ML20235A738

Ack Receipt of 870902 Response to Violations Noted in Insp Rept 50-285/87-15 & Notice of Violation . Implementation of Corrective Actions Will Be Reviewed During Future Insp

ML20235A738
Person / Time
Site:	Fort Calhoun
Issue date:	09/21/1987
From:	Gagliardo J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Andrews R OMAHA PUBLIC POWER DISTRICT
References
NUDOCS 8709230402
Download: ML20235A738 (2)

See also: IR 05000285/1987015

Text

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In Reply Refer To: -

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Docket: 50-285/87-15- g a

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Omaha Public Power District #n '

ATTN: R..L. Andrews, Division Manager- g-

Nuclear Production e

1623 Harney Street , ,

Omaha., Nebraska -68102 '/ . i

Gentlemen:

-Thank you for'your letter of September 2,1987, in response to our

, . letter and Notice of Violation dated July 30, 1987. We have reviewed your  ;

' reply and find it responsive to the concerns raised in our Notice.of Violation. cj L

We will review the implementation of your corrective actions during a future .[

inspection to_ deterraine that full compliance has been achieved and will be :l

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maintained. c< /

Sincerely, ,

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Ortalnal Signed By

D. E. Gagliardo

J. E. Gagliardo, Chief y/3

Reactor Projects Branch ^^ ,

cc:

W. G. Gates, Manager "

Fort Calhoun Station ,

P. O. Box ~399 .

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Fort Calhoun, Nebraska 68023 ,

Harry H. Voigt. Esq. .

LeBoeuf Lamb, Leiby & MacRae

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1333 New Hampshire Avenue, NW ^

Wash 5gton, DC 20036 , ,

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U. S. Nuclear Regulatory Commission __._

ATTN: Document Control Desk

Washington, DC 20555

References: 1. Docket No. 50 285 l

2. Letter from NRC (J. E. Gagliardo) to OPPD (R. L. Andrews)

dated July 30, 1987

Gentlemen:

SUBJECT: Inspection Report 50-285/87-15

The subject inspection report identified one violation and one deviation. The

violation involved the installation of a modification to a plant system without

appropriate procedural control. The deviation concerned the failure to com-

plete an action noted in a Licensee Event Report prior to the submittal of that

report. Pursuant to the provisions of 10 CFR Part 2.201, please find attached

the Omaha Public Power District's response to the violation and deviation. As

was discussed in a telephone conversation on August 31, 1987, between Mr. D.

Hunter of Region IV and Mr. J. Fisicaro of my staff, an additional two days was

requested to submit the response. If you have any questions concerning this

matter, please do not hesitate to contact us.

Sincerely,

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R. L. Andrews

Division Manager

Nuclear Production

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Attachment

c: LeBoeuf, Lamb, Leiby & MacRae

1333 New Hampshire Ave., N. W.

Washington, DC 20036

M R. D. Martin, NRC Regional Administrator, Region IV

Mr. A. Bournia, NRC Project Manager

Mr. P. H. Harrell, NRC Senior Resident Inspector j Oj

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ATTACHMENT A

l RESPONSE TO NOTJCE OF VIOLATION

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j 0 ding /an NRC inspection conducted on June 1 through July 15, 1987, a violation

of NRr, requirements was identified. The"nolation involved the failure to

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provide appropriate instructions for the Edification of a safety-rglated

system. In accordance with the "Osneral Statement of Policy and Procedure for

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.NRC Enforcement Actions," 10 CiR P s t'~b, Appendix C, (1987), the violation is

r' ;i gisted below; i,

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/ Criterion V of'P)ppendix B to 10 CFR Part 50 requires hat activities affect-

/ ing quality shall be prescribed by'docaented instructions, procedures, or

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drawings, of a't.ppe appropriate blthe circumstances and shall be accom- -

/ plished in accordance with these ' instructions, procedures, or drawings.

Section 5.1, " Control of Plant Debign and Eddifications," of the licensee's '

Quality Assurance Manual and Proctdure S0-G-21, " Station Modification Con-

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trol," have been established ta ierlement requirements of Appendix B and

require that modification of eq,uhgent be performed in accordance with

/; written procedures.

