ML20216J248
| ML20216J248 | |
| Person / Time | |
|---|---|
| Site: | Calvert Cliffs  |
| Issue date: | 09/11/1997 |
| From: | Cruse C BALTIMORE GAS & ELECTRIC CO. |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| 50-317-97-02, 50-317-97-03, 50-317-97-2, 50-317-97-3, 50-318-97-02, 50-318-97-03, 50-318-97-2, 50-318-97-3, NUDOCS 9709170203 | |
| Download: ML20216J248 (36) | |
Text
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Curutis II CuesE Baltimore Gas and Electric Company Vice President Calvert Cliffs Nuclear Power Plant Nuclear Energy 1650 Cahen Clif fs Parkway Lusby, Maryland 20657 410 495-4455 September 11,1997
)
g U. S. Nuclear Regulatory Commission Washington, DC 20555 A'ITENTION:
Mr. Jarnes Lieberman Director, Office of Enforcement
SUBJECT:
Calvert Cliffs Nuclear Power Plant E
Unit Nos.1 & 2; Docket Nos. 50-317 & 50-318 Reply to Notice of Violation -- Notice of Violation and Proposed Imposition of Civil Penalties - $176.000
REFERENCES:
(a)
Letter from Mr. II. J. Miller (NRC) to Mr. C.11. Cruse (BGE), dated August i1,1997, Notice of Violation and Proposed Imposition of Civil Penalties - $176,000 (NRC Inspection Reports Nos. 50-317/97-02 &
50-318/97-02;50-317/97-03 & 50-318/97-03) 7 (b)
Letter from Mr. C. H. Cruse (BGE) to NRC Document Control Desk, Q
dated April 25,1997, Action Plan to Resume Unit 2 Refueling h
(c)
Letter from Mr. C.11. Cruse (BGE) to Mr. L. T. Doerflein (NRC), dated May 9,1997, Request for Additional Information This letter provides Baltimore Gas and Electric Company's response to Reference (a). Your letter identified f
violations involving failure to etTectively control activities during a dive evolution conducted in the Calvert h
Cliffs Unit 2 Spent Fuel Pool, inadequate radiation protection controls, and inadequate fuel handling
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operations. These issues, their root causes, and corrective actions were discussed with the Nuclear k.
Regulatory Commission at an Enforcement Conference on June 12,1997. Each of the violations cited has P
been individually addressed as specified in the Enclosure to Reference (a). Individual responses to each of these violations are provided in Attachments (1) through (13). Also enclosed is Baltimore Gas and Electric e
Company Check No. 3109529 in the amount of $176.000, h
[b Safety is and will remain our number one priority at Calvert Cliffs Nuclear Power Plant. Failure to /
maintain positive control over the diver performing repairs on fuel handling equipment in the Spent Fuel Pool is a significant concern to us. The diver moved from the approved work area into an unsurveyed area k
of the Spent Fuel Pool. The unsurveyed area of the Spent Fuel Pool included specific localized areas where
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adiation fields were intense enough to constitute a very high r,diation area. Aller his radiation monitoring f-ll},'l[lf][((]l,[ll, i
9709170203 970911 4
PDR ADOCK 05000317 G
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Mr. James Lieberman September 11,1997 Page 2 equipment alarmed, the diver was directed to attempt to locate the source of the radiation. When his radiation monitoring indication began to increase, he was directed to leave the pool. Although the diver was not injured and received less than ten percent of the allowable federal limit for occupational exposure to radiation, control of the diver was inadequete to prevent his entry into an area of the Spent Fuel Pool that contained very high radiation area Delds.
We consider this event signiGcant and have declared it a Calvert Cliffs Nuclear Plant incident.
Declaration of an event as a Calvert Cliffs Nuclear Plant incident focuses management attention on the event and can also impact achievement of site goals and reduce employee incentive pay.
We have completed a root cause analysis for tNs event, and we hwe taken decisive steps to address the issues revealed by it. Specific corrective actions to control diving operations have been implemented.
Stricter controls over work performed in radiation areas in general and for dives in particular have been implemented. Procedures were revised to assure better control over the actions of divers in the Spent Fuel Pool. Positive controls are now in place to prevent madvertent access into very high radiation areas during radiological dives. Dosimetry enhancements have also been implemented for future dives in radiological Dives in radiation areas are now designated as infrequent Maintenance Evolutions. Infrequent areas.
Maintenance Evolutions are non-routine maintenance activities that if performed incorrectly could have a significant impact on personnel or nuclear safety. An Infrequent Maintenance Evolution requires establishment of clear leadership roles and enhanced supervisory oversite to ensure event-free results.
l Leadership training has been provided to site supervision and work leaders by senior plant management.
l This training was designed to sensitize supervisors to the event and emphasize single person ownership, setting and monitoring performance standards, exercising command and control, clear communications, and effectively managing change.
We did not initially realize the seriousness of this event as evidenced by allowing a subsequent dive to occur in the Spent Fuel Pool privr to fully understanding the root causes of the diver entering the unsurveyed area of the Spent Fuel Pool. We missed several opportunities to prevent the diver from moving out of the surveyed area. Actions leading to the dive and after the dive did not demonstrate a conservative approach to the conduct of plant activities, nor the appropriate responsibility for understanding the root causes of this significant event prior to proceeding with an additional dive in summary, this issue did not get the prompt and aggressive follow-up warranted when it first occurred.
Closer attention to detail, more precise communications, or conservative decision-making could have prevented this event.
There were two additional radiation safety events during our 1997 Refueling Outage that involved workers not following procedures and not paying attention to their work environment. In one case, the worker did not wear his personal radiation monitoring equipment while working in a high radiation area. In another case, workers erected a scaffold into an overhad area that had not been radiologically surveyed. Although these workers received only a small amount cIexposure, both events demonstrated an immediate need to reafGrm the site's emphe on personal respon;ibihty for radiation safety.
In response to these radiation safety events, we are restructuring the Radiation Protection Program to emphasize personal responsibility for radiation safety, as we successfully did with the sites indu: trial safety program. We conducted safety breaks to emphasize that Personal Safety equals Industrial Safety plus Radiation Safety. This includes ensuring that all site management feels accountable for radiation
's Mr. James Lieberman September 11,1997 Page 3 safety as opposed to placing the full responsibility for radiation safety on our Radiation Safety Section.
We detailed these actions, and others, in References (b) and (c).
The Nuclear Performance Assessment Department has conducted a thorough audit and review of our site Radiation Protection Program to validate performance of the program and identify any programmatic concerns. An independent review team, headed by the Chairman of our Plant Onerations and Safety Review Committee, provided input into the audit plan. This audit included an assessment of the following Radiation Protection Program elements: organization and administration, procedure adequacy and use, self-assessment, plant worker knowledge and ability, survey and count room equipment, personnel contamination controls, corrective actions, internal exposure, radiation protection worker knowledge, personnel dosimetry, and external exposure control. Although this audit determined that the Radiation Protection Program meets regulatory requirements, the following elements were determined to have limiting weaknesses. The elements, listed in order of perceived signincance are organization and administration, procedure adequacy and use, and self assessment.
Corrective actions for these weaknesses are being addressed via our Corrective Action process.
In addition, an Assessment Team led by an independent consultant is assessing our Radiation Protection Prop?m and corrective actions for the dive event. This team will present its findings to senior management.
Another significant concern to us is the physical condition of fuel handling equipment. There were several examples of failure to promptly identify and correct deficiencies with refueling equipment during defueling.
l These examples indicated inadequate ownership and control of fuel handling equipment and a lack of overall responsibility for refueling activities.
Among the improvements made following the fuel handibg violations was the implementation of a more aggressive maintenance program for fuel handling equipment, designation of the Superintendent-Nuclear Operations as the program owner for refueling activities, and designation of refueling as an infrequent evolution requiring additional management attention as prescribed in an established plant procedure, in addition, we are accelerating many of the previously approved upgrades to this equipment and have added refueling equipment into the scope of our Maintenance Rule program. In Septen,ber 1996, we implemented the new System Manager concept at Calvert Cliffs. The System Managers focus on a proactive approach to the long-term performance of plant equipment. We feel the implementation of the System Manager concept will minimize the potential for additional similar situations with other plant equipment.
We have considered the extent to which production pressure could be an underlying root cause for these events. Although Management's message to employees has consistently been that safety and quality will lead to effective production, and we have identified no production pressure from management, it is possible that employees are generating personal production pressure. We will assess how well management's message has been internalized down through the organization and take the appropriate actions to ensure that management expectations on safety are effectively implemented.
