ML20216E094

Responds to Violations Noted in Insp Rept 50-346/98-02. Corrective actions:re-opened Valve Mu 38 & Referred to & Verified That Proper Actions Were Taken for Procedures DB-OP-06005 & DB-OP-02515 & Counseled Personnel Involved

ML20216E094
Person / Time
Site:	Davis Besse
Issue date:	04/09/1998
From:	Jeffery Wood CENTERIOR ENERGY
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
1-1153, 50-346-98-02, 50-346-98-2, NUDOCS 9804160086
Download: ML20216E094 (8)

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.lohn K. Wood 419-249-2300 Vice President - Nuclear far 419-321-8337 Docket Number 50-346 License Number NPF-3 Serial Number 1-1153 April 9, 1998 United States Nuclear Regulatory Commission Document Control Desk Washington, D. C. 20555-0001

Subject:

Response to Inspection Report Number 50-346/98002 (DRP)

Ladies and Gentlemen:

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Toledo Edison (TE) has received Inspection Repon Number 50-346/98002 (TE Log Number 1-3948) and the two enclosed Notices of Viohtion (NOV) which require a response.

The responses to the violations contained in IR98002 are provided in Attachment I to this letter .

The first NOV of the Inspection Report deals with failure to properly implement procedures at l the Davis-Besse Nuclear Power Station (DBNPS). The management of the DBNPS recognizes l the importance of the two occurrences associated with this violation and their potential impact on '

l plant safety and reliebility. As a result, the Potential Condition Adverse To Quality Reforts for l these oct ,rrences have been categorized within the corrective action process to receive increased

! management review and over-site, l

The management of the DBNPS continues to emphasize self-checking and verbal communications in the course of daily operations in an effort to prevent errors founded in human performance deficiencies. Emphasis on these strategies has been effective in reducing errors of the type identified in the violation examples. Although the first violation is based in part on deficient procedural implementation, the deviations resulted from non-intentional human errors.

Differentiation of human performance issues from a resultant procedural violation is necessary to i achieve continued improvement in the operation of the DBNPS.

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For the purposes of clarification relative to the first violation, the Inspection Report body j contained references to the inadvertent isolation of Reactor Coolant Pump seal injection. The  !

event cited involved inadvertent isolation of seal return. g

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9804160086 980409 PDR ADOCK 05000346 0 PDR

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Docket Number 50-346 License Number NPF-3 Serial Number 1-1153 Page 2 Should you have any questiccs or require additional information, please contact Mr. James L.

Freels, Manager - Regulatory Affairs, at (419) 321-8466. i l

Very truly yours, D L /laj enclosure cc: A. B. Beach, Regional Administrator, NRC Region III S. J. Campbell, DB-1 NRC Senior Resident Inspector A. G. Hansen, DB-1 NRC/NRR Project Manager Utility Radiological Safety Board 1

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,, Docket Number 50-346

, License Number NPF-3 Serial Number 1-1142 At,tachment i Page1 i

Reolv to a Notice of Violation (50-346/98002-01IDRP1) l Alleged Violation i I. Technical Specification 6.8.1 states, in pa:r, that written procedures be established, I implemented and maintained covering surveillance and test activities of safety-related equipment and that written procedures be established, implemented and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide (RG) 1.33, November,1972.

A. Technical Specification Surveillance Requirement 4.4.6.2.1.d states, in part, that a I reactor coolant system water inventory balance be performed at least once per 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady state operation.

Procedure DB-SP-03357, Revision 01,"RCS Water Inventory Balance," implements Technical Specification Surveillance Requirement 4.4.6.2.1.d. Step 4.1.10 of Procedure DB-SP-03357 requires that Demineralized Water Isolation Valve l DW-6831B be opened.

B. Appendix A of RG 1.33, November,1972, Section A.4, requires administrative i procedures for procedure adherence. Procedure NG-DB-00225," Procedure Use and I Adherence," implements RG 1.33, to establish and implement procedures covering adherence.

Step 6.8.1 of Procedure NG-DB-00225 requires, in part, that procedures be performed as numerically sequenced in the body of the procedure.

l Contrary to the above- l A. On January 6,1998, during performance of Procedure DB-SP-03357, Revision 01, i "RCS Water Inventory Balance," Step 4.1.10, a reactor operator erroneously closed Reactor Coolant Pump Seal Return Valve MU-38 instead of opening Demineralized Water Isolation Valve DW-6831B.