Contrary to the above, durir.),the 1987 refueling outage, the licensee i

' regiioemed a modification to the containment sump discharge line by in-

, , afdlation of a pressure gage 'and

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tubing without the use of a written and l

1> spproved procedure.

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This is a Severity Level IV violation. (Supplement I)(285/8715-02)

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EPPD'S RM0!.[SE >

THE REAS04 F0f THE VIOLATION IF ADMil,T_ED

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OPPD admits the violation occurred. Investigation into the alleged failure to

provide 4ppropriate instructions (w,the' modification of a safety-related

system (i.e., pressure gauge and aneciated tubing found installed in the

containment sump discharge line) revealed that no documentation could be

loc?ted supporting the installation of the modification.

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TJIE CORRECTIVE STEPS THATjiAVE BEOi TAKE;I AND THE RESULTS ACHIEVED

The pressure gauge and associated tubing were immediately removed from the con-

/ tainment sump discharge line by plant personnel upon notification by the NRC

inspector. A limited survey was conducted to determine if other similar prob-

lems existed, , None were discovered; OPPD believes that this was an isolated

incident.

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THE CORRECTIVE STEPS TMAT WILL BE TAKEN T0.AV01) FURTHER VIOLATIONS

Based urion reviews done, the situation does rot appear to be indicative of a

generic problem, so no changes to plant procedures were deemed necessary.

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ATTACHMENT A

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.THE CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER VIOLATIONS

fcontinued)

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Information will be distributed to plant personnel via the Hotline program

discussing this incident and stressing the importance of following standing

orders to ensure that no future unauthorized modifications are made to station

equipment.

THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED

Information with regard to this incident will be distributed to applicable

plant personnel via the Hotline program by September 30, 1987.

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ATTACHMENT B

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RESPONSE TO NOTICE OF DEVIATION

Based on the results of an NRC inspection conducted on June 1 through July 15,

1987, a deviation of your commitments made to the NRC was identified. The

deviation consisted of the failure to revise a surveillance procedure as stated

in a licensee. event report (LER). In accordance with the " General Statement of

Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C

(1987), the deviation is listed below:

The licensee issued LER 87-001 on February 7, 1987, to describe an event

where a Technical Specification limiting condition for operation was

entered when safety-related equipment in redundant trains was concurrently

out of service. The equipment was inadvertently removed from service

during performance of Surveillance Test Procedure ST-ESF-2. In LER 87-001,

) the licensee stated that Procedure ST-ESF-2 had been revised to designate

the responsibility for ensuring no equipment was inoperable to the shift

supervisor prior to performing the surveillance test.

In deviation from the above, the licensee did not revise Procedure ST-ESF-2

to reflect the designation of responsibility to the shift supervisor until

March 20, 1987. (285/8715-01)

OPPD'S RESPONSE

THE REASON FOR THE DEVIATION. IF ADMITTED

The deviation in question resulted from a statement made in an LER sent in

February 1987. Actions stated in the LER as " completed" were not, in fact,

completed until mid-March 1987. At the time of the deviation, in January 1987,

(when LER-87-001 was submitted), OPPD did not utilize a dedicated group to

write Licensee Event Reports (LERs). A determination of which group would

write the LER depended primarily upon whomever was most " responsible" for the

event, whether in terms of personnel error, or area of responsibility for a

particular system or type of equipment. In this instance, the event was

documented internally via OPPD's Operations Incident Report process. Upon

presentation of the Operations Incident Report to the Plant Review Committee,

an assignment of responsibility was made. The responsible individual designa-

ted a person to prepare a draft of the LER, and that draft was forwarded to the

Licensing group for processing. The draft was formalized, and provided to

selected individuals within OPPD for a review of content, etc., according to

the provisions of the Nuclear Production Division Procedure governing internal

review of documents to be submitted to the NRC. Upon satisfactory completion

of the review process, the LER was signed by the cognizant authorized OPPD

person, and was submitted to the NRC.