An additional common issue running through several of these violations is failure by supervision to successfully manage change. Refueling and outage activities ollen present workers and supervision with unanticipated situations, or confusing requirements. We recognized that factors creating potential for change must be controlled to insure that activities are conducted within existing requirements and standards.
During the recently completed site leadership training, senior plant management addressed with supervision
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N Mr. James Liebcrman September 11,1997 r ge4 this element of change management. This training focused on recognizing actual change or a potential for change that would cause deviation from established methods, processes, and standards.
Finally, prior to these events occurring, we recognized that human performance is an area that needs improvement. Leadership behaviors are not.s effective as they should be to achieve our goals and teamwork behaviors are not as effective as required for outstanding performance. We are currently in the planning stsges of our Perfonnance Through People opermional initiative. This site-wide initiative will focus on improving human performance by fully utilizing the talent, energy, and ideas of every worker and emphasizing effective leadership and teamwork qualities. We feel that this initiative can improve human perfonnance and reduce plant events.
I
'e e
Mr. James Li:bennan September 11,1997 Page 5 Should you have questions regarding this matter, we will be pleased to discuss them with you.
Very truly yours, p/
/
-f r s,o STATE OF MARYLAND
- TO WIT:
COUNTY OF CALVERT 1, Charles 11. Cruse, being duly sworn, state that I am Vice President, Nuclear Energy Division, Baltimore Gas and Electric Company (DGE), and that I am duly authorized to execute and Ole this response on behalf of BGE. To the best of my knowledge and belief, the statements contained in this document are true and correct. To the extent that these statements are not based on my personal knowledge, they are based upon information provided by other BGE employees and/or consultants. Such information has been reviewed in accordance with compan Igikcend I belie o be reliable.
N.AMAL
/
1 Subgeribpd and sworn before me, a Notary J'ublic in apd fqr the State of Mej!and and County of U1LLLdnLJ
,thislC day of ALnfI_ w ish.1997.
(-
WITNESS my Hand and Notarial Scal:
fall _4fJ b RLt D>
Notary Public My Commission Expires:
A 9
bate '
CllC/CDS/bjd Attachments
Enclosure:
BGE Check No. 3109529, $176,000, Payment of Civil Penalty cc:
Document Control Desk, NRC H. J. Miller, NRC R. S. Fleishman, Esquire Resident Inspector, NRC J. E. Silberg, Esquire R.1. McLean. DNR Director, Project Directorate I-1, NRC L II. Walter, PSC A. W. Dromerick, NRC
5 ATTACIIMENT (1)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50-317/(318)/97 02 AND 50-317(318)/97-03 VIOLATION 01012 1.A.
10 CFR 20.1602 requires that in addition to the requirements in 10 CFR 20.1601, the licensee shall institute additional measures to ensure that an individual is not able to gain unauthori:ed or inadvertent access to areas in which radiation levels could be encountered at 500 rods or more in an hour at one meterfrom a radiation source or any surface through which the radiation penetrates.
Contrary to the above. on April 3,1997, adequate measures were not provided to ensure that an individual uorking as a diver in the Unit 2 spentfuelpool was not able to gain unauthori:ed or inadvertent access to areas in which radiation levels could be encountered at 300 rads or more per hour. Specifically, while working in the Unit 2 spentfuelpool, a diver inadvertently accessed and uvrked in areas in which radiation levels could be encountered at 500 rads or more in an hour.
I.
ADMISSION OR DENIAL OF TIIE ALLEGED VIOLATION Baltimore Gas and Electric Company accepts the violation.
II.
REASONS FOR TIIE VIOLATION l
The three primary causes contributing to this event were:
l A.
Responsibility for positive control of diver movement was not clearly established.
B.
Clear overall control and leadership for dives in Radiologically Controlled Areas were not established.
C.
Communications were unclear and did not meet site expectations.
111. CORRECTIVE STFPS TIIAT IIAVE BEEN TAKEN AND RESULTS ACIIIEVED Site Radiation Safen ad Maintenance procedures were revised to include the following during future Radiologically Controih.d Area dive evolutions:
A.
Positive control of the diver's movement underwater and specific reasons (e.g., loss of visual contact with diver in the water) for immediate dive termination.
B.
Diving activities are defined as infrequent Maintenance Evolutions.
Infrequent Maintenance Evolutions are non-routine maintenance activities that if performed incorrectly could have a significant impact on personnel or nuclear safety. We require additional supervisory oversite to ensure event-free results for Infrequent Maintenance Evolutions.
C.
Leadership roles are clearly established.
D.
Team roles are clearly defined for all members participating in the dive 1
ATTACllMENT (1)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50 317(318)/97-03 VIOLATION 01012 E.
Radiation Safety roles are clearly established to ensure positive controls are in place to prevent access to high radiation areas.
F.
Communication methods are clearly defined.
G.
Monitoring of diver location is improved through the use of a dedicated camera system.
It Briefing criteria requirements must now be documented on a procedure checklist.
I.
Training requirements for all dive team members are defined.
J.
Maintenance pre-dive checklist is provided and must be completed prior to each dive.
K.
Walkdowns must be conducted by the dive team prior to the dive.
L.
Diver understanding of thejob scope and survey information is required to be documented.
1 M.
Improved survey maps / survey techniques have been developed for the Spent Fuel Pool.
N.
Dive area boundaries are required to be verified by the divers, Maintenance personnel, and Radiation Safety personnel.
O.
Diver training for use of undenvater radiation detection instrumentation is required to be conducted and verified.
P.
Radiation Safety pre-dive checklist is now required to be used.
We have conducted site-wide tailgate training on this event.
Leadership training has been provided to site supervisors and work leaders by senior plant management, iw v.her radiological dive activities have occurred at Calvert Cliffs since April 3,1997.
IV.
CORRECTIVE JNS TIIAT WILL HE TAKEN TO AVOID FURTHER VIOLATIONS A.
A dry run will be conducted to caluate the effectiveness of the revised procedures, use of a physical barrier, and identify and correct any deficiencies. When practical, physical barriers will be provided to prevent divers access to irradiated fuel elements and other high radiation items or areas. These barriers will be evaluated to compare safety benefits to any attendant dose increases, personnel safety risks, or other disadvantages.
J B.
Upgrade all radiological dive survey maps to show physical equipment and component layouts.
2
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ATTACilMENT (1)
NOTICE OF VIOLATION AND PitOPOSED IMPOSITION OF CIVIL PENALTY NI(C INSPECTION REPORTS NOS. 50-317/(318)/97-02 AND 50-317(318)/97-03 V!OLATION 01012 C,
Review other maintenance activities for any that should be considered Infrequent Maintenance Evolutions.
V.
DATE WIIEN FULL COMPLIANCE WILL HE AClllEVED Full compliance will be achieved with the successful completion of the diving evolution dry run and the resolution of any identified procedure deficiencies prior to the next radiological dive, Our next Spent Fuel Pool dive is currently scheduled for October 27, 1997 to peiform maintenance on refueling equipment.
3
's A'ITACilMENT (2)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50-317/(318)/97-02 AND 50-317(318)/97 G3 VIOLATION 01022 IB.
10 CFR 19.12 requires, in part, that all individuals working in or frequenting any portion of a restricted area be kept idormed of the storage, transfer, or use of radioactive materials or of radiation in suchportions ofthe restricted area l
Contrary to the above, on the morning ofApril 3,1997, the licensee did not adequately inform a diver, diving in the Unit 2 spentfuel storage pool, a restricted area. of the storage of radioactive maserials or of radiation in the spentfuelpool that the diver might encounter. Specifically, the instructions provided to the worker did not adequately provide the location of radiation surveys made to support the diver's uork in the south end of the spentfuelpool, did not adequately limit the scope of uwk performed by the diver commensurate with those radiation surveys, and did not instruct the diver as to the location ofirradiatedfuel assemblies. As a result, the diver movedfrom the dive area at the south end ofthe Unit 2 spentfuelpool(duat had been comprehensively surveyed and had been approvedfor work), traversed an unswieyedportion of the spentfuelpool, traveled to the north end ofthe spentfuel storage pool which had not been approvedfor entry, and entered high radiationfl: Ids caused by radiation emanatingfrom irradiated spentfuel elements.
1.
ADMISSION OR DENIAL OF TIIE AlITGED VIOLATION Baltimore Gas and Electric Company accepts the violation.
l 11.
REASONS FOR TIIE VIOLATION The three primary causes contributing to this event were:
A.
Communications were unclear and did not meet site expectations. In particular the pre-job brief was not effective.
