ML20235X449
| ML20235X449 | |
| Person / Time | |
|---|---|
| Site: | Catawba  |
| Issue date: | 07/17/1987 |
| From: | Lawyer L, Long A, Shymlock M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20235X418 | List: |
| References | |
| 50-413-87-21, 50-414-87-21, NUDOCS 8707240190 | |
| Download: ML20235X449 (11) | |
See also: IR 05000413/1987021
Text
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pM REGg
UNITED STATES
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RUCLEAR REGULATORY COMMISSION
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REGION ll
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101 MARIETTA STREET, N.W.
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2
ATLANTA, GEORGI A 30323
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Report Nos.: 50-413/87-21 and 50-414/87-21
Licensee: Duke Power Company
422 South Church Street
Charlotte, NC 28242
Docket Nos.: 60-413 and 50-414
License Nos.:
Facility Name: Catawba 1 and 2
Inspection Conducted: June
-19,,1987
Inspect rs:
. AW
vA.R. pong
Date Signed
k (N e n
'ACO7
L.'L. Lawyer ~
s
Date Signed
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Approved by:
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7[/7[f'7
M. B. Shymlock', Section Chief 1' '
Date Signed
Operations Branch
Division of Reactor Safety
SUMMARY
Scope:
This routine, announced inspection was in the area of closecut of open
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inspection items.
Results:
No violations or deviations were identified.
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REPORT DETAILS
1.
Persons Contacted
Licensee Personnel:
G. Barrett, Training Records Document Control Specialist
- H. B. Barron, Superintendent of Operations
- W. H. Barron, Director of Operations Training
- M. A. Cote', Licensing Specialist
- J. R. -Fergeson, Unit Scheduling Engineer
- C. L. Hartzell, Compliance Engineer
M. Janeski, Operations Training Instructor
R. Neigenfind, Staff Engineer
G. C. Rogers, Project Engineer
R. T. Simril, Assistant Operations Engineer
- G. T. Smith, Superintendent,-Maintenance
- R. F. Wordell, Superintendent, Technical Services
Other licensee personnel contacted included engineers, technicians,
operators, mechanics, security office members and office personnel.
NRC Resident Inspectors
- M. Lesser, Resident Inspector
- Attended Exit Interview
2.
Exit Interview
The inspection scope and findings were summarized on June 19, 1987, with
those persons indicated in paragraph 1 above.
The inspectors described
the areas inspected and discussed in detail the inspection findings,
including those listed below.
No dissenting comments were received from
the licensee.
Item Number
Status
Description / Paragraph
IFI 414/87-21-01
Open
Design and Implementation of Corrections to
Identified Human Engineering Deficiencies
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(Paragraph 3.a)
VIO 414/86-27-01
Closed
Procedural Errors and Failures to Implement
Procedures . on Loss of Control Room Test
(Paragraph 3.a)
UNR 414/86-27-02
Closed
Failure
to
Provide Adequate Operator
Requalification Training on loss of Control
Room (Paragraph 3.b)
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UNR 413/86-05-05
Open
Environmental
Qualification
of Hydrogen
Skimmer Fans - Open Pending NRC Policy
Determination (Paragraph 3.c)
IFI 413/86-05-01
Open
Revision of Station - Directive 3.2.2 to
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Require Shift Supervisor Notification of-
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Missed Surveillance Tests (Paragraph 5.a)
IFI 414/86-07-03
Closed
Review and Implementation of Environmental
Qualification Maintenance Program (Paragraph
5.b)
The licensee did not identify as proprietary any of the material provided
to or reviewed by the inspectors during this inspection.
3.
Licensee Action on Previous Enforcement Matters (92702)
a.
(Closed) Violation 414/86-27-01:
Procedural Errors and Failures to -
Implement Procedures on Loss of Control Room Test
During the Unit 2 Loss of Control ' Room Test on June 27, 1986, the
transfer of control of Steam Generator Power Operated Relief Valves
(PORVs) to the Auxiliary Feedwater. Pump Turbine Control Panel
(AFWPTCP) erroneously commanded all four PORVs to open to seventy-
five percent of full stroke. Reactor pressure and pressurizer level,
which had been decreasing slosly as a result of the cooldown after
the reactor trip at the start of the test, fell rapidly. Within a
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minute of the transfer, pressurizer level indication was lost, and
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within two more minutes pressure had dropped below 1845 psig gener-
ating a safety injection (SI) demand signal. By design, the transfer
of control to the auxiliary panels had blocked automatic SI initia-
tion.
