ML20216B733
| ML20216B733 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 01/30/1997 |
| From: | Letts B, Elizabeth Wilson NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20216B689 | List: |
| References | |
| FOIA-98-81 1-96-039, 1-96-39, NUDOCS 9804140083 | |
| Download: ML20216B733 (13) | |
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Title:
SUSQUEHANNA UNIT 2:
TECH SPEC VIOLATION DUE TO FAILURE OF NUCLEAR PLANT OPERATORS TO CONDUCT ADEQUATE SURVEILLANCES AND FALSIFICATION OF RESULTS Licensee:
Case No.:
1 96 039 Pennsylvania Power & Light Company Report Date: January 30, 1997 2 North Ninth Street' Allentown, Pennsylvania 18101 Control Office: 01:RI i
Docket No.: 50 388 Status: CLOSED Reported by:
Reviewed and Approved by:
f Att?
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/ Ernest'P.Wilsiin.SpecialAsent Barry R. Lbtts,lirector Office of Investigations Office of Investigations Field Office., Region I Field Office, Region I i
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SYNOPSIS On October 18,1996,-The Office of Investigations (OI), Region I, initiated this investigation in order to review Pennsylvania Power & Light's (PP&L's) internal investigation and audit reports concerning: (1) the failure of Nuclear Plant Operators (NP0s).to detect a misalignment of an "E" Diesel generator breaker at Susquehanna Unit #2 from June 14 to July 4,1996, and the potential falsification of tech spec required surveillance logs that included inspection of the breaker in question; and (2) the failure of multiple NP0s to conduct a number of alarm panel tests from January to June 1996 during procedure required operator rounds (ors), and the potential falsification of the OR logs that included the testing of the alarm panel.
Based on 0I's review of PP&L's internal investigation and audic reports on these matters, it is concluded that multiple NP0s wilfully failed to conduct adequate tech spec required surveillances and procedure required ors, and created inaccurate logs of those activities. 01's review of PP&L's internal reports determined that additional investigation by 01 would not likely result in alternative findings, and, therefore, the further expenditure of 01 resources is not warranted, I
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TABLE OF CONTENTS l
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SYNOPSIS 1
' DETAILS OF INVESTIGATION 5
t-Applicable Regulations........:../............. 5 Pur>ose of Investigation 5
Bac(ground........................'..... 5 Coordination with Regional Staff 5
Evidence-...................
6 Conclusion 8
SUPPLEMENTAL INFORMATION 9
' LIST OF EXHIBITS........................... '.
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DETAILS OF INVESTIGATION Aoolicable Reaulations i
10 CFR 50.5: Deliberate misconduct 10 CFR 50.9: Completeness and accuracy of information Technical Specification No. 4.8.3.1.1 (Surveillances) i Purpose of Investication i
I On October 18, 1996, the Office of Investigations (OI), Region I (RI),
initiated this investigation in order to review Pennsylvania Power & Light's 1
(PP&L's) internal investigation and audit reports concerning:
(1) the failure of Nuclear Plant Operators (NP0s) to detect a misalignment of an "E" Diesel generator breaker at Susquehanna Unit #2 from June 14 to July 4,1996. and the potential falsification of tech spec required surveillance logs that included inspection of the breaker in question; and (2) the failure of multiple NP0s to conduct a number of alarm panel tests from January to June 1996 during i
procedure required operator rounds (ors), and the potential falsification of the OR logs that included the testing of alarm panel 0C577E (Exhibit 1).
Backaround j
On July 26, 1996, during a telephone call briefing by PP&L (Exhibit 2),
licensee concerns were reported to the NRC. Those concerns involved the potential deliberate failure of NP0s to perform certain tech spec required surveillances and procedure required ors, and the potential falsification of logs associated with those activities. The E Diesel Generator Breaker Hisalignment Event was discovered on July 4,1996, and resulted in PP&L chartering 3 internal investigations / audits of that event and associated issues.
Coordination with Reaional Staff On October 15, 1996, the RI staff, 01, and the Office of Enforcement (0E),
convened an enforcement panel to discuss a course'of action to address these licensee reported concerns.
It was determined that 01 should review the internal PP&L investigations and audits for adequacy, and if deemed appropriate, conduct such other investigation as required.
On January 23, 1997, 0I:RI met with NRC's Brain J. McDERM0TT, Resident Inspector, Susquehanna 1 and 2.