B.
Clear overall control and leadership for dives in Radiologically Controlled Areas were not -
established.
C, Responsibility for positive control of the diver movement was not clearly established.
111. CORRECTIVE STEPS TIIAT IIAVE BEEN TAKEN AND RESULTS ACIIIEVED Site Radiation Safety and Maintenance Procedures were revised to include the following during future Radiologically Controlled Area dive evolutions:
A.
Pre-dive briefings are now required to include that the diver and the dive team are instructed in job scope, work locations, travel path, and diver movement protocol. Requirements for diving evolution pre-dive radiological briefings have been proceduralized and will be used during future dive activities.
B.
A documented review of the radiological survey map is now required to ensure that the dive team is aware of the limitations of the survey, locations of the spent fuel, irradiated and 1
b ATTACllMENT (2)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50-317/(318)/97-02 AND 50-317(318)/97-03 VIOLATION 01022 major pool components all boundaries and barricades, dive station, grid survey, and the entire pool area.
C.
A radiological verification briefing is now required to ensure all radiological protection instructions are clear and completely understood by the dive team.
D.
Radiation Safety pre-dive checklist is required to be completed prior to all diving evolutions.
E.
Maintenance pre-dive checklist is provided and must be completed prior to each dive.
F.
Diving activities are deilned as infrequent Maintenance Evolutions.
Infrequent Maintenance Evolutions are non-routine maintenance activities that if performed incorrectly could have a significant impact on personnel or nuclear safety. We require additional supervisory oversite to ensure event-free results for Infrequent Maintenance Evolutions.
l G.
Leadership roles are clearly established.
It Team roles are clearly defined for all members participating in the dive.
1.
Responsibility is defined for positive control of the diver's movement undenvater.
J.
Established procedures to ensure that the dive station is properly setup and all radiological postings, boundaries, barricades are established.
We have conducted site-wide tailgate training on this event.
Leadership training has been provided to site supervisors and work leaders by senior plant management.
No other radiological dive activities have occurred at Calvert Cliffs since April 3,1997.
I IV.
CORRECTIVE STEPS TIIAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS A.
All radiological dive survey maps will be upgraded to show physical equipment and component layouts.
B.
A dry run will be conducted to evaluate the effectiveness of the revised procedures, use of a physical barrier, and identify and correct any deficiencies.
s 2
(
l c
ATTACitMENT (2)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTV NRC INSPECTION REPORTS NOS. $0-317/(318)/97-02 AND 50-317(318)/97-03 VIOLATION 01022
. V.
DATE WilEN FULL COMPLIANCE WILL BE ACilIEVED Full compliance will be achieved with the successful completion of the diving evolution dry run and the resolution of any identified procedure deficiencies prior to the next radiological dive. Our next Spent Fuel Pool dive is currently scheduled for October 27, 1997 to perform maintenance on refueling equipment.
l 1
l 3
I.
t A1TACllMENT (3)
NOTICE OF VIOLA'llON AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(3181/97 02 AND $0 317(318)/97 03 YlOLATION 01032 4
- 1. C.
10 CFR 20.1301 requires, in part, that licensees make or cause to be inade surveys that may be necessary to comply with he regulations in 10 CFR Part 20 and are reasonable under the circumstances to evaluate the extent ofradiation levels and the potential radiological hasards that could be present. 10 CFR 20.1201 provides limitsfor occupational exposures, including exposure limits cf 30 rems (shallow dose) to the skin or any extremity and 3 rems to the whole boh (total effective dose),
i l
Contrary to the above, on April 3,1997, while the diver was supplied wl!h radiation surveying Instruments and multiple personal dosimetry devices capable of real thne indication, surveys
]
performed with these devices were inadequate to assure comp l lance with occupational dose limits in that: (1)the diver was not trained in the use and limitations of the radiation survey instruments; (2) the diverfailed to carry and use the survey instruments at all finses when he was i
in the smsurveyed portion of the spentfuel pool; (3) no personal radiation dosimetry real time measuring devices were sufficiently located to monitor exposure to the diver's lower extremities as he traversed the unsurveyedportion of the spentfuelpool: (4) the diver was directed to re enter an area having unknown radiation levels without any verification or evaluation of the potentialfor personnel exposure in excess of regulatory limits; and (3) upon discovery that the diver had been in an unsurveyed area in which there was high potentialfor personnel exposure in excess of regulatory limits, the individual was permitted to re enter radiologically controlled areas prior to evaluatingpersonnel dosimetry devicesfor exposure assessment.
J I.
ADA11SSION OR DENIAL OF Tile ALLEGED VIQLAllOE Baltimore Gas and Electric Company accepts the violation.
1
]
II.
REASONS FOR Tile VIOLATION The reasons for this violation were determined to be:
A.
An inadequate pre job brienng and an assumption that the diver had the necessary technical qualincations for radiological work, based on his previous experience of diving in Spent Fuel Pools at other facilities. The diver was not formally trained in the use of the radiation detection instrumentation while at Calvert Cliffs Nuclear Power Plant.
D.
Positive control over the diver was not maintained. The diver brieny placed the radiation detection probe on the pool Door without the Radiation Safety Technician's concurrence or awareness.
C.
The special work permit and job coverage standard for the diving evolution did not require the use of real time monitoring on the diver's lower extremities.
a D,
- There was no specine requirement for immediate dive tennination if unusual radiological conditions were encountered.
i 1
\\
ATTACIIMENT (3)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENAL /rY NRC INSPECTION REPORTS NOS. 50-317/(3t8)/97 02 AND 50-317(318)/97-03 VIOLATION 01032 E.
There was no procedural guidance requiring the evaluation of an individual's dosimetry devices, in which there was a high potentini for personnel exposure in excess of regulatory limits, before permitting re-entry into Radiologically Controlled Areas.
Ill. C.ORRECTIVE STEPS TJ1AT llAVE llEEN TAlG2 LAND RESULTS ACillEVEI)
The Site's Radiation Safety and Maintenance Procedures have been revised to specify the following:
A.
Training will be required for the dive team on the use, proper survey techniques, and limitations of teledosimetry and radiation detection instrumentation prior to the diving evolution.
D.
A requirement for location of the diver's dosimetry for diving evolutions, including real.
I time extremity monitoring.
C.
A requirement for direct reading dosimetry to be employed when special dosimetry (thermoluminescent dosimeters) is used.
D.
Positive control of the diver's movement undenvater and specine reasons (e.g., unusual or unexpected radiation levels are encountered) for immediate dive termination.
E.
An evaluation of an individual's special dosimetry devices will be required to be conoucted prior to permitting re entry to a Radiologically Controlled Area.
Leadership training has been provided to site supervisors and work leaders by senior plant management.
No other radiological dive activities have occurred at Calvert Cliffs since April 3,1997.
IV.
CORRECTIVE STEPS TilAT WILL Bl' TAKEN TO AVOID FURTilER YlOLATIONS A dry nm will be conducted to evaluate the effectiveness of the revised procedures and to identify and correct any deficiencies. This activity will include training and operation of the radiation detection instrumentation.
V.
DATE WilEN FULL COMPLIANCE WILL HE ACIIIEVED Full compliance will be achieved with the successful completion of the diving evolution dry nm and the resolution of any identified procedure deficiencies prior to the next radiological dive. Our next Spent Fuel Pool dive is currently scheduled for October 27, 1997 to perform maintenance on refueling equipment.
2
1 e
ATTACllhlFNT (4)
NOTICE OF YlOLATION AND PROPOSED ISIPOSITION OF CIVIL PENALTY s
NRC INSPECTION RI: PORTS NOS. 50 317/(318)/97 02 AND 50 317(318)/97 03 VIOLATION 02014 ll.A. Technical &>ccylcation 6.4.1, " Procedures", requires, in part, that the licensee establish, implement.
and rnalntain the applicable procedures recommended in Appendit A of Regulatory Guide 1.33.
Revision 2, February 1978 Appendit A of Regulatory Guide 1.33 recommends, in Section 7.e.,
" Radiation Protection Procedures", that procedures be establishedfor access control to radiation areas.
1.
Licensee radiation protection procedure RSP l 104, " Area Posting and llarricading" Revision 10, requires in Section 6J, %cked High Radiation Area", that areas exhibiting radiation levels in excess of1000 millirem at 30 centimeters from the radiction source be provided with a locked barrier or ensure that the area is provided with continuous direct or electronic surveillance capable ofpreventing unauthorised entry.
