ML20215G069
| ML20215G069 | |
| Person / Time | |
|---|---|
| Site: | LaSalle  |
| Issue date: | 08/22/1986 |
| From: | Allen C COMMONWEALTH EDISON CO. |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| References | |
| 2014K, NUDOCS 8610160471 | |
| Download: ML20215G069 (16) | |
Text
A} Commonwealth Edison 3&$
/
[
--. y One First National Plaza, Chicago, lilinois
\\ // Address Reply t : Post Office Box 76F'
'v Chicago, Illinois 60690 0767 August 22, 1986 Mr. James G. Keppler Regional Adm!c.istrator U.S. Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137
Subject:
LaSalle County Station Units 1 and 2 Enforcement Conference Held August 13, 1986 Regarding Mispositioned Control Rod NRC Docket Nos. 50-373 and 50-374 Reference (a):
C. E. Norelius letter to Cordell Reed dated August 4, 1986, transmitting Inspection Report Noe. 50-373/86021 and 50-374/86020.
Dear Mr. Keppler:
This letter transmits a copy of the visuals utilized by Commonwealth Edison at the Enforcement Conference to discuss the status of corrective actions with regard to recent personnel errors.
If you have any further questions regarding this matter, please direct them to this office.
Very truly yours, C. M. Allen Nuclear Licensing Administrator im Attachment cc: NRC Resident Inspector - LSCS Dr. A. Bournia - NRR 86101604h $IO 73 PDR ADO PDR 2014K e
AUG 2 91986 ZEoI'\\\\
ENFORCEMENT CONFERENCE PRESENTATION AUGUST 13, 1986 MISPOSITIONED CONTROL R0D ON MARCH 26, 1986 PROPOSED AGENDA A.
OPENING COMMENTS B.
OVERVIEW OF EVENT C.
EVENT DISCUSSION 1.
CHRONOLOGY 2.
ISSUES D.
CORPORATE OVERVIEW OF EVENT E.
ENFORCEMENT POLICY APPLICABILITY DOCUMENT ID #16-013
EVENT IDENTIFICATION UNIT 2 REACTOR AT ABOUT 22% POWER.
PRESCRIBED CONTROL ROD SEQUENCE INADVERTANTLY VIOLATED.
NSO RETURNED ROD TO PROPER POSITION WITHOUT FOLLOWING WITH THE STATION PROCEDURE FOR A MISPOSITIONED CONTROL ROD.
1 L
l DOCUMENT ID #16-013
e EVENT CHRONOLOGY WITHDRAWING RODS TO INCREASE POWER POWER APPROXIMATELY 22%
+
RWM BYPASSED
+
VERIFIER IN PLACE, ALTHOUGH NOT REQUIRED FIRST ROD OF NEW STEP WITHDRAWN l
l 1
i 1
l l
l l
DOCUMENT ID #16-013 l
l
~,...
EVENT CHRONOLOGY (CONTINUED)
ROD PULLED TO 48 VICE 24 i
VERIFIER NOTICES ERROR, CHECKS SEQUENCE SIMULTANEOUSLY, NSO STARTS PULLING NEXT ROD VERIFIER NOTIFIES NSO 0F PROBLEM NSO STOPS ROD WITHDRAWAL NSO REINSERTS FIRST ROD TO PROPER POSITION I
I l
DOCUMENT ID #16-013 l
c
4 EVENT CHRONOLOGY (CONTINUED)
SCRE INFORMED STATION PROCEDURE CONSULTED NUCLEAR ENGINEER CONTACTED
+
CHECKED STATUS VIA COMPUTER j
+
CONCURRED WITH OPERATOR ACTIONS
+
VERIFIED NO SAFETY SIGNIFICANCE POWER ASCENSION RESUMED DOCUMENT ID #16-013
J EVENT CHRONOLOGY (CONTINUED)
PLANT AND OFF-SITE MANAGEMENT ADVISED OF EVENT
+
UNIT OPERATING ENGINEER
+
PRODUCTION SUPERINTENDENT
+
LEAD NUCLEAR ENGINEER, VERIFIED NO SAFETY SIGNIFICANCE l
+
DIVISION VICE PRESIDENT i
l l
r t
i l
DOCUMENT ID #16-013
4 k
SPECIFIC ISSUES RELATED TO THIS EVENT GENERAL CORRECTIVE ACTIONS TO ADDRESS PERSONNEL PERFORMANCE
^
PARTICULARLY, PROCEDURAL ADHERENCE, ATTENTION TO DETAIL AND THE NEED FOR EXCELLENCE 1
i e
e-e 4
-,-n-r,.., -,,. - - -----,-.n.-,
n,
, - + -... - - - -,- - ------ - - - -.