The person assigned responsibility for writing the LER in this case was well

acquainted with the event, but was somewhat unfamiliar with the administrative

aspects of the process. He was directed to write the LER, which he interpreted

as only a writing assignment. He incorrectly assumed that other individuals in

the LER process were responsible for completing items which he described in the

LER. Therefore, he developed the corrective action (i.e., a procedural revi-

sion), noted it in the LER, and assumed someone else in the process would

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ATTACHMENT B

PAGE 2

THE REASON FOR THE DEVIATION. IF ADMITTED (continued)

complete the action. Other persons reviewing the LER, unaware that the actions

described had not been taken, incorrectly assumed that the procedure had been

revised. Consequently, the resulting deviation occurred.

CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND THE RESVLTS ACHIEVED

At stated in the Notice of Deviation, the procedure cited in the LER was

revised to conform to the LER statement. This action was taken after

notification by the NRC of the inconsistency.

From a generic perspective, the circumstances surrounding this deviation were

investigated. OPPD found this item particularly disturbing because the

controls in place apparently failed to preclude an incorrect statement being

made to the NRC. In 1984, the system to track, assign, and process items

submitted to the NRC was extensively revised. The driving force for this

effort was a need to assure accuracy in items prepared to submit to the NRC

under oath or affirmation. The changes made at that time were primarily to

establish an independent review program for such submittals.

A " checking" process was formalized for responses to other NRC requests which

were not required to be submitted under oath or affirmation. This process has

proven successful over the past 3 years for these types of submittals. The

investigation into this event revealed that the previous corrective action did

not address activities such as LERs and Special Reports.

OPPD has procedures in place to verify and assure the accuracy of correspon-

dence submitted to the NRC. In the case of an NRC-initiated request, a series

of mechanisms exist to assure assigned responsibility, completeness, and

accuracy. However, in some cases, a report or submittal to the NRC is required

without being prompted by an NRC request. Instances of this nature are general-

ly event-related, such as LERs, Special Reports, or the need to apply for an

amendment to the Technical Specifications or for exemption from a regulation.

With the submittals which are not initiated by NRC requests, (but rather arise

from an OPPD-identified need), no assigned response under the provisions of the

action tracking program applies, and the provisions of those procedures do not

come into play. Consequently, the normal checks and balances on the accuracy

of submitted information may be bypassed. The final review conducted before

submittal is primarily om for acceptability in terms of corporate philosophy,

management overview, ant' tone. Technical accuracy is not the primary reason

for this review as it ;s addressed in the preparation phase of the process.

OPPD-initiated documents are not procedurally controlled by this process.

Thus, inappropriate reliance upon a process which was not always required led

to the deviation. Changes to the administrative processes are underway as

described in " Corrective Steps Which Will be Taken."

Additionally, LERs are currently being written within one group. This practice l

reduces the problems associated with their being written by individuals with no

experience in formal written communication with the NRC. As experience level i

warrants, other groups may also be responsible for LER writing, but the primary l

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responsibility now lies with the Shift Technical Advisor group.

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ATTACHMENT B l

PAGE 3 i

CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED (continued)

CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FUTURE DEVIATIONS

To correct these findings, changes to the Standing Order on Operations Inci-

dents (which initiate the LER process) will be made to require a certification

of accuracy be documented prior to providing any required report to the

Licensing group for final processing. Additionally, a certification process

will be implemented for Special Reports (as necessary), and other categories of

unsolicited submittals to the Commission. This process will include a

signature form to document the accuracy of responses in unsolicited submittals

in the same manner in which NRC-initiated submittals are documented.

The revisions to the procedures and processes described above will provide a

traceable and documentable basis for submittals made to the NRC which are not

encompassed by the action tracking system controls. The changes will also

serve to raise the level of awareness of OPPD personnel to the potential for

errors of this sort.

LER and other report writing by select groups of individuals, in conjunction

with formalizing the transmittal process for these items will provide added

assurance that future deviations of this nature will be avoided.

DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED

In that the deviation cited in the report was corrected in March, 1987, OPPD is

currently in full compliance. Procedure revisions to the Operations Incident

procedure will be finalized by the end of September 1987. Generic procedural

reviews and changes, if deemed appropriate, will be completed by the end of

1987.