Contrary to the above, on February 16,1997, areas inside the Unit 2 Containment exhibited radiation levels greater than 1000 millirem at 30 centimeters, and at the time, the access door (Unit 2 Emergency Airlock door) was not locked. and the area was not provided with continuous direct or electronic surveillance capable ofpreventing unauthorised entry.
I.
ADMISSION OR DENIAL OF TIIE ALLi'GED VIOLATION llattimore Gas and Electric Company accepts the violation.
11.
REASONS FOR Tile VIOLATION There was unclear understanding regarding the use of the locking mechanism on the emergency air lock (EAL) vestibule door. A decision was made by the Radiation Safety Technicians involved, to leave the EAL unlocked since security maintains the EAL vestibule doors locked. "The procedural guidance r.nd f
f requirementn were inconsistent and did not adequately define actions necessary to maintain contrn' of the
- EAL, in addition, on August 7,1997, a Radiation Safety Technician failed to correctly install the high radiation area padlock on the Unit 2 EAL vestibule door for approximately four hours. This violation was due to personnel :rror.
111. CORRECTIVE STEPS TilAT llAVE BEEN TAKEN AND RESULTS AClllEVED A.
Upon discovery, the EAL was immediately secured with a high radiailon area padlock in both instances.
B.
Radiation Safety Technicians have been trained on the EAL locking requirements, the specific issue Reports generated as a result of this issue, causal factors, and corrective actions.
C.
The appropriate personnel actions were taken.
D.
Subsequent to the February 16, 1997 event described above, the site procedure for Containment entry was revised to document the installation and verification oflocking devices 1
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_A
e ATTACllMENT (4)
NOTICE OF YlOLATION AND PROPOSED IMPOSITION OF ClYlb PENA 111T NRC INSPECTION REPORTS NOS. 50-317/(318)/97 02 AND 50 317(31N)/97 03 VIOLATION 02014 on the EAL On August 13,1997, this procedure was revised to require a second check verification that the high radiation area padlock on the EAL vestibule door has been re installed.
l IV. CI)RRECTIVP STEI'S TIIAT WILL llE TAKEN TO AVOID FURT((ER I
VIOLATIONS A.
A new style locking device will be installed on the EAL vestibule door to provide unfettered i
egress, yet prohibit unauthorized access to the EAL.
l 11.
Site procedures are being evaluated to credit the use of the security lock for providing positive access control for the EAL.
C.
A root cause investigation will be completed to evaluate the August 7,1997 event (Unit 2 EAL). As a result of this review, additional corrective action will be taken, as appropriate.
Y, DATE WilEN FULL COMI'LIANCE WILL llE AClllEVED Full compliance was achieved on February 16,1997 and on August 7,1997, when the Unit 2 EAL was properly locked.
2
ATTACllMENT (5)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENAllrY NRC INSPECTION REPORTS NOS. 50-317/(318)/97 02 AND 50 317(318)/97 03 VIOLATION 03014 II.A. Technical Spec @ cation 6.4.1, " Procedures", requires, in jurt, that the licensee establish, implement, 1
and rnalntain the applicable procedures reconunended in Appendis A of Regulatory Guide 1.33, Revision 2, February 1978. Appendit A of Regulatory Guide 1.33 recommends, in Section 7.e.,
" Radiation Protection Procedures", that procedures be establishedfor access control to radiation areas.
2.
Licensee procedure RP.J 100, " Radiation Protection," states that a high radiation area shall be posted with a sign stating " Caution: liigh Radiation Area," and that entry into the area mshales a requirementfor dosimetry. Procedure RP.I.100 also defines a high radiation area as any area accessible to personnel in which radiation levels cotdd result in an individual receiving a dose in excess of100 millirem in one hour, Contrary to the above, on 3fmc 1,1997, a plant worker entered and uvrked in the Unit 2 n.
reactor coolant pump bm', which is posted as a high radiation area. with no dosimetry.
I.
ADMISSION OR DENIAL OF Tile ALLEGED VIOLATION Baltimore Gas and Electric Company accepts the violation.
II.
REASONS FOR Tile VIOLATION
'the reasons for this violation were determined to be as follows:
A.
l' allure of the plant worker to perform a self check to ensure he had his proper dosimetry.
11.
Inconsistent monitoring of radiation workers by Radiation Safety Technicians led to the plant worker not being challenged prior to entry into the Containment without his dosimetry.
Ill. CORRECTIVE STEl S TilAT IIAVE IlEEN TAKEN AND RESULTS ACIIIEVED Our letter from Mr. C. II. Cruse (Baltimore Gas and Electric Company) to Mr. L. T. Doerflein (Nuclear Regulatory Commission), dated May 9,1997, described the immediate and interim corrective actions for this violation.
A.
The plant worker (Baltimore Gas and Electric Company employec) was removed from the Radiologically Controlled Area and his access to the area was temprarily suspended. A dose assessment of the event was completed.
B.
The Plant General Manager stopped all work in high radiation areas. Plant General Manager atthorization was required to resume work in high radiation areas.
C.
A Iluman Performance Enhancement System evaluation was performed to identify the causal factors that contributed to this event.
I
ATTACilMENT (5)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50-317/(31N)/97-02 AND $0-317(318)/97 03 VIOLATION 03014 D.
Increased radiation safety supervisory oversite coverage was provided during non normal working hours for the duration of the 1997 Refueling Outage.
E.
Additional enntrols were added to an established site Radiation Safety procedure. The controls consisted of the implementation of checklists for routine access verification prior to l
personnel entry into Radiologically Controlled Areas, Containment, and high radiation areas. Approprice radiation safety and contractor personnel were trained on the procedural changes.
F.
The Plant General Manager authorized the resumption of work in high radiation areas on May 1,1997 upon implementation ofinterim corrective actions.
G.
The Plant General Manager issued a memorandum (dated May 1,1997), with the access verification checklists attached, to all Calvert Cliffs Site Supervisors directing them to promptly discuss these checklists with their personnel to ensure they understand and comply with the new requirements for working in Radiologically Controlled Areas.
II.
The Nuclear Performance Assessment Depanment has conducted a thorough audit and review of our site Radiation Protection Program to validate performance of the program and identify any programmatic concerns. An independent review team, headed by the Chairman of our Plant Operations and Safety Review Committee, provided input into the audit plan.
This audit included an assessment of the following Radiation Protection Program elements:
organization and administration, procedure adequacy and use, self assessment, plant worker knowledge and ability, survey and count room equipment, personnel contamination controls, corrective actions, internal exposure, radiation protection worker knowledge, personnel dosimetry, and external exposure control. Although this audit determined that the Radiation Protection Program meets regulatory requirements, the following elements were determined to have limiting weaknesses. The elements, listed in order of perceived significance are organization and administration, procedure adequacy and use, and self-assessment. Corrective actions for these weaknesses are being addressed via our Corrective Action process.
There have been no additional similar events, since May 1,1997, involving entry into a high radiation area without the proper dosimetry.
IV. CORRECTIVE STEPS TIIAT WILL HE TAKEN TO AVOID FURTIIER VIOLATIONS A.
This event contributed to a realization that a comprehensive assessment of the Radiation Safety Program was warranted. Site and Radiation Safety procedures are being evaluated, organizational processes reviewed, and ownership of various elements of the Radiation Protection Program determined. Final corrective actions that result from our ongoing investigation and analysis of the events will be implemented, as appropriate.
2
NITACitMENT (5)
NOTICE OF VIOLATION AND PROPOSED thlPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50-317/(318)/97 02 AND 50 317(318)/97 03 VIOLA 110N 03014 B.
In addition, an independent Assessment Team led by an independent consultant will be assessing our Radiation Protection Program.
V.
- 1) ATE WilEN FULL CO31PLIANCE WILL llE ACIllEVEI)
Full compliance was achieved on May 1,1997, upon implementation of the immediate and interim corrective actions, t
i I
3
?
ATTACithlENT (6)
NOTICE OF VIOLATION AND PROPOSED IhlPOSITION OF CIVIL PENALTY NRC INSPECTION HEPORTS NOS. 50 317/(318)/97 02 AND 50-317(318)/97 03 i
VIOLATION 04014 ll.A. TechnicalSpec{fication U.1, " Procedures", requires, in part, that the licensee establish. Implement.
and maintain the applicable procedures recommended in Appendit A of Regulatory Guide 1.33 Revision 2 February 1978. Appendis A of Regulatory Guide L33 reconunends, in Section 7.e.,
" Radiation Protection Procedures", that procedures be establishedfor access control to radiation areas.
2.