After another three and one-half minutes of unsuccessful
attempts to manage the situation from the suxiliary panels, control
was returned to the control room.
The transfer back to the control
room automatically intiated SI. By this time pressure had dropped as
low as 702 psig.
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The underlying cause of the event was the failure to specify in the
Design Change Authot izatf on or other documents that the mode of
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control of the steam generator PORV controllers at the AFWPTCP had
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been changed. This in turn led to a failure by station personnel to
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change procedures and train operators on this modification.
The
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situation was further exacerbated by human engineering deficiencies
introduced by the modifications. Other contributing factors included
the lack of a human engineering deficiency review of the shutdown
panels, inadequate training on shutdown panel
instruments and
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controls, inconsistencies in labeling of instruments and controls,
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and reluctance to terminate the test.
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The NRC issued a Confirmation of Action Letter (CAL) on July 3,1986,
containing corrective actions applicable to Units l' and 2.
As
documented in NRC Inspection Reports 413/86-27, 414/86-30, and
413/86-36, 414/86-39 the corrective actions in the CAL were completed
and the test was successfully repeated on July 11, 1986.
NRC Inspection Report 414/86-27 identified as Violation 414/86-27-01
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five examples of inadequate procedures or failures to follow proce-
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dures related to the June 1986 depressurization event.
The five.
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. examples of Violation 86-27-01 were subsequently cited as two
violations in Escalated Enforcement Action (EA) .86-147, issued
November 12, 1986. The licensee responded on December 12, 1986, with
an admission of Violation A with comments, and a denial of Violation
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B.
As a result, the NRC modified Violation' B.2, and stated in the
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April 14, 1987 letter to the ' licensee that additional. corrective
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actions were necessary for the item.
Corrective action commitments
for the other items in the Notice were considered acceptable by the
NRC.
(1) EA 86-147 Violation A.1: Failure to Review Design Change
Authorization for Impact on Established Operating Procedures
Background:
The licensee's program for design controls had not assured that
Design Change Authorization (DCA) CN-2-M-1527, which changed the
design basis for the mode of control for the Steam Generator
(SG) Power Operated Relief Valves (PORVs), was reflected in
necessary procedural modification.
DCA CN-2-M-1527 was not
properly reviewed by plant personnel as required by ' Station
Directive
3.0.3,
Management of Shutdown Requests, for the
effects on existing ope rr.ti ng procedures.
As a result,
Procedure OP/2/A/6100/04 was not modified and incorrectly
specified the setpoint of the SG PORVs.
Instead of remaining
closed, the SG PORVs opened to approximately 75 percent of full
open, contributing to the depressurization event.
In the December 12. 1986, response to the Notice of Violation,
the licensee stated that the following corrective actions had
been implennted prior to the restart of Unit 2:
A review of all Unit 2 design changes and shutdown requests
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implemented after Hot Functional Testing And prior to Fuel
Load
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Revision of the Auxiliary Shutdown Pan 91 operating proce-
dure and the Loss of Control Room abnormal procedure to
reflect the changes to the panels.
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Resolution:
Prior to the restart cf Unit 2, the licensee reviewed all Unit 2
Design Change Requests (DCRs) and Shutdown Requests implemented
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between Hot Functional Testing and Fuel Load, for ef fects 'on
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established procedures and for human factors significance.. The
inspectors reviewed the . findings presented in a letter from
W. R. McCollum to File, dated July 3,1986. The licensee DCR
review identified the need to replace a particular valve label
which. contained a typographical error. The licensee verified
for the inspectors, by checking the label on the valve, that
this relabeling had been accomplished. The- licensee review of
Shutdown Requests identified the need to add Lighting Panel and
Breaker numbers to Procedure HP/0/B/1001/18, EMF Sampling. The
inspectors verified that this was accomplished in Revision 3 to
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the procedure, approved December 15, 1986. Also as a result of
the review of Shutdown Requests, Procedure OP/2/A/6200/01,
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Chemical and Volume Control System, was ravised on February 3,
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1987, to properly indicate new controller locations on the valve
checkli sts.