an,.,-a.
.,me--
-r--,,
ISSUE:
PROCEDURAL COMPLIANCE FACTS:
NSO WITHDREW CONTROL ROD FROM NOTCH 12 TO 48 INSTEAD OF 12 TO 24 IDENTIFIED BY INDEPENDENT VERIFIER AT POSITION 48 ROD REINSERTED IMMEDIATELY AFTER CONFIRMING ERROR W/ VERIFIER ELAPSED TIME FROM ROD AT 48 TO. REINSERT TO 24 - 1 MINUTE PROCEDURE REQ'D A.
DEMAND OD-7, ETC.
B.
CONSULT NUCLEAR ENGINEER C.
CHECK 0FF 6AS RAD LEVEL D.
RETURN CONTROL ROD TO ITS IN SEQUENCE POSITION l'
DOCUMENT ID #16-020 1
CONCLUSIONS:
INITIAL ERROR NSO DID NOT PAY SUFFICIENT ATTENTION TO THE ROD WITHDRAWAL SEQUENCE THERE WAS NOT SUFFICIENT COMMUNICATION BETWEEN THE OPERATOR AND THE VERIFIER SUBSEQUENT ACTIONS NS0'S ACTION WAS TECHNICALLY SOUND
" DISCUSSION" SECTION OF PROCEDURES CONVEYED THE INTENT OF THE PROCEDURE -
I.E., "lT IS IMPORTANT TO RETURN THE ROD TO ITS' CORRECT POSITION AS QUICKLY AS POSSIBLE.
NSO DID NOT FOLLOW THE RECOVER
Y. PROCEDURE
VERBATIM DOCUMENT ID #16-020
CORRECTIVE ACTIONS (EVENT SPECIFIC)
NSO GIVEN LETTER OF REPRIMAND TRAINED OPERATORS ON THIS EVENT REVIEW OF ROD POSITIONING ERRORS AT OTHER SITES PROCEDURES REVISED TO REQUIRE A STRUCTURED METHOD OF COMMUNICATION BETWEEN OPERATOR AND VERIFIER PRIOR TO EACH ROD MOVEMENT - I.E.
" REPEAT BACK" LOA-RD-03 REVISED TO IMPROVE RESPONSE TO ROD ERRORS i
DOCUMENT ID #16-020
ISSUE:
INDEPENDENT VERIFIER FACTS:
CAUGHT ERROR NO DIRECT ORAL COMMUNICATION BETWEEN OPERATOR AND VERIFIER RWM WOULD HAVE CAUGHT ERROR AT POSITION 48 (NOT BEFORE) IF IN SERVICE.
CONCLUSIONS:
1 ALTHOUGH CAUGHT BY VERIFIER, IT SHOULD HAVE BEEN CAUGHT EARLIER.
BETTER COMMUNICATION BETWEEN OPERATOR / VERIFIER PRIOR TO ROD MOVEMENT COULD HAVE PREVENTED IT ALTOGETHER.