Licensee procedure RP.I 100, " Radiation Protection. " states that a high radiation area shall be posted seith a sign stating " Caution: High Radiation Area." and that entry into the area inchides a requirementfor dosimetry. Procedure RP l.100 also defines a high radiation area as any area accessible to personnel in which radiation levels could result in an Individual receiving a dose in excess of100 millirem in one hour.
b.
Contrary to the above, on May.I,1997, plant workers erected scafalding into an area of appratimately 300 milliremper hour that was notposted as a high radiation area 1.
ADMISSION OR DENIAL OF TIIE AlIIGED VIOLATION Daltimore Gas and Electric Company accepts the violation.
II.
REASONS FOR Tile VIOLATION The reasons for this violation were:
A.
The failure to use good judgment and conservative decision making when determining if another survey was necessary prior to erection of the next tier of scaffold.
D.
Failure to follow a radiation safety procedu e concerning the performance of necessary surveys. Therefore, no liigh Radiation Area sign was posted as required.
111. CORRECTIVE STEPS TJIAT IIAVE IlEEN TAKEN AND RESULTS ACillEVED Our letter from Mr. C.11. Cruse (Baltimore Gas and Electric Company) to Mr. L. T. Doerflein (Nuclear Regulatory Commission), dated May 9,1997, described the immediate and interim corrective actions for this violation.
A.
The workers (contractor employees) were removed from the Radiologically Controlled Area and their access to the area was suspended while a dose assessment of the event was performed.
D.
A radiation survey of the work location (top platform of scaffold) was conducted.
C.
The Plant General Manager stopped all work inside the Radiologically Controlled Area, with exception of work necessary to support safe operation of Unit 1.
1
I NITACllMENT (6)
NOTICE OF YlOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50 317(318)/97-03 VIOLATION 04014 D.
A Iluman Performance Enhancement System evaluation was conducted to identify the causal factors that contributed to this event.
E.
Electronic personal dosimeter alarm setpoint limits were changed from 99 mrem / hour to 80 mrem / hour or less for non high radiation areas work permits.
F.
The source of the radiation in this case was a section of a resin transfer pipe in the overhead.
An informational posting was put in place identifying this section of the pipe as a potential l
source of high radiation.
G.
The General Supervisor Radiation Safety implemented controls for the restart of work in the Radiologically Controlled Area in a memorandum to Radiation Safety supervision, and briefed the appropriate Radiation Safety personnel on these controls, the event, and conservative decision making. With these controls ir, place and necessary brienngs conducted, the Plant General Manager authorized resumption of limited work in the Radiologically Controlled Area.
11.
Appropriate personnel action was taken.
1.
The Nuclear Performance Assessment Department has conducted a thorough audit and
[
review of our site Radiation Protection Program to validate performance of the program and identify any programmatic concerns. An independent review team, headed by the Chairman i
of our Plant Operations and Safety Review Committee, provided input into the audit plan.
This audit included an assessment of the following Radiation Protection Program elements:
organization and administration, procedure adequacy and use, self assessment, plant worker knowledge and ability, survey and count room equipment, personnel contamination controls, corrective actions, internal exposure, radiation protection worker knowledge, personnel dosimetry, and external exposure control. Although this audit determined that the Radiation Protection Program meets regulatory requirements, the following elements were detennined to have limiting weaknesses. The elements, listed in order of perceived signincance are organization and administration, procedure adequacy and use, and self-assessment. Corrective actiw or these weaknesses are being addressed via our Corrective r
Action process.
Here have been no similar events, since May 4,1997, involving entry into a high radiation area due to inadequate surveys and postings.
IV.
CORRECTIVE STEPS TIIAT WILL HE TAKEN TO AVOID FURTilER VIOLATIONS A.
This event contributed to a realization that a comprehensive assessment of the Radiation Safety Program was warranted. Site and Radiation Safety procedures are being evaluated, organizational processes reviewed, and ownership of various elements of the Radiation 2
ATTACllMENT (6)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTV NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50 317(318)/97 03 VIOLATION 04014 l
Protection Program determined. Final corrective actions that result from our ongoing investigation and analysis of the events will be implemented, as appropriate.
B.
In addition, an independent Assessment Team led by an independent consultant will be assessing our Radiation Protection Program.
V.
DATE WilEN FULL COMPLIANCE WILL HE.ACElEVED Full compliance was achieved on May 6,1997, upon implementation of the immediate and interim l
corrective actions.
3
.- - ~_
'e o,
ATTACllMENT (7)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIYil PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50-_317(318)/97-03 VIOLATION 05014 ll.B. 10 CFR Part 33, Appendix B, Criterion l', " Instruction, Procedures, Drawings," states that activities afecting quality shall be prescribed byprocedures and shall be accomplished in accordance with the procedures.
10 CFR Part 30. Appendit B, Criterion 11. " Quality Assurance Program," states that applicants studl identify the major organi:ations subject to the requirements of Appendit B through the Quality Assurance Program. Baltimore Gas and Electric Quality Assurance Polky, Revision 47, dated October 18,1996, states the Plant General Manager is responsiblefor the radiation sqfety and also for directing investigations ofsignificant events to determine the root cause andfor recommending corrective actions. lhe Polley statrs the issues Assessment Unit reviews issue reports, and aufgns follow-up actions, under Ihe direction ofthe Plant General Man:.ger.
Procedure No. QL-2100, Revision 3, " Issue Reporting and Assessment", provides that an issue report be taed to document an actual or suspected condition adverse to quality or a sigmficant condition adverse to quality and provides a methodfor notl& lng afected groups and initiating corrective actions. Further, Section 4. 7, spectfles that reviewing supervisors ernure issue reports are received by the issues assessment unit group within three uvrking days ofbeing initiated.
Contrary to the above, in February 1997, issue reports were writtenfor a high radiation area access control concern and a safety concern associated with locking and control of Unit 2 containment emergency airlocks. The reviewing rupervisor was aware of the issue reports: however, neither report was provided to the issues Assessment Grouppr cmac and corrective action determination.
1.
ADMISSION OR DENIAL OF Tile AlI EGED VIOLATION Baltimore Gas and Electric Company accepts the violation.
11.
REASONS FOR Tile VIOLATION A.
A single human error most likely caused misfiling or loss of both issue reports, it is not known why these issue Reports were misplaced or lost since the originals were never found.
B.
A possible contributing factor is that issue Reports are no longer a distinctive color, issue Reports originally had a red border to make them stand out. The issue Reports with colored -
borders are being phased out and replaced with black and white issue Reports it is possible that the original Issue Reports were mistakenly thought to be only a copy of the original and were filed or recycled.
III. CORRECTIVE STEPS TilAT IIAVE HEEN TAKEN AND RESULTS ACIIIEVED A.
PM! don Safety proceeded with corrective actions for the issue Reports that were lost even i
.nough the issue Reports were not received by the issues Assessment Unit (IAU).
1
4 ATTACllMENT (7)
NOTICE OF YlOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND $0-317(31N)/97 03 VIOLATION 05014 11.
Corrective actions completed by Radiation Safety to ensure that issue Repotis are received in I AU within three working days are as follows:
1, The General Supervisor Radiation Safety Section established and :ommunicated clear expectations identifying the actions aral responsibilities of the issue report initiator, issue report reviewing supervisor, and individual unit clerks.
2.
Training was provided to Radiation Safety personnel on the Corrective Action process.
C.
A site wide search was conducted by lAU to see if other issue Reports might have been misplaced. Five additional issue Reports were identified as misplaced or lost in 1997.
Corrective Actions for these issue Reports continued even though a copy of tie issue Report or the original was not received by lAU in a prompt manner. In each case 4.he Reviewing Supervisor or the issue Report Initiator pursued the issue for cause and coTective action determination.
1.
Two issue Reports were inadvertently attached to Personnel Contamination incident reports but were later tumed in to I AU.
2.
Two issue Reports were misplaced after being signed by the Operation's Shill Supervisor. Follow up by the issue Report initiators resulted in copies of the issue Reports being sent to I AU, 3.
One hardware (non programmatic) Issue Report was misplaced after the equipment was repaired under a Rover Maintenance Order. Follow up by the issue Report initiator resulted in a new issue Report being written to document the hardware failure.
IV.
CORRECTIVE STEPS TIlAT WILL llE TAKEN TO AVOID FUJITlIER VIOLATIONS A.
The Plant General Manager will communicate to all site supervisors, his expectations for promptly transmitting issue Reports to I AU.
1.
_ Training will be provided to site personnel on this expectation.
2.