The inspectors verified that Operating Procedure OP/2/A/6100/04,
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Enclosure 4.5 has been modified to specify the correct initial
positions for 2NV-294 and ENV-309 based upon the test data from
TT/2/A/9100/03, Auxiliary Shutdown Panel and Turbine Centrol
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Panel Supplemental test, which was written to verify proper
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functioning of the various valves while at the Auxiliary Shut-
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down Panel (ASP). This test was performed satisfactorily prior
to the Loss of Control Room retest on July 11, 1986.
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The inspectors also verified that training on the aforementioned
procedure changes has been included in operator requalification
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training (Paragraph 3.b).
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(2) EA 86-147 Violation A.2: Failure to Adequately Review Shutdown
Requests for Human Factors Considerations as Required
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Background:
The control mode of the Steam . Generator (SG) Power Operated
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Relief Valves (PORVs) had been changed through Design Change
Authorization (DCA) CN-2-M-1527 without any visible change to
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the SG PORV controller or labeling at the Auxiliary Feedwater
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Pump Turbine Control Panel (AFWPTCP). This. occurred as a result
of the DCA not having been properly reviewed by' design
personnel.
The licensee stated in the December 12, 1986 response to the
Notice of Violation that the following corrective actions h'ad
been completed or were ongoing:
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A review of Main Control Board, ASPS and AFWPTCPs for both
units to identify differences between units and to verify
proper labeling nomenclature and units of measure (prior to
Unit 2 startup).
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Revision of Design Procedure EDP-3.17, Control Room Change
- Handling, to clarify the need for review of modifications
to the ASP and AFWPTCP and to clarify responsibility for
initiating the Control Room Change Form
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Revision of Instrumentation and Controls Workplace proce-
dure PR-3 to assure emphasis on labeling and scaling of
manual loaders, controllers, etc.
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Correction of all Human Engineering Deficiencies identified
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in NSM-CN-20227
Resolution:
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The inspectors verified that prior to the restart of Unit 2, the
licensee reviewed all Unit 2 Design Change Requests (DCRs) and
Shutdown Requests implemented between Hot Functional Testing and
Fuel Load, for human factors significance as well as effects on
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established procedures (Paragraph 3.a 1).
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The inspectors observed the ASP and the AFWPTCP labeling nomen-
clature, meter unit designations, and controller position
labeling changes and verified that significant human factors
improvements had been made to the panels.
This observation
confirmed that "0" and "C" (0 pen and Closed) labeling had. been
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adaed to the panels, as well as labels which clearly identified
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the control mode of the Steam Generator PORV controllers.
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Design Procedure EDP-3.17, Control Room Change - Handling, was
revised to clarify the need for review of modifications to the
Motor Driven Auxiliary Feedwater Pump Control Panels, the ASPS
or the AFWPTCPs by the appropriate Design Group. _ Revision ' 3,
dated August 4,1986, clarified that the procedure applies to
the subject panels when the arrangement of. devices is modified;
when operator interface devices are added, deleted, or modified;
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or when the appearance, labeling, or functioning of a device on
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the subject panels is modified.
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The Electrical Division Procedure ECPI-PR-3 was revised to
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ensure emphasis on labeling and scaling of manual loaders,
controllers, etc.
This was accomplished in Revision 1, dated
April 24, 1986, by changing Section 6.11, Operator Interface, to
read, " Scaling and labeling of components to support the
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functional description should be reviewed and documented on the
I&C list and the Instrument Detail. When changes or additions
to Main Control Boards, Auxiliary Shutdown Panels or Auxiliary
Pump Turbine Control Panels are required, a human factor review
in accordance with EDP 3.17 shall be requested."
As required by the Confirmation of Action Letter of June 27,
1986, the licensee reviewed all Human Engineering Deficiencies
(HEDs) identified in NSM-CN-20227 and their schedules for
implementation.
As a result, complete re-engraving of al.1
nameplates on the ASPS and AFWPTCPs was accomplished prior to
August 22, 1986. As discussed in a July 30, 1986 letter, the
remaining portions of NS'M-CN-20227 could not be implemented at
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that time since the remaining section required de-energizing
part or all of the systems on the ASPS or the AFWPTCPs.