B. On February 11,1998, the licensee did not properly perform the sequence of steps in 1 Procedure DB-OP-06001, " Boron Concentration Control," in that a reactor operator failed to complete Step 3.5.18 to open Booster System Bypass Valve WC-3526 while performing Procedure Steps 3.5.17 through 3.5.19.

This is a Severity Level IV viola

• ion (Supplement 1).

I l D*o cket Number 50-346 l

l , License Number NPF-3 l

i Serial Number 1-1142 1 Attachment i Page 2 '

Reason for the Violation A. The valve MU 38 is the containment isolation valve for the Reactor Coolant Pump (RCP) seal return flow path. This violation involved the inadvertent isolation of the RCP seal return flow path. The reason for the wrong valve (MU38) being cycled during the performance of DB-SP-03357 was less than adequate work practices. The causal factor for this occurrence was that self-checking was not applied to ensure the correct component was being cycled. After reading the procedure, the Reactor Operator proceeded to the back Control Room panel with the intent of re-positioning l DW6831B. The switch for MU 38 is directly below the switch for DW 6831B on the back panel. Prior to performing the valve operation, the operator did not apply appropriate seif-checking techniques to verify performance of the correct procedural action.

During the course ofinvestigation of this occurrence, additional conditions were identified and are being addressed in the Davis-Besse Nuclear Power Station (DBNPS) I corrective action program. When the Reactor Operator realized that the wrong valve (MU 38) had been repositioned, he immediately re-opened the valve. The action to 1 re-open MU 38 was the correct operator action in DB-OP-02515, " Reactor Coolant l Pump and Motor Abnormal Procedure." However, this immediate action was inconsistent with management's expectations. Operational expectations in this case would be to identify the incorrect action, notify the Control Room Senior Reactor Operator, refer to the appropriate controlling procedure and take action as directed by the Control Room Senior Reactor Operator.

B. While placing Deborating Demin #2 in service to reduce Reactor Coolant System Boron Concentration, WC 3526, Booster System Bypass Valve was inadvertently left  ;

closed. This interrupted the flowpath from the Reactor Coolant System, resulting in  !

the lifting of Relief Valve MU 1890 and allowing approximately 30 gallons of Reactor

. Coolant System water to f'ow to the Reactor Coolant System Drain Tank. The reasons for this occurrence involve deficiencies in procedural guidance and inappropriate work  ;

practices. '

l There were two causal factors with regard to inappropriate work practices. The procedure DB-OP-06001 was not followed correctly. The licensed Reactor Operator failed to open WC 3526, Booster System Bypass Valve as required by procedure DB-OP-06001. The procedure being used by the operator had been previously used to perform a deboration, which is repeatedly performed over a period of approximately one month near the end of an operating cycle. Since the procedure copy had been previously used and signed off to perform a deboratiu, during a previous deboration, the step for opening WC 3526 had been signed off. The Reactor Operator had not added additional sign off lines or other place keeping measures to the procedure, and was not inidaling each step as he performed the step. The Control Room Senior Reactor Operator was unaware that a procedure was being re-used for that evolution.

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• ~ D'ocket Number 50-346 License Number NPF-3 Serial Number 1-1142 Attachment 1 Page 3 Re-use of the procedure eliminated the place keeping aid (step initials) that serves as a barrier for missing a step during performance.

The procedure DB OP-06001 was deficient in the formatting of a procedure step and the omission of relevant information from a caution statement. Direction for this evolution is contained in DB-OP-06001, Subsection 3.5, Deboration Using Deborating Demineralizers. The last step in this Subsection includes a step "WHEN processing is complete, TIJFE restore the Clean Radwaste System Lineups." Since additional processing using the Deborating Demineralizer was expected, this step was not performed and the procedure remained open. The Operators continued to re-use this procedure copy. This provided the conditions for the place keeping device (step initials) to not be available for the Reactor Operator in this event. The step directing opening WC 3526 had already been signed off during a previous performance. A caution statement was provided for step 3.5.17 and stated, "MU 40 shall be open prior to positioning MU 11 to the CLN WST position." This caution is intended to prevent lifting MU 1890, since MU 40 is in the Letdown Flowpath. This exact same condition is also applicable to WC 3526 as well. The caution does not provide information related to the required position for WC 3526. The Reactor Operator specifically remembered rechecking the position of MU 40 prior to placing MU 11 in the CLN l WST position based on this caution, but did not check the position of WC 3526.

