are being provided illustrating a lack of pertinent information and, in some cases, incorrect detenninations on documentation associated with temporary variations and their associated safety reviews. These personnel are responding well in recognizing their responsibility to provide greater attention to documentation to assure

, proper content, control of interim measures with regard to testing and recovery, and to assure accurate determinations regarding safety. These personnel were directed to review, prior to restart, all currently outstanding temporary variations, In order to verify proper performance and review of these activities, the Nuclear Assurance Division will Institute increased oversight of thf s process for the next two to three months, with particular attention to temporary varf ations and associated safety determinations / evaluations. Ocf fciencies identified from this review will oc addressed promptly, In the longer term, a vacuum breaker incident investigation team has i been created and staffed by the Nuclear $afety Assessment Department to

! continue the CPUN investfgation and identify other long term actions that may i

be required or desirable. The scope and depth of this review will be guided by the Managemont Oversight and Risk Tree (M0iti) process, this process will '

examine the controls and barriers (personnel, procedurvs. and equipment) in place which should haw

• prevented this event. It will ersmine the need for improve m nts in those barriers such that greater ass panot is obtained to preclude events of this natura in the future, The management system factors will also be investigated to ascertain any other contributors to this event.

As a result, improvements in our abfilty to prevent occurrence of oversights or omissions will be made, included in the rovfew will be an examination of the Temporary Variation Program, implementation of the ssfsty review process, augmented shf f t staffing during unusually busy periods, the influence of schedular requiremnts, and contributors to personnel error.

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. . 05 07/87 16:19 GFui OCtGS LICEt1 to.008 005 Mr. Willfaa Russell, Administrator ,

US NRC Page 4 The ongoing Perfonnance Assessment Task Force had previously identifled time delays in the disposition of technical concerns. While all final recomendations of the task force are not complete, it is believed that these delay problems will be reduced by effective adoption of a system working group concept whereby individuals from Plant Engineering, Operations, and Maintenance take responsibilf / for the status of a particular plant system and/or component. Recently, the company has achieved excellent results by utf1f zing a task force approach to problem resolutfon of particularly broad scope or technical dif ficulty. It is reasonable to assume this process will be utilized in the future, As a follow up to the procedure 108 and 130 trafning of key individuals before restart, all other Oyster Creek personnel previously qualified as Responsible Technical Reviewers and/or Independent Safety Reviewers will recefve addftional training on these procedures subsequent, wtthin a month, to plant startup.

Other concerns have been identified by GPUN and NRC inspection personno). These concerns and the associated GpVN actions are as follows:

1. Untimely reporting of events in accordance with 10 CFR 50.72 has been noted especially in the area of events resulting from human e rror. Strict guidance has been given to operations management to be more aggressive in strictly interpreting the reporting reg!remer.t: cf 10 CTR 50.72, i.e., when in doubt report.

2. The Vacuum Breaker System, both Reactor Duf1 ding to Torus check valves and the Drywc11 to Torus check valves, are princfpally passive systems. Due to a number of identiffed discrepancies over the past 8 to 10 years, it appears that some lack of sonsttivity may extSt with respect to the safety function of these valves.

Therefore, a memo will be developed and circulated to all personnel reiterating the purpose of these valves and their importance to plant safety. Additionally, the training program for those systems will be revised to include a discussion of past occurrences with regard to operation and maintenance of these systems and components.

3. CpuN recognitos the continuing need to reduce the number of operator and technician errors. By GPUN standards, an undue number of errors has been tiuted in several fnternal evaluations prevfously per fonned. In addition to those actions described in our $ Alp responta of April 28, 1987, corrective measures which are greently in progress or are planned include the following:

a. ?ne feedwater system f s recognired as a complicated system to operate; therefore, the training module is botng revised to emphastre proper control and operation.

. . 05 07 8a 16:19 CFUti OCNGS L!CEN NO.008 006 Mr. William Russell, Administrator US NRC Page 5

b. In the past, the need for strict procedural compliance has been emphasized and disciplinary action has been administered where appropriate. Continued emphasis is this area will be stressed.

c. Where spectfic personnel related deficiencies are observed, retraining of personnel is conducted,

d. The Performance Assessment Task Force is evaluating potential actions to reduce challenges to the operators.

e. Improved formality and profes'stonalism is one of our top goals.

In summary, those actions being taken in the short term, prior to startup, will significantly improve operator and responsible management perfomance with regard to temporary variations and their safety reviews. The effectiveness of these actions will be monitored to assure continued visibility until substantial improvement is vertfled. The application of the MORT process which has been initiated will provide an integrated overview of personnel interfaces, responsibillties, and management system factors. Deficient areas resulting from this review will be corrected. The need for additional training in deffcfent areas will be identified and given to all involved personnel.

GPUN not only recognizes the seriousness of this event, but also the importance of addresstng all of the factors which may have contributed to tnts event as well as any other deficiencies identiffed. We have initiated those actions discussed above in order to verify acceptability of currently installed temporary variations and signtficantly improve performance in the near term and will followup our investigation to assure that pertinent problems have been identf fied and properly resolved in the long tem.

Very truly yours, P

t edTer b))

Yte.e President and Director Oyster Crook P8F/MWL/ded (0664A) cc: Mr. Aleiander W. Dromrick, Project Manager U,$. Nuclear Regulatory Comission 01vf sf sn of Roctor Projects I/II 7920 Norfolk Avenue, Phillips 01dg.

Bethesda, MD 20014 NRC Resident inspector Oyster Creek Nuclear Generating Station