All
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HEDs are required to be corrected- prior to restart from the
first refueling outage in accordance with the Facility Operating
License.
The design and implementation of corrections to the
HEDs identified in NSM-CN-20227 will be reviewed in a future
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inspection and will be tracked as IFI 413,414/87-21-01.
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The inspectors verified that training was provided to appro-
priate personnel and included labeling and surface changes .made
to the ASPS and Unit 1/ Unit 2 control differences.
(3) EA 86-147 Violation B.1:
Erroneous Valve Setpoints
Background:
During the Loss of Control Room test on June 27, 1986, depres-
surization occurred due to an inadequate procedure. . Enclosure
4.5 of Operating Procedure OP/2/A/6100/04, Shutdown Outside the
Control Room from Hot Standby to Cold Shutdown'specified initial
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settings for valves 2NV-294 and 2NV-309 which were inappropriate
and resulted in tnese valves assuming an incorrect. position when
control was transferred to the remote shutdown panels.
Resolution:
The inspectors verified that Operating Procedure OP/2/A/6100/04,
Enclosure 4.5 has been modified to specify initial positions.for
and 2NV-309
based
upon the
test data
from
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TT/2/A/9100/03, Auxiliary Shutdown Panel and Tur31ne Control
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Panel Supplemental Test, which was written to verify proper
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function of the various valves while at the ASP. This test was
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performed satisfactorily prior to the Loss of Control Room
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retest on July 11, 1986.
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Failure to Transfer Control Back to
(4) EA 86-147 Violation B.2:
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Control Room
Background:
Test Procedure TP/2/A/2650/03, Loss of Control ' Room Functional
Test, was not properly implemented in - that control was not
transferred back to the control room when a situation arose that
could not be adequately c .ntrolled from the auxiliary shutdown
panels.
Resolution:
Operator requalification training specifically itddressing proper
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implementation of TP/2/A/2650/03 and lessons learned from the
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June 27, 1986 depressurization, has been completed for all
reactor operators and senior reactor operators (Paragraph 3.b)
(5) EA 86-147 Violation B.3:
Remote Shutdown Panel Labeling
Background:
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Operations Management Procedure OMP 1-6, Control Panel Informa-
tion Changes, dated May 10, 1982, stated that any informational
changes to the control panel will conform to human factor
guidelines and agree with the setpoints, limits, and precautions
established in approved operating procedures.
Contrary to this
procedure, the labels on the controllers at-the remote shutdown
panel for valves 2NV-294 and 2NV-309 were re' versed and indicated
the opposite of the intended and anticipated meaning. The NRC
considered the effect of the valve mislabeling to be significant
to the June 27, 1986 depressurization event.
Resolution:
The inspectors verified that the relabeling of .the ASP control-
1ers for valves 2NV-294 and 2NV-309, and other modifications to-
the ASP, had been approved and dncumented on the OMP 1-6 forms -
for control panel informational changes.
Through interviews with licensee personnel, the inspector
verified that OMP 1-6 is now being used to document control
panel labeling changes.
Except for the resolution of the identified Human Engineering Defi-
ciencies, which will be- tracked as IFI 414/87-21-01, the inspectors
concluded that the licensee had corrected the previous problems and
developed corrective actions to preclude recurrence of- similar
problems.
Corrective actions stated in the licensee response to the
Notice of Violation have been implemented.
The item is therefore
closed.
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b.
(Closed) Unresolved Item 414/86-27-02: Failure to Provide Adequate
Operator Requalification Training on Loss of Control Room
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Background:
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Prior to the June 1986 depressurization event, an upgrade of .the
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Steam Generator PORV had been performed in accordance- with DCA
CN-2-M1527. This change as applied to the AFWPTCP led to confusion
because the operator was unaware that the same pressure setpoint
varying controller was being used to indicate and control Steam
Generator PORV valve position.
Training was deficient in not
adequately teaching the Steam Generator PORV design change: to each
licensed operator and senior operator.
NRC Inspection Report 414/86-27 identified as a violation the failure
to provide adequate operator requalification training on facility
design changes in acccrdance with Technical Specification 6.4.1.
The
NRC letter f rom J . Helson Grace to Duke Power Company, dated
November 12, 1986, stated that in accordance with the current NRC
policy statement on training and qualification of nuclear power plant
personnel the violation was not cited.