1 Corrective Stens that have been Taken and Results Achieved A. After MU 38 was re-opened, DB-OP-06005, " Reactor Coolant Pump Operating Procedure" and DB-OP-02515, " Reactor Coolant Pump and Motor Abnormal Operating Procedure," were referred to and verified, by the operators, that the proper actions were taken. The RCP operating parameters were reviewed including temperature, seal retum flow, and seal cavity pressures. DB-OP-00000, " Conduct Of Operations," Attachment 7, for a component found out of its desired position was l completed. '

The individuals involved in the occurrence were counseled for the areas in which they demonstrated weaknesses. This counseling emphasized management expectations for procedure use practices.

B. The operator involved in this occurrence has been counseled by Operation's management regarding the expectations for procedure use and adherence. This counseling included performance of procedures in the proper step sequence.

The format deficiency within DB-OP-06001, step 3.5.25 was corrected by procedure alteration TA98-0418. Step 3.5.25 now r,ays,"IE no further Deborating Demineralizer processing is planned, THEN restxe Clean Radwaste System Lineups." This change allows the procedure subsection to be closed, while recognizing that further use of the deborating demineralizers has been planned. The Clean Radwaste System lineup can

I Docket Number 50-346

, License Number NPF-3 Serial Number 1-1142 Attachment I l Page 4 1 be left in the proper alignment for demineralizer use and will allow the procedure subsection to be closed.

The omission of relevant procedure information was also corrected by TA 98-0418.

l The caution for step 3.5.17 stated,"MU 40 shall be open prior to positioning MU 11 to l the CLN WST position." The caution has been altered and placed at step 3.5.20 by TA 98-0418. The new caution states "MU 40 and WC 3526 shall be open prior to I positioning MU 11 to the CLN WST position." The altered caution provides l information related to the required position for WC 3526 as well as MU 40.

! Corrective Steos that will be Taken to Avoid Further Violations )

l l A. Procedure implementation mistakes resulting from inadequate human performance have been dealt with both on an individual basis, with the Plant Operations shifts during shift turn-over and in Operator Requalification Training. Individual counseling has been completed for this occurrence. The weaknesses identified in the specific

! actions related to this occurrence will be discussed in Operator Requalification I

! Training and will be completed by Atgust 31,1998.

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( B. The procedure copy of DB-OP-06001 that was being used by the Reactor Operator had been previously used to perform a deboration. During a prior performance, the step for opening WC 3526 had been signed off. The re-use of this procedure l l eliminated the place keeping aid that serves as a barrier for skipping a step during performance. DB-OP-06001, Boron Concentration Control contains lines to be initialed by the operator as each step is performed. The procedures and policies l currently in place at the DBNPS do not provide guidance on the acceptability of re-

! using procedures for multiple performances of the same evolution. NG-DB-00225, Procedure Use and Adherence will be altered to provide direction for this situation.

This action will be completed by . August 31,1998.

Events involving operation of a wrong component have been infrequent at the DBNPS, l based on Plant Operations Section Performance Indicators. A review of Plant Operations Section Performance Indicators for 1996,1997 and 1998 o date was conducted for procedural use errors. The quarterly goals for each quarter of 1996, 1997 and the first quarter of 1998 have been met. Although procedure use events have previously occurred, none of the prior events involved reusing a procedure foi a repetitive evolution. This performance indicator demonstrates recent improvement in this area. In the first two quarters of 1997, six events occurred. In the last two quarters of 1997 and the first quarter of 1998, only two events have occurred, including this one. The current Plant Operations Initiatives for performance improvement are effectively reducing the number of events.

" Docket Number 50-346

, License Number NPF-3 Serial Number 1-1142 Attachment 1 Page 5 Date When Full Comoliance Will Be Achieved A. Full compliance was achieved on January 6, E ien the valve MU 38 was re-opened to re-establish seal return flow. This action was verified to be correct upon i review of the appropriate procedures.