McDERM0TT advised that the formal surveillances at issue in this case are required by tech spec, and that the ors are required by PP&L internal procedure. The NP0s involved in the breaker misalignment issue, the failure to detect the misalignment through ors or surveillances, and the alarm panel. issues were all non licensed NP0s during the time in question.
McDERM0TT reported that different forms of disciplinary action have been meted out to 21 NP0s as a result of the PP&L internal investigations and audits. Actions included, depending on the level of Case No. 1 96 039 5
involvement of the individual NPO, firings, letters of reprimand, and the l
placement of individuals into the Responsible Behavior Program. The NRC has issued 21 Demand For Information (DFI) letters to the implicated NP0s. As of January 24, 1996, the majority of the individuals have responded to the DFIs:
a few of them have been granted an extension at the request of their attorneys.
[This 01 Report of Investigation does not include a review of the individual responses to the DFIs. That review is being accomplished by the NRC's RI technical staff.]
Evidence l
Review of Pertinent Documentation The following internal PP&L investigation and audit reports on these matters were reviewed by 01:RI:
1.
PP&L's Independent Safety Evaluation Services (ISES) Project Report 3 96, Investigation of E Diesel Generator In operability Event, dated July 24, 1996 (Exhibit 3):
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Corporate Audit Services' Confidential Report of PP&L Com)any Investigation of 'E' Diesel Breaker Hisalignment, Job Num>er i
739619 96, dated July 25, 1996, and a Supplement to this investigation dated August 16, 1996 (Exhibit 4);
3.
Corporate Audit Services' Confidential Report of PP&L Com)any, Review of NPO Testing of 'E' Diesel Alarm OC577E, Job Num>er 739619 1 96, dated August 13, 1996, and supplements dated August 20 and 30, 1996, including interviews with 21 NP0s (Exhibit 5).
Summary of PP&L Findinas The ISES report (Exhibit 3) of the E Diesel Generator In operability Event found, among other things, the following:
During the 20 day interval from June 14 through July 4,1996, the 'E' diesel generator was technically in operable because the circuit breaker had been improperly aligned, and over 80 ors completed by 15 NP0s, and 3 formal surveillances were conducted without detecting the problem. This led to a Tech Spec limit of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> being exceeded (pp. 2, 3, and 6):
Three separate operators initialed weekly surveillances dated June 20, June 27 and July 4,1996, confirming that the breaker in question (0A51105 1E Supply to 0B565) was "0 PEN and RACKED IN," however,
... it is almost certain..." that there was no breaker in the cubicle in question (pp. 2, 3, and 22).
Regarding Panel Alarm OC577E, the plant process computer records each alarm initiated by the NP0s during ors. The computer data show that in 19 cases an NP0 checked the log sheet indicating that he/she completed an action that had not been done (pp. 21 and 22).
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The PP&L investigation / audit of the E Diesel Breaker Misalignment, with l
Supplement (Exhibit 4), included interviews with 5 NP0s and found, among other things, the foll eing:
"We believe that human error, in particular inattentiveness to detail by NP0s, is the reason the misalignment remained undetected from June 14 until July 4, 1996"-(p. 2).
Generally, one NPO admitted that his surveillance may not have_ been accurate and evidence would suggest that he conducted the surveillance too quickly; another NPO had past performance problems associated with inattentiveness to detail and performing work too quickly, and admitted that he might have made a mistake by inspecting the wrong breaker on June.27, 190.6, during an approximate 5 minute. surveillance and OR that, as he stated, normally takes him 1015 minutes-to complete: another.NPO suspected a problem with the E Diesel breaker panel on July 3. 1996, during an OR, but did not investigate the problem that night: and another NPO observed signs of a problem with the breaker during a surveillance but then convinced himself that no problem existed an'd took no further action (pp. 2 6).
Based on-interviews with knowledgeable personnel and performance of a mock / test surveillance, it was learned that it takes approximately 8 minutes to properly complete an adequate surveillance. Specifically, ' in
.this case, the June 20, 1996, surveillance was completed in 2 minutes -
.11 seconds, and, as indicated above, another NPO completed the June 27, 1996. surveillance /0R in approximately 5 minutes. As a result, PP&L concluded that these 2 surveillances were not thorough and/or accurate.
Additionally, for 1 of the surveillances conducted on July 4,1996, an NPO admitted that he did not open the OA51105 breaker panel to verify bre;ker position (pp. 5 and 6).