The issues Assessment Unit will monitor the implementation of the Plant General Manager's expectations and will provide periodic performance reports to Plant Management.
B.
The issues Assessment Unit will evaluate changing the color or other characteristics of issue Reports to make them more distinctive.
2
A1TACilhlENT (7)
NOTICE OF VIOLATION ANI) PROPOSED IhlPOSITION OF CIVIL PENALTV NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50 317(318)/97-03 VIOLATION 05014 V.
DATE.WilEN FULL COhiPUANCE WILL HE ACillEVEI)
Full compliance will be achieved upon co.npletion of Paragraph IV.A above by December 15,1997.
l l
3
\\
A'ITACitMENT (N)
NOTICE OF VIOLATION AND PROPOSEI) IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND 50 317(318)/97 03 VIOLATION 06014 Ill.A. 10 CFR Part 30. Appendh B, Criterion Xi'l, " Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such asfailures, deficiencies, defective equipment, and noncoriformances are promptly ident$cd and corrected in the case of signWeant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to prechtde repetition. The ident$ cation of the condition adverse to quality, the cause of the condition, and the corrective action taken shall be dxuwnted and reported to appropriate levels ofmanagement.
10 CFR Part 30, Appendix B, Criterion 11, " Quality Assurance Program," requires that applicants establish in their Quality Assurance Programs those structures, systems, and components which are to be subject to the requirements of Appendix B. Baltimore Gas and Electric Quality Assurance Policy, Revision 47, dated October 18, 1996, states that systems and components subject to the requirements ofthe Quality Assurance Policy are spec @ed on a Quality List (Q-List). All refueling equ;, ument is specyled on the Q-List.
Contrary to the above, c: of Alarch 30,1997, the licensee's actions to identify and correct certain conditions adverse to qtudity were inadequate to prechtde the numerous and repeatedproblems with refueling equipment during defueling of Calvert Chffs Unit 2 in Afarch 1997, as evidenced by the following examples, each of which is a separate violation:
1.
On Alarch 28, 1997, a missing capscrewfor a limit switch actuating magnet had not been identifiedduringpreparationsfor spentfuel handling activities. Subsequently, the loose magnet became dislodged and caused the fuel transfer carriage carrying a spent fuel assembly to become stuck in thefuel transfer tube.
1.
ADMISSION OR DENIAL OF Tile ALLEGED VIOLATION Baltimore Gas and Electric Company accepts the violation.
II..
REASONS FOR TIIE VIOLATION A.
A 1989 moditication to install the limit switch actuating magnets was not performed properly, allowing the magnets to interfere with the travel of the Unit 2 fuel transfer carriage into the Spent Fuel Pool upender, The problems with the modification included improper sizing and placement of the magnets on the upender and improper lockwiring of the retaining capscrews. In addition, the documentation of the magnet orientation on the carriage was insofficient to allow comparison with vendor design documents to verify adequacy of the installation or to permit t'mely troubleshooting of the equipment when problems were experienced in 1997.
B.
There was no program for performing comprehensive video or diver inspections of the fuel transfer equipment prior to use during a refueling outage to verify material readiness.
I
ATTACilMENT (8)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND 50 317(318)/97 03 VIOLATION 06014 111. CORRECTIVE STEPS THAT llAVE IIEEN TAKEN AND RESULTS AC111EVED A.
The Unit 2 fuel transfer machine limit switch actuating magnets have been replaced with a new design that will not interfere with carriage travel. 'Ihe design does not incorporate the use oflockwire. All lockwire on the Unit 2 fuel transfer machine has been inspected by a diver and repaired or replaced as necessary. The divers were given training on proper lockwiring skills.
It The current Cahert Cliffs Engineering Service Process Overview (EN 1 100) would not allow the limit switch modification to have been implemented as it was in 1989.
For example, EN.I 100 requires the use of Deld measurements as input to modi 0 cations if, as it was in this case, the drawings do not supply sufficient detail, if it is not possible to obtain measurements beforehand, then information must be confirmed during installation to assure proper dimensions, if the design dimensions are incompatible with the field measurements, the package must be returned to Design. In contrast, the procedure used for i
this modification in the late 1980's (Cr! vert Cliffs Instruction 126) allowed non safety related modifications such as this one to be installed under very general engineering guidelines with the details worked-out in the field. Drawings were then developed based on the as built configuration of the equipment in=talled in the plant.
IV. CORRECTIVE STEPS TIIAT WILI llE TAKEN T O __ A V O ID FURTilER Y10LATIONS A.
The Unit i fuel transfer machine limit switch magnets will be replaced prior to fuel movement during the upcoming Unit 1 1998 Refueling Outage.
t B.
A procedure will be developed that will require a comprehensive video or diver inspection of refueling equipment prior to each refueling outage.
V.
DATE WilEN FULL COMPLIANCE WILL llE ACillEVED Full compliance will be achieved prior to fuel movement for the Unit i 1998 Refueling Outage. At that time, the Unit I fuel transfer machine limit switches will be replaced and inspections of the refueling equipment will be complete.
2 m
's ATTACilMENT (9)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND 50 317(318)/97-03 VIOLATION 07014 Ill.A. 10 CFR Part 30, Appendh B, Criterion Xil, " Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such asfailures, deficiencies, defective 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 stermined and e rrectke action taken to prechtde repetition. The identification of the condition adverse to quahty, the cause of the condition, and the corrective action taken shall be documented and reported
\\
to ap;>ropriate levels ofmanagement.
10 CFR Part 30, Appendix B, Criterion 11, " Quality Assurance Program " requires that applicants establish in their Quality Assurance Progrants those structures, systems, and components which are to be sullect to the requirements of Appendix D. Baltimore Gas and Electric Quality Assurance t
Policy, Revision.I7, dated October 18, 1996, states that systents and components subject to the requirements of the Quality Assurance Policy are spectfled on a Quality List (Q List). All refueling equipment is spectfled on the Q-List.
Contrary to the above, as of Afarch 30,1997, the licensce's actions to identify and correct certain conilitions adverse to quality u ere inadequate to prechide the numerous and repeatedproblems with refueling equipment during d< fueling of Calvert Cll((s Unit 2 in Afarch 1997, as evidenced by the following examples, each of uhich is a separate violation:
2.
On Afarch 28, I997, after the stuckfuel assembly was removedfrom thefuel transfer carriage, but prior to completing defueling, metallic debris u as identified in the carriage arul noted in the refueling log; however, an evaluallon of the debris was not done, and the problem was not reported to management.
I.
ADA11SSION OR DENIAL OF TIIE AlIIGED VIOLATION llaltimore Gas and Electric Company accepts the violation.
11.
REASONS FOR Tile VIOLATION A.
This issue was noted on the Nuclear Fuel Management Refueling Log, but was not documented on an issue Report as required by issue Reporting and Assessment, QL-24100, Neither the Nuclear Fuel Management shift engineer nor the reviewing supervisor identified this issue as a potential condition adverse to quality that needed to be documented on an issue Repon.
D.
We under estimated the potential significance of this observation and, therefore, did not write an Issue Report in this instance. Even though no issue Repon was initiated, the log entry was made to ensure the issue was not dropped.
I c
NITACilhlENT (9)
NOTICE OF VIOLATION AND PROPOSED IhlPOSITION OF CIYll PENALTV NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50 317(318)/97 03 VIOLATION 07014 III. CORRECTIVE STEPS TilAT IIAVE BEEN TAKEN AND RESULTS ACIIIEVED We interviewed the person w ho made the log entry, performed walkdowns, and reviewed the video tapes that had been taken of the fuel transfer carriage at the same approximate time the log entry was made.
No evidence of any metallic debris was found.
IV.
CORRECTIVE STEPS TIIAT WILL BE TAKEN TO AVOID FURTIIER VIOLATIONS A.
The Principal Engineer Nuclear Fuel Management will establish and communicate expectations for evaluating refueling log entries for issues that require issue Reports.
D.
The supervisory review of the Nuclear Fuel Management Refueling Log will ensure that the appropriate threshold for initiating issue Reports required by QL 2100 is being met.
C.
We have developed a new training program concerning QL 2100. This training program will be administered as " top down" training starting with plant management and downward through the site organizations. 'llis training will include examples of some past failures to prepare issue reports, including the failure to document several degraded and non-conforming conditions noted in the Nuclear Fuel Management Refueling Log on issue Reports.
V.
DATE WilEN FULL COMPLIANCE WILL BE ACIIIEVED Full compliance will be achieved upon completion of actions to implement the training described in 4
Paragraph IV.C above. We expect this training to be complete sometime near the end of 1997.