B. Full compliance was achieved on February 11,1998 when the Reactor Operator re- {

opened the flow path from the Reactor Coolant System to the Makeup Tank which {

allowed relief valve MU 1890 to close.' The relief valve was also confirmed to be l closed per procedural guidance.

Reolv to a Notice of Violation (50-346/98002-03IDRP1)  ;

Alleged Violation l

II. 10 CFR 50.72 (b)(1)(ii)(B), "Non-Emergency Events - one hour reports," requires, in part. i that the licensee notify the NRC as soon as practical and in all cases within one hour of the occurrence of a condition that is outside the design basis of the plant.

Contrary to the above, on December 12,1997, the licensee did not notify the NRC within one hour of the discovery that the speed sensing circuitry for EDO #1, equipment required for safe shutdown of the plant dar:ng a postulated fire, was not designed in accordance with

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10 CFR Part 50, Appendix R, design criteria for hot shoit protection. The design deficiency l of the speed sensing circuit is a condition outside the des gn basis of the plant. )

l This is a Severity Level IV violation (Supplement 1).

Reason for the Violation Licensee Event Report (LER)97-015, " Emergency Diesel Generator Tachometer Circuit Outside  !

10 CFR 50 Appendix R Design Basis," submitted on January 12,1998, provided an apparent cause for this occurrence. The LER also discussed the delay in immedia'e notification reporting relative to this occurrence being outside the design basis of 10 CFR 50, Appendix R.

When this condition was identified in Potential Condition Adverse To Quality Report 97-1624 on December 12,1997, Technical Specification 3.3.3.5.2 was consulted, which specifies inoperable circuits must be restored to operable status within 30 days, or a Special report must be prepared and submitted. No other actions are required by this Technical Specification. The Shift Supervisor consulted vrith Plant Engineering staff personnel and the Fire Protection Coordinator about how the identified condition affected the Emergency Diesel Generator speed circuit during a hot short scenario. As a result of this discussion, the disconnect switch was considered inoperable and Technical Specification 3.3.3.5.2.b was entered.

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,. Ifocket Number 50-346

,. License Number NPF-3 Serial Number 1-1142 Attachment 1 Page 6 After further review, it was determined on December 18,1997, that the plant was being operated in a condition outside the design basis. It was believed that Technical Specification 3.3.3.5.2 applied to this condition due to the interpretation of the Technical Specification wording about l

control circuitry. Upon further review of this issue and upon review of License Amendment i Request (LAR)92-010 (TE Serial Number 2101, incorporated into the Technical Specifications under Amendment 187), it was realized that the term " control circuitry" only applied to components that would be enabled when a disconnect switch was repositioned to allow local control of associated equipment. Since the EDO 1 tachometer circuit was provided for indication purposes only and performed no control function for the EDG, Technical Specification 3.3.3.5.2 only applied to the ability of the disconnect switch to isolate the control room tachometer.

Corrective Steos that have been Taken and Results Achieved l Upon further evaluation of the condition described in PCAQR 97-1624, it was determined that the design requirements involving a hot short in the EDG 1 tachometer circuit were not being -

satisfied. Potential Condition Advers: to Quality Report 97-1658 was initiated which identified the proper reportability and completed the required one hour notification of the NRC. Corrective actions taken for the EDG tachometer circuit are described in LER 97-015.  !

Specific to not notifying the NRC within one hour of discovery in accordance with 10CFR50.72(b)(1)(ii)(B), training was conducted on the interface between the Technical Specifications and situations that represent conditions outside the design basis of the plant. This training was provided to Senior Operating Licensed personnel during Licensed Operator Requalification Training Cycle 98-01 which was completed on February 20,1998.

Corrective Steos that will be Taken to Avoid Further Violations Training will be conducted on the interface between Technical Specifications and situations that represent conditions outside the design basis of the plant for Regulatory Affairs - Compliance Unit personnel that are involved in reportability evaluations. This training will be completed by April 17,1998.

Date When Full Comoliance Will Be Achieved Full compliance was achieved at 1415 hours0.0164 days <br />0.393 hours <br />0.00234 weeks <br />5.384075e-4 months <br /> on December 18,1997 when the NRC was notified via the Emergency Notification System of this occurrence in accordance with 10CFR50.72(b)(1)(ii)(B).