The PP&L Review of NPO Testing of *E' Diesel Alarm OC577E'-(Exhibit 5) found, among other' things, the following:
"In our-opinion, each of the ten NP0s [ eleven additional NP0s were subsequently interviewed by PP&L Corporate Auditing] did not exercise due care in conducting required tests of the OC577E alarm in the 'E' Diesel Generator Building. -NP0s provided us with various scenarios (reasons / explanations) pertaining to why they initialed the Plant Log indicating they completed the alarm test yet the Plant Computer System did not register the alarm test" (p. 2).
"Although the NP0s indicated various reasons for not properly performing the alarm test, we believe the fact remains that the NP0s annotated the Plant. Log indicating that they conducted the OC577E alarm test yet the evidence (Plant Computer System data) suggests that certain. tests were not conducted" (p. 2).
... we believe that NP0s have a fundamental duty to read, understand and perform the alarm test as noted on the NP0 Plant Log that they initial. We believe that the Plant Log clearly indicates the Ca.e No. 1 96 039 7
requirement for NP0s to test Alarm OC577E twice per shift...."
(p. 2).
Conclusion Based on 01's review of PP&L's internal investigation and audit reports on these matters. it is concluded that multiple NPCs wilfully failed to conduct adequate tech spec required surveillances and procedure required ors, and created inaccurate logs on those activities. OI's review of PP&L's internal l
reports determined that additional investigation by 01 would not likely result in alternative findings, and, therefore, the further expenditure of 01 resources is not warranted.
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SUPPLEMENTAL INFORMATION The NRC's RI technical staff is reviewing the individual responses to the DFI letters in preparation for anticipated Enforcement Conferences on NP0 issues.
The staff has informed OI:RI that possible mitigating factors, such as potential weakness in NPO training, supervisory oversight of NP0s, and the general culture at Susquehanna Units 1 and 2, will be considered prior to any enforcement action.
On January 30, 1997, William SELLERS, Senior Legal Advisor, U.S. Department of Justice (D0J), Fraud Section, Washington, D.C., was apprised of the facts contained in PP&L's internal investigation and audit reports, as reviewed by
- 01. SELLERS indicated that he did not feel that the case warranted prosecution and advised that D0J would defer to the NRC for agency action, as appropriate.
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LIST OF EXHIBITS Exhibit No.
Descriotion 1
Investigation Status Record, dated October 18, 1996.
2 Memorandum, JENISDN to Logan (0I),
Subject:
Phone Call with PP&L.
dated July 26, 1996.
3 PP&L's ISES Investigation Report of the "E" Diesel Generator In Op Event, dated July 24,.1996.
4 Confidential PP&L Investigation Report of the 'E' Diesel Breaker Misalignment Event, dated July 25, 1996, with Supplement, dated August 16, 1996.
5 Confidential PP&L Review of NP0 Testing of 'E' Diesel Alarm OC577E, dated August 13, 1996, with Supplements, dated August 20 and 30, 1996.
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(IT IB ON E
P LIC L )S E-:
l INVESTIGATION STATUS RECORD I
Case No.:
1-96-039 Facility: SUSOUEHANNA UNIT 2 l
Allegation No.: RI-96-A-0206 Case Agent: WILSON Docket No.:
50-388 Date Opened:
10/18/96 Source of Allegation:
LICENSEE (L)
Notified by:
PASCIAK (DRP)
Priority: HIGH Category: WR/AE Case. Code:
RP Subject / Allegation: TECH SPEC VIOLATION DUE TO FAILURE OF NP0s TO CONDUCT l
ADFOUATE SURVEILLANCES AND FALSIFICATION OF THE SURVEILLANCE RESULTS Remarks: REFER TO ASSIST T0 iNSPECTTON'A1296 '026 Monthly Status ReDort:
10/18/96: On October 15. 1996. the Region I staff. OI. and OE convened an enforcement panel to discuss a course of action related to the-failure of nuclear plant operators (NP0s) at Susquehanna Unit 2. to detect an "E" diesel breaker misalignment during three weekly surveillances from June 14 to July 4. 1996.
This failure resulted in an "E" diesel generator inoperability event and a tech spec limit of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> being exceeded. Also, multiple NP0s failed to conduct an alarm Janel test during shift rounds. These alarm checks are i
required )y procedure (operator round sheets) as opposed to technical specifications. The licensee. Pennsylvania Power & Light (PPL)-Company chartered internal investigations of these events.
The Confidential internal investigation reports were provided to 01.
OI was requested by the staff to review the relevant licensee reports on these matters and to. conduct an additional investigation, if warranted.
Status:
FWP ECO (90 days):
01/97.
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EXHIBIT
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CASEN0 1-96-039e
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