Resolution:
The Steam Generator PORV design change as performed under DCA
CN-2-M1527 displayed several deficiencies, predominately in the human
factors engineering aspects of the change. These deficiencies were
identified
in
Nuclear
Station
Modification
NSM-CN-20227.
Deficiencies relating to changes to nameplates and labels on the ASPS
and AFWPTCPs were identified,
incorporated into lesson plan
transparencies and layout drawings, and instruction was provided'to
all licensed reactor operators and senior reactor operators.
In addition, training included a detailed discussion of the June 27,
1986 incident. The lesson included the changes that were made to
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Procedures OP/2/A/6100/04, Shutdown Outside the' Control Room from Hot
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Standby to Cold Shutdown, and AP/2/A/5500/017, Loss of Control Room.
The training also covered labeling and panel surface changes made to
the ASPS, control differences between Unit 1 and Unit 2, and proper
use of the newly revised panels and procedures to shutdown the
reactor and plant.
Based on this information, the item is closed.
c.
(0 pen) Unresolved Item 413/86-05-05: Environmental Qualification of
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Hydrogen Skimmer Fans - Open Pending NRC Policy Decision
Status:
The item remains open pending an NRC policy decision on Environmental
Qualification.
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4.
Unresolved Items
No unresolved items were identified during the inspection.
5.
Licensee Action on Previously Identified Inspector Followup Items (92701)
a.
(0 pen) Inspector Followup Item 413/86-05-01:
Revision of Station
Directive 3.2.2 to Require Shif t Supervisor Notification of Missed
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Surveillance Tests
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Background:
During an inspection in March,1985 it was noted that Station Direc-
tive (SD) 3.2.2 was inadequate in several respects and was not being
followed in all cases.
All of these problems have been resolved
except for one.
It was noted that Station Directive 3.2.2 only
addressed the notification of Performance and Compliance when a
surveillance test could not be performed within the required time
interval. The procedure did not state that the Shift Supervisor must
be immediately notified if a surveillance interval had passed.
The
licensee had stated that SD 3.2.2 would be revised. The licensee
noted that failure to meet a surveillance requirement was covered
under the provisions of Station Directive 3.1.8.
Status:
As of June 19, 1987, Station Directive 3.2.2 had not been revised to
require notification of the Shift Supervisor when a test had not been
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completed within the interval required in Technical Specifications.
The licensee committed at the Exit Interview to complete this action
by August 31, 1987,
b.
(Closed) Inspector Followup Item 413/86-05-06, 414/86-07-03: Review
and Implementation of Environmental Qualification Maintenance Program
Background:
10 CFR 50.49 requires that a record of environmental qualification
(EQ) of electrical equipment important to safety must be maintained
to permit verification that each item meets its specified perforniance
requirements when it must perform its safety function up to the end
of its qualified life.
Implicit in this requirement is the
constraint that records must be kept to substantiate that periodic
maintenance activities required to maintain a piece of equipment in
its qualified condition have been performed.
The licensee specifies these periodic maintenance requirements in the
Station Equipment Qualification Reference Index (EQRI). When the EQRI
was first being implemented, it contained numerous references to
instruction manuals and it was not clear which periodic maintenance
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activities were actually required for EQ. In a letter dated March = 27,
1985, outstanding maintenance activities or_ alternative actions taken-
by the station were identified for a Design Engineering Review to -
verify that all EQ-mandated maintenance had been accomplished. NRC
Inspection 86-07 identified that as of January 9,1986, the Design
Engineering Review had not been completed.
Although an in-depth
review and revision of the EQRI was curtsntly in progress, the
potential existed that the qualifications of some equipment may have
been compromised or invalidated through a failure to perform
necessary periodic maintenance.
Resolution:
The inspector verified that the concerns presented in the March 1985
letter had been adequately resolved, as documented in a. letter dated
January 27, 1986. No equipment qualifications appeared to _ have been
invalidated or compromised by the identified ~ alternative maintenance
actions.
The EQRI manual has been completed by the licensee. The inspectors
verified that EQ-mandated maintenance now is identified in the EQRI
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Manual.
The sources of the EQ requirements are also referenced.
Based on the above information, the item is closed.
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