ML20217N520
| ML20217N520 | |
| Person / Time | |
|---|---|
| Site: | Waterford  |
| Issue date: | 08/22/1997 |
| From: | Ewing E ENTERGY OPERATIONS, INC. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-382-97-05, 50-382-97-5, W3F1-97-0214, W3F1-97-214, NUDOCS 9708260223 | |
| Download: ML20217N520 (5) | |
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'bg Ente gy per:tions,Inc.
Kiliona. LA 70066 Tel 504 739 6242 Early C. Ewing, til Safety & Regulawy Aff aws W3F1-97-0214 A4.05 PR August 22,1997 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C. 20555 l
Subject:
Waterford 3 SES Docket No. 50-382 License No. NPF-38 NRC Inspection Report 97-05 Supplemental Information to Reply to Notice of Violation (IR 9705-03)
Gentlemen:
In accordance with 10CFR2.201, Entergy Operations, Inc. hereby submits in the additional information for Violation 50-382/97-05 requested in your letter dated July 25,1997, if you have any questions concerning this response, please contact Tim Gaudet at (504) 739-6666.
Very truly yours, I
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E.C. Ewing
- Director, Nuclear Safety & Regulatory Affairs ECE/GCS/tjs Attachment cc:
E.W. Merschoff (NRC Region IV), C.P. Patel (NRC-NRR),
111.181.5,5185151R
. o J. Smith, N.S. Reynolds, NRC Resident Inspectors Office o n,m.
9708260223 90022 "
PDR ADOcK 05000302 G
PDR,
AttachmOnt to VV3F1-97-0214 Page 1 of 4 ATTACHMENT 1 ENTERGY OPERATIOjlS, INC. ADDITIONAL RESPONSE TO VIOLATION 9705-03 AdditionalInformation Requested in a telephone conversation between your staff and Waterford 3 personnel on July 22,1997, and by letter dated July 25,1997, you requested additional information regarding our response to Example 4 of violation 9705-03. The July 22,1997 letter states that Example 4 revealed many breached barriers end that we should provide proposed corrective actions to remedy the causes that led to the barrier failures.
Our original response to Example 4 of the violation was premature in that the RCA investigation was not yet completed. Provided below is our revised response that includes the additional information you requested.
RESPONSE
(1)
Reason for the Violation Work Authorization (WA) #01153561 was written to install a half-coupling on Safety Injection (SI) Line 2Sl8-113RL1 A to allow for system venting, Initial tasks associated with the work included prefabrications, work location walkdowns, and pre-job briefs. For example, the Day Shift Lead performed a walkdown of the work location with his work crew. The day shift work crew staged the tools in the work area and identified the correct location where the half-coupling was to be installed. The day shift work crew marked this location by center punching the line. Because the day shift crew was unable to finish the job, the WA was turned over to the night shift crew.
The Night Shift Lead performed a walkdown of the work area with his work crew. The location for the. installation of the half-coupling was in a contaminated area that required protective clothing as a condition of entry.
The Night Shift Lead stood outside the contaminated area and pointed to the Si line rather than dress out and enter the contaminated area.
When it came time to weld the half-coupling to the SI Line, the Night Shift Lead was not available and the job was given to an Alternate Night Shift Lead that had not been involved with the job. The original Night Shift Lead and the Alternate Night Shift Lead went to the job site to walkdown the job. The work crew assigned to perform the job was comprised of some of the original night shift work crew and some of the Alternate Night Shift Lead's work crew.
When the Alternate Night Shift Lead arrived at the job site, the workers had mistakenly identified the Containment Spray (CS) line, which is located in proximity to the SI Line, as the line where the half-coupling was to be installed.
Att: chm:nt to VV3F1-97-0214
-Page 2 of 4 Scaffolding had been erected and was in the correct configuration to allow for work on the SI Line, however,- the Alternate Night Shift Lead and work crew -
had the scaffolding modified in order to perform the work on the CS line.
Prior to welding the half-coupling to the CS line, QA performed a cleanliness and fit-up inspection. The inspector verified the cleanliness and fit-up as satisfactory but failed to notice that the work crew was working on the wrong line.
The night shift crew welded the half-coupling to the CS line and turned the work over to the day shift crew. When the day shift arrived at the job location they did not see the half-coupling welded on the Si line. After surveying the area, they noticed that a half-coupling was welded on the nearby CS line. The work crew notified the Day Shift Lead that the half-coupling _ appeared to be welded to the wrong line.-
A Root Cause Analysis (RCA) Team was formed to investigate this event.
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The RCA Team identified the following root causes:
1.
Poor communication during the job walkdown. The method used to communicate the line to be worked resulted in a misunderstanding of i
the correct line. This method did not meet management expectations regarding positive identification of components required to be worked.
2.
Inadequate turnover. The Day Shift Lead did not turnover to the Night Shift Lead that the line had been center punched for coupling location purposes.
3.
Inadequate self-checking. The work crew failed to ensure they were working on the correct line by checking the penetration number and line description against the WA documents.
The RCA Team identified the following as missed opportunities to identify this condition:
1.
Prior to welding the half-coupling to the CS line, a QA inspector performed a cleanliness and fit-up inspection. The QA inspector did not recognize that work was being performed on the wrong line.
2.
Although the SI system was properly tagged-out and Si components were correctly labeled and matched information on the WA, workers did not recognize that they were working on the wrong line.
i J
Att: chm:nt to VV3F1-97-0214 Page 3 of 4 (2)
Corrective Steps That Have Been Taken and the Results Achieved The half coupling was removed from the Containment Spray line and a half coupling was placed on the Si line as required.
The Containment Spray line was inspected to ensure there was no damage to the line.
The Night Shift Lead involved with the welding activity was counseled.
The OA Inspector involved with the cleanliness and fit-up activity for the welding activity was counseled.
it was emphasized at a department meeting that QA inspectors are expected to verify components being worked match the components identified in work instructions.
QA developed a check-list c' additiona! critical information to be examined when performing a welding inspection.
Welding personnel, including Entergy and Contractor employees, were informed in a shop meeting format of the occurrence of this event. Use of the STAR (Stop, Think, Act and Review) process was emphasized.
A discussion of the STAR process was held with QA welding inspectors.
in addition to the above, because the failure to identify the correct component to be worked is not just a welding issue, Maintenance Personnel have also been briefed by the Maintenance Manager on the importance of positive component identification and use of the STAR process when performing a walkdown orjob briefing. The importance of a complete job turnover was also stressed during the briefing.
(3)
Corrective Steps Which Will Be Taken to Avoid Further Violations The pre-job briefing form in Maintenance Directive #7, " Guidance for Conducting Pre-Job / Post-Job Briefings," will be revised to include in its checklist a step to verify components that are scheduled to be worked.
The in-House Event Analysis (IHEA) group will review the recent incidents of plant personnel working on incorrect components to determine if these occurrences represent an adverse trend. Appropriate corrective measures, if required, will be taken to address the trend.
Attachmant to W3F1-97-0214 Page 4 of 4 The Quality Assurance department will perform a survey in approximately six months to determine if any incidents of working on incorrect components have occurred since September 1,1997.
A training program will be developed for welding inspectors that will consist of i
l required reading of controlled documents listed in procedure OAP-016, L
" Inspector Qualification / Certification," and the Weld Specification Data Sheet i
Planner lesson plan.
(4)-
Date When Cull Compliance Will Be Achieved Corrective steps taken to date have restored compliance to requirements.
The additional corrective steps which will be taken to avoid further violations, I
including verification of effectiveness, will be achieved by April 30,1998, i
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