4 4
t f
2
ATTACllMENT (10)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND 50 317(318)/97 03 VIOLATION 08014 IILA. 10 CFR Part 50, Appendit B, Criterion X11, " Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such asfailures, deficiencies, defective equipment, and nonconformances are promptly identified and corrected in the case of significant conditions adverse to quality, the meawres shallassure that the cause of the condition is determined and corrective action taken to prechade repetition. The identification of the condition adverse to quality, the cause ofthe condition, and the corrective action taken shall be documented and reported to appropriate levels ofmanagement.
10 CFR Part 50, Appendix B Criterion 11, " Quality Assurance Program." requires that applicants estabihh in their Quality Assurance Programs those structures, systems, and components uhich are to b.= subject to the requirements of Appendit B. Baltimore Gas and Electric Quality Assurance Policy, Revision 47, dated October 18, 1996, states that systems and components subject to the requirements of the Quality Assurance Policy are specified on a Quality List (G-List). All refueling equipment is specified on the Q-List.
Contrary to the above, as of Afarch 30,1997, the licensee's actions to identify and correct certain conditions adverse to quality were inadequate to preclude the numerous and repeatedproblems with refueling equipment during defueling of Calvert Chffs Unit 2 in Afarch 1997, as evidenced by the following examples, each of which is a separate violation:
3.
On Afarch 28,1997, during initialfuel moves in the spentfuel pool, a grapple closed light remainedlit when the grapple open light was lit,' however, fuel movement continued without an evaluation ofthe cause or the corrective actions.
1.
ADMISSION OR DENIAL OF Tile ALLEGED VIOLATION Ilattimore Gas and Electric Company accepts the violation. Although we do not agree that fuel movement continued on March 28,1997 without an evaluation of the cause or the corrective actions, we do agree that this issue was not promptly corrected ofter it was first discovered.
11.
REASONS FOR TIIE VIOLATION This problem was known to have existed before March 1995, when Operating Instruction (OI) 25A, Spent Fuelllandling Machine, was changed to specocally allow use of a camera or spotter in lieu of the grapple indicating lights. This problem was an intermStent problem that had been documented on issue Reports prior to 1995.
The cause of this violation was that we failed to determine that the cause of the problem was the position of the proximity switch relative to the switch magnets. Rather, we concluded the problem was failure of the proximity switch itself and we replaced it several times in the past. Due to the intermittent failure mechanism of the switch, the proximity switch replacements appeared each time to correct the problem.
On January 29,1997, this issue was again documented in Issue Report IRI 054 255. The issue report was presented to the Shin Supervisor, who had no operability concern. This Issue Report was dispositioned to be worked under Maintenance Order (MOl99700736). Ilowever, it was determined that 1
1mi-
ATTACllMENT (10)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND 50-317(318)/97 03 VIOLATION 08014 an Engineering Package needed to be completed before the work could proceed. On April 10,1997, the i
Engineering Service package (ES199700489) was completed to modify the grapple position indicating sensors. The modification was completed on April 14,1997 during the defueled period of the outage.
The modification successfully resolved the problem.
111. CDjil{ECTIVE STEPS TilAT llAVE 11EEN TAKEN AND RESULTS ACillEVED A modification was completed during the 1997 Refueling Outage to correct this hardware problem.
IV.
CORRECTIVE STEPS TilAT WILL llE TAKEN TO AVOJD FURTilER YlOLATIONS A.
We are accelerating many of the previously approved upgrades to this equipment.
D.
We are developing and implementing a more aggressive maintenance program for fuel handling equipment and have added it to the scope our Maintenance Rule program.
C.
Ti.e new System Manager concept has been impleniented at Calvert Cliffs. This concept provides a better focus on a proactive approach to the long term perfonnance of plant equipment, including refueling equipment.
V.
DATE WilEN FULL.CD31PLIANCE WILL llWilEVED Full compliance was achieved on April 14,1997 when the grapple position indication modification was completed.
2
g..i ATTACllMENT (11)
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORTS NOS. 50 317/(3181/9102 AND 50-317(318)/97-03 VIOLATION 09014 Ill A. 10 CFR Part 30, Appendis B Criterion XVI, " Corrective Action," states, in part, that measures shall be established to casure that conditions adverse to quality, such as failures, deficiencies, defective equipment, and noncorthrmances 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 prechtde repetition. The identification of the condition adverse to qualltv, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels ofmanagement.
10 CFR Part 50, Appendix B, Criterion 11, " Quality Assurance Program " requires that applicants establish in their Quality Assurance Programs those structures, systems, and components which are to be subject to the requirements of Appendix B. Baltimore Gas and Electric Quality Assurance Policy, Revision 47, dated October 18, 1296, states that systems and components subject to the requirements ofthe Quality Assurance Policy are specified on a Quality List (0-List). All refueling equipment is specified on the Q-List.
Contrary to the above, as of Afa ch 30,1997, the licensee's actions to idennp and correct certain conditions adverse to quality were inadequate to preclude the numerous and repeatedproblems with refueling equipment during defueling of Calvert CliVs Unit 2 in Afarch 1997, as erldenced by the following examples, each of which is a separate violation:
4.
On Afarch 31,1997, a reliefvalve stuck open on the refueling upender, preventing lowering the upender,* the cause of the valve being stuck open was sludge and other debris in the upender hydraulle system. Although the sludge had been identified in previous inspections, corrective actions toprevent recurringproblems were not taken.
1.
ADMISSION OR DENIAL OF TIIE ALLEGED VIOLATION Daltimore Gas and Electric Company accepts the violation, 11.
REASONS FOR TIIE VIOLATION On March 31, 1997, we had stopped defueling and were perfoaming comprehensive fuel handling equipment inspections, checkouts, and repairs. No fuel was in the fuel transfer system. While performing underwater vacuuming around the refueling pool upender, the upender was raised to allow vacuuming underneath it. Afterwards, we found the upender would not lower because of a stuck open relief valve. We could not positively attribute the relief valve failure to contaminants in the hydraulic system, but we recognized the possibility existed it is also possible that the failure occurred due to normal wear, A preventive mainten.mcc procedure called for the periodic replacement of the filter in the upender hydraulics, and this had been performed at the begianing of the outage. 110 wever, the preventive maintenance did not call for draining and refilling the hydraulic system. A subsequent detailed review of the upender maintenance history revealed that contaminants had been found in 1993, along with a clogged filter, We have not discovered any previous failures of this relief valve, I
1
A*lTACithtENT (11)
NOTICE OF VIO!ATION AND PROPOSED ISIPOSITION OF ClYll PENALTY NRC INSPECTION REPORTS NOS. 50-317/(318)/97-02 AND 50 317(318)/97 03 VIOLATION 09014 The Preventive Maintenance Program in 1993 did contain a feedback mechanism to incorporate changes based on field experience; however, in 1996, the feedback mechanism was concluded to be less than fully effective.
111. CORRECTIVE STEPS. TilAT llAVE IIEEN TAKEN AND RESULTS AClllEVED A.
The hydraulic system was drained and renlied.
B.
The relief valve was replaced.
C.
The Preventive Maintenance Program for the upenders was revised to require the hydraulle system to be drained and refilled prior to use during a refueling outage.
D.
The Preventiv i Maintenance Program change process that existed in 1993 allowed changes to the program $v completing a Preventive Maintenance Task Change Request Form. This process was changed in 1996 to require that individuals identifying the potential need for a Preventhe Maintenance Program initiate an issue Report according to issue Reporting and Assesstnent, QL-2100. The 1996 procedure change td* included a comprehensive list of the types of Preventive Maintenance Program changes, including preventive maintenance task additions and deletions, that require issue Reports.
IV. CORRECTIVE STEPS TilAT WILL llE TAKEN TO AVOID FURTIIER l
ylOLATIONS A.
We are developing and implementing a more aggressive maintenance program for the refueling equipment and have added it to the scope of our Maintenance Rule Program.
11.
We are accelerating many of the previously approved upgrades to refueling equipment.
C, The new System Manager concept has been implemented at Calvert Cliffs. This concept provides a better focus on a proactive approach to the long term performance of plant equipment, including refueling equipment.
V.
DATE WIIEN FULL COMPLIANCE WILL llE ACillEVED Full compliance was achieved when the relief valves were replaced and the hydraulic system was drained and Alled on March 21, 1997 prior to restarting refueling. Both upenders operated properly during equipment checkouts prior to recommencing fuel movement.