CORRECTIVE ACTIONS COUNSELED VERIFIER ON TIMELY DETECTION OF ERRORS l
REVISED PROCEDURES TO " STRUCTURE" COMMUNICATION l
BETWEEN NSO AND VERIFIER PRIOR TO EACH ROD MOVEMENT.
l I
STATE INTENDED MOVE l
l VERIFIER REPEATS BACK MOVE AND AUTHORIZES l
EACH ROD MOVEMENT DOCUMENT ID #16-020 l
l
4 4
GENERAL CORRECTIVE ACTI'ONS TO ADDRESS PERSONNEL PERFORMANCE MONTHLY'" FREE FORM" MEETING PROVIDES DIRECT INFORMATION EXCHANGE BETWEEN STATION MANAGER AND SELECTED PERSONNEL FROM VARIOUS WORKING LEVEL PERSONNEL.
STARTED MID JUNE.
[
WEEKLY DEPARTMENTAL COMMUNICATIONS MEETINGS.
+
REVIEW PERSONNEL ERROR EVENTS, LESSONS LEARNED, 4
ETC. WITH ALL STATION PERSONNEL i
GOAL OF 6 MONTHS OF ERROR FREE OPERATION.
UNIT 2 STARTUP PLAN.
I
+
PROMPT, HIGH LEVEL REVIEW OF NEW PERSONNEL ERRORS, WITH PARTICIPATION BY WORKING LEVEL PERSONNEL.
+
SEVEN DAY SPECIAL REVIEWS.
+
EXTRA PERSONNEL ON SHIFT TO HELP PREVENT ERRORS i
AND EMPHASIZE IMPORTANCE OF "DOING IT RIGHT" DURING l
U-2 STARTUP.
EXTRA SRO " FOREMAN SENIOR MANAGER ON SHIFT NUCLEAR ENGINEER INSTRUMENT MAINTENANCE OVERVIEW i
+
SPECIAL SHIFT MEETINGS WITH EMPHASIS ON COMMUNICATIONS l
DOCUMENT ID #16-020 l
l
+
EXPECTATIONS MEETINGS BY D. P. GALLE AND STATION MANAGER - ALL STATION PERSONNEL LASALLE REGULATORY PERFORMANCE HISTORY RECENT LIST OF PERSONNEL ERRORS WE HAVE TURNED THIS CORNER, BUT STILL NEED TO DO BETTER FOCUS FOR NEXT 6 MONTHS IS GOAL OF ERROR FREE OPERATION IT'S UP TO US TO CHANGE THE PERCEPTION BY STRIVING FOR EXCELLENCE WE MUST PULL TOGETHER AS A TEAM 50 DAYS WITHOUT A REPORTABLE ERROR DOCUMENT ID #16-020
~~
2, r
CORPORATE OVERVIEW o
RECOGNIZE SERIOUSNESS OF CONTROL R0D MIS-MANIPULATIONS DEVIATION REPORT FOR 5/26/86 LASALLE EVENT SENT TO OTHER STATIONS.
REVIEW BY OPER. & NUC. ENG.
INP0 REPORTS (SER's, SOER 84-2) SENT TO STATIONS &
NFS FOR REVIEW 0
5/26/86 EVENT NOT SAFETY SIGNIFICANT AT THAT POWER LEVEL R0D DROP ACCIDENT NOT A PROBLEM IF )> 20% POWER EVEN IF dC 20%, PROMPTLY CAUGHT ERROR: R0D TO POS.
48 WITHIN BPWS RULES./.N0 R0D DROP PROBLEM.
DO NOT ROUTINELY MAKE R0D MOVES AT HIGH POWER l
l l
\\
1 CORPORATE OVERVIEW (CONT'D.)
O CECO NUCLEAR FUEL SERVICES (NFS) INITIATIVES:
BWR CONTROL R0D SEQUENCE EXECUTION METHODS REVIEW &
RECOMMENDATIONS USER-FRIENDLY TO OPERATORS COMPLETE REVIEW FALL 1986 HANDLING MISPOSITION ERRORS.
CONSIDER:
O POWER LEVEL 0
HOW FAR OUT OF SEQUENCE o
TIME FOR ACTION 0
NUC. ENG. INVOLVEMENT 0
OTHER PLANT CONDITIONS (I.E.
RECOMMENDATIONS FOR STATION PROCEDURES -
FALL 1986
. - _ - _.