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ATTACHMENT (12)
NOTICE OF VIOleTION AND PROPOSED IMPOSITION OF CIYil PENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97-02 AND 50 317(318)/97 03 VIOLATION 10014 Ill.A. 10 CFR Part 30. Appendix B, Criterion XI7, " Corrective Action," states, in part, that measures.shall be established to assure that conditions adverse to quality, such asfailures, deficiencies, defective equipment, and noncorformances are promptly ident@cd and corrected in the case of significant conditions adverse to quality, the measures shall assure that the cause qf the condition is determined and correct lYC action taken to prechkh repetition. lhe ident@ cation of the condition adverse to quality, the cause ofthe condition, and the corrective action taken studl be documented and reported to appropriate levels ofmanagement.
10 CFR Part 30, Appendit B, Criterion 11. " Quality Assurance Program " requires that applicants establish in their Quality Assurance Programs those structures, systems, and components which are to be subject to the requirements of Appendix B. Baltimore Gas and Electric Quality Assurance Policy, Revision 47, dated October 18, 1996, states that systems and components sub)cct to the l
requirements of the Quality Assurance Policy are spec @ed on a Quality List (Q41st). All refueling equipment is spec @edon the Q41st.
Contrary to the above, as of March 30,1997, the licensee's actions to identify and correct certain conditions adverse to quality wre inadequate to preclude the numerous and repeatedproblems with refueling equipment during defueling of Calvert Cli[fs Unit 2 in Afarch 1997, as evidenced by the following examples, each of which is a separate violation:
3.
Duringfuel handling activities on Afarch 27,1997, a control element drive mechanism cable was caught by the moving refueling machine and damaged Corrective action, including determining the cause of the problem to prechule recurrence, was not talen.
I, ADMISSION OR DENIAL OF T!!E AlIIGED VIOLATION Baltimore Gas and Electric Company accepts the violation, 11, REASONS FOR TIIE VIOLATION During refueling activities on hiarch 27,1997, a control element drive mechanism (CEDht) cable was lying coiled and stored on the steam generator platform. On one occasion, when the R;fuelina Machine
-(RFM) moved past it, the RFM's festooned power cable was caught by the CEDM cable and suticid two broken tie wraps (between the festooned cable trolley trucks) and minor damage to the festooned power cable's outer jacket, luvest! ation revealed the most probable cause was passing workers 3
inadvertently disturbing the CEDM cable such that part of it protruded slightly under the platform handrail. The RFM operators are typically very skilled at ensuring the machine's travel path is clear; however, this particular interference was probably very difficult to detect.
Prompt corrective action did occur. Two 3/32 inch tie wraps were replaced and the outer jacket of the cable was repaired under Maintenance Order 2199601642 on March 29,1997, Issue Report IRI-053 455 was written to document the problem after the repair was completed on March 29,1997.
This issue was promptly corrected. As allowed for conditions adverse to quality that are not significant, no specific actions to prevent recurrence were taken. Tl 3 issue did not recur.
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NOTICE OF VIOLATION AND l'ROPOSED lh1 POSITION OF CIVIL l'ENAl,TV NRC INSPECTION RI: PORTS NOS, 50 317/(318)/97-02 AND 50 317(318)/97 03 VIOLATION 10014 llowever, the issue was not promptly documented on an issue Report when it was disco <ered on hiarch 27,1997. It was not documented until two days later on h1 arch 29,1997 aller repairs were complete. The ;<rson who discosered this issue did not identify it as a potential condition adverse to quality that needed to be documented on an issue Report, 111. GRRECTIVE STEPS TIMT_llAVE BEEN TAKEN AND RESULTS AClllEVED The demage to the festooned cable has been repaired.
IV.. CORRECTIVE STEPS TilAT WILL llE TAKEN TO AVOID FURTilER VIOLATIONS A.
We have developed a new training program concerning QL 2100. This training program will be administered as " top down" training starting with plant management and downward through the site organizations. This training will include examples of some past failures to prepare issue reports, including the failure to document several degraded and non-conforming conditions noted in the Nuclear Fuel hianagement Refueling Log on issue Reports.
IL This event will be included in the pre-outage training for the RFht operators to refresh them on the need to maintain constant vigilance over the RFhi travel path, V.
DATE WIIEN FULL COMPLIANCE WILL HE ACillMEl}
Full compliance will be achieved upon completion of actions to implement the training described in Paragraph IV.A above. We expect this training will be complete sometime near the end of 1997, 2
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NOTICE OF VIOL ATION AND PROPOSED IMPOSITION OF CIVIL l'ENALTY NRC INSPECTION REPORTS NOS. 50 317/(318)/97 02 AND 50-317(318)/97 03 VIOLATION 11014 IH B.10 CFR part 30, Appendir ll, Criterion l', " Instructions procedures, and Drmvings," requires that activities qfecting quality be prescribed by docwnented procedures, of a type appropriate to the circumstances and be accomplished in accordance with these procedures. Operation of the spent fuel handling machine is accomphshed in accordance with Operating Instruct!an Ol 23A, " Spent Fuelllandling Machine," and 0122D, "Fuelllandhng Area l'entilation System", uhich states that spentfuel ventilation mw: be in service with charcocdfilters when spentfuel handling will occur.
Calvert Cliffs Updated Sqfety Analysis Report, Section 9.8, Revision 20, states, in part, that the limitations placed on the spentfuelpool area ventilallon system were to ensure that in the event ofa fuel handhng accident, all of the radioactive material released would befiltered thrvugh the IWPA fikers and charcoal absorbcts prior to discharge to the atmosphere. 0123A, Step 6.1.B.2.a requires that the charcocdfikers beplaced in operation prior to anyfuel movement.
1 Contrary to the above, on April 23, 1997, activities were not accomplished in accordance with l
procedures when Unit 2 refueling commenced without properly ahgning the spentfuel pool area ventilation system charcoalfiltersfor operation in accordance wkh Step 6.1.B.2a of 0125A. This condition existed until thefollowing dm', April 24,1997, when it was identified during a shift change.
1.
ADMISSION OR DENIAL OF TIIE All EGED VIOLATION Haltimore Gas and Electric Company accepts the violation.
f II, REASONS FOR TIIE VIOLATION l
The cause of the violation was the result of a combination of verbal communications (standard tenninology and methodology not used), enforcemeat of standards and policies for communications and procedure usage less than adequate, prejob briefmg less than adequate, and lack of procedure check-off requirement.
Details concerning this violation, its causes and corrective actions, were submitted to the Nuclear Regulatory Commission in Licensee Event Report 317/97 003, Ill. CORRECTIVE STEPS TIIAT llAVE BEEN TAKEN AND RESULTS ACillEVED All core reload activities were suspended pending a site wide review of all hardware and processes related to fuel handling. Corrective actions A through F below were taken as immediate corrective actions prior to the recommencement of core reload activities:
A.
Awareness training was provided conceming the specifics of this event and reinforcement of management's expectations conceming self checking, procedure compliance, and adequate communications.
B.
Review of the training qualifications for all personnel involved in fuel handling was performed.
C.
Operations management reinforced their expectations concerning individual accountabhny as it pertains to panel walkdowns and ownership of watchstations.
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NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTV NRC INSPECTION REPORTS NOS. 50 317/(31N)/97 02 AND 50 317(318)/97 03 VIOLATION 11014 D.
Refueling was designated as an infrequent evolution and all procedure controls and pre-evolution briefings that are a:sociated with infrequent tests or evolutions were fully applied to the subsequent reload activities.
E.
All procedures associated with fuel handling were reviewed and revised where necessary.
F.
Management's expectation for the conduct and attendance at pre evolution briefs has been reinfotted.
Core reload was recommenced on April 28,1997 at 1:50 a.m. and completed on May 3,1997 at 12:30 p.m.
without any further similar incidents.
IV.
CORRECTIVE STEPS TIIAT WILL BE TAKEN TO AVOID FURTilER
.YlOLATIONS A.
An evaluation of the effectiveness of addressing weaknesses and areas for improvement identified in the Operations self assessment of the fuel move evolution is in progress.
Appropriate additional corrective actions will be implemented based on the results of this self-assessment.
11.
Enhancement of the pre-evolution brief process stressing the teamwork aspect of the brief and the importance of shift management attendance.
C.
Enhancement to existing training provided to refueling contractors in the areas of prcredure usage and communications is being evaluated to ensure that instrt.ctions are provided on how procedure numbers and procedure steps are communicated.
V.
DATE WilEN FULL COMPLIANCE WILL BE AClllEVED Full compliance was achieved on April 28,1997, upon completion of the corrective actions identified in Paragraph 111 above.
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