ML20236K695
| ML20236K695 | |
| Person / Time | |
|---|---|
| Site: | Catawba, 05000000 |
| Issue date: | 11/03/1986 |
| From: | Grace J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Heltemes C NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| Shared Package | |
| ML20236K265 | List:
|
| References | |
| FOIA-87-377 NUDOCS 8708070224 | |
| Download: ML20236K695 (7) | |
Text
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SQ QEG UNITED STATES
'o NUCLEAR REGULATORY COMMISSION 5
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N REGION 41 j I. 1 101 MARIETTA STREET, N.W.
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November 3, 1986 J
7 A, 1
MEMORANDUM FOR:
Clemens J. Heltemes, Jr., Director, Office for Analysis and h4 l
Evaluation of Operational Data y/t F
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FROM:
J. Nelson Grace, Regional Administrator
SUBJECT:
INPUT FOR THE ABNORMAL OCCURRENCE (AO) REPORT TO CONGRESS FOR
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THE THIRD QUARTER CY 1986 l
l Enclosed are the writeups on the Abnormal Occurrence Report to Congress for the Third Quarter CY 1986 as requested by your memorandum dated October 8,1986.
j Region II concurs that Item 1. A.1, Numerous Deficiencies During a Remote Shutdown Test at Catawba Unit 2, constitutes an abnormal occurrence and an appropriate writeup is included as Enclosure 1 to this memorandum.
Your memorandun proposed that the Confirmatory Order and Notice of Civil Penalties of August 12, 1986, at the Turkey Point facility be reported to Congress I
as an Abnormal Occurrence.
Region II does not concur that this issue is an A0 l
for several reasons, i
First, the notice of violation was purposefully structured to contain separate i
Severity Level III violations involving somewhat different areas, events, and I
time frames.
A more serious alternative would have been to issue one violatien I
to focus on management.
Secondly, due to the time span of inspection involved and the time span of I
activities involved, many activities were being corrected long before the notice of violation was issued.
The licensee's management was already taking strong corrective action that had already produced positive results.
The order that was issued folded the new corrective actions into a two year old program that had already produced massive changes at the site in virtually every activity.
Next, the inspection results from the Turkey Point design inspection are not '
different in type from results at other facilities and are not viewed as significantly different in magnitude than most of the design inspection results.
f Finally, to label the group of violations as an A0 at this late date would not recognize the corrective actions already being pursued by Florida Power and Light Company.
The proper perspective is as stated in the forwarding letter for the latest Systematic Assessment of Licensee Performance report:
CONTACT:
K. Landis FTS:
242-5509 8708070224 870804 PDR FOIA GORDONB7-377 PDR YW
Clemens J. Heltemes, Jr.
2 November 3, 1986 i
I N
"As noted by the SALP Board, you will need to continue your intense manage-ment involvement in activities associated with your Turkey Point facility.
l Your major personnel, material, and financial commitments are recognized and are having a positive effect, but weaknesses in facility performance have been noted in the areas of plant operations, maintenance, the quality program and administrative controls affecting quality, and training and qualification effectiveness.
The emergency preparedness area has improved to become a major strength.
The various parts of the Performance Enhancement Program (PEP) have been pursued vigorously as have your other initiatives to improve performance.
While the general trend is improving, and the plant and its staff are in better condition, a number of individual significant events and inspection findings during the period covered have precluded l
higher ratings at this time.
Two of yu-especially significant initiatives were commenced during this period.
These are the reconstitution of safety system design bases and changeover to modified Standard Technical Specifica-I tions.
These initiatives will not only benefit Turkey Point but are expected l
to serve as a model for other utilities.
We recognize that these initiatives I
are being closely managed and are scheduled to be completed during the next SALP period.
We believe that they are the key to improved performance since they will provide your people-your most important resource--with better tools on which to base decisions on."
.). M J. Nelson Grace
Enclosure:
Report to Congress on Abnormal l
Occurrences, July-September 86 Nuclear Power Plants e
t
T November 3, 1986 ENCLOSURE j
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REPORT TO CONGRESS ON ABNORMAL OCCURRENCES l
JULY-SEPTEMBER 1986 NUCLEAR POWER PLANTS The NRC is reviewing events reported at the nuclear power plants licensed to operate during the third calendar quarter of 1986.
As of the date of this report, 1
the NRC had determined that the following were abnormal occurrences.
86-XX, Abnormal Cooldown Transient Appendix A of this report notes that a series of events (where individual events are not of major importance), recurring incidents, and incidents with implica-tions for similar facilities (generic incidents), which create major safety concerns can be considered an abnormal occurrence.
Date and Place - On June 27, 1986, Duke Power Company (the licensee) conducted a startup test at Catawba Unit 2 for Loss of Control Room.
During the test from the remotely located control panels, a cooldown and depressurization occurred and the safety injection system was automatically blocked.
If the decay heat load had been greater and if the use o the remote control panels were actually r
required, a more severe transient ecold have occurred.
Catawba Unit 2 utilizes a Westinghouse-designed pressurized water reactor and is located in York County, South Carolina.
Nature and Probable Consequences - At 9:41 a.m. on June 27, 1986, a Loss of Control Room Test was initiated on Catawba Unit 2 to fulfill one of the commitments for startup testing made in FSAR Table 14.2.12-2 page 32.
A crew of five, simulating the minimum shift crew available to Unit 2 operations, started the test by leaving the control room, tripped the reactor from the trip breaker panel, and proceeded to tha two remotely-located auxiliary shutdown panels (ASPS) and the auxiliary feedwater pump turbine control panel (AFWPTCP).
At the ASPS '
and AFWPTCP, switches were activated transferring control of vital functions y
from the control room to the auxiliary panels.
By design, the transfer blocked f
automatic initiation of safety injection (SI).
By error, the transfer of control of steam generator (S/G) power operated relief valves (PORV) to the AFWPTCP also I
commanded all four PORVs to open to seventy-five percent of full stroke.
Reactor pressure and pressurizer level, which had been decreasing slowly as a result of 4
the cooldown after the trip, fell rapidly.
Within a minute of the transfer, pressurizer level indication was lost; and within two more minutes, pressure had dropped below 184S psig generating an SI demand signal.
After another three and one-half minutes of unsuccessful attempts to manage the situation from the ASPS and AFWPTCP, control was returned to the control room which was staffed by the regular operations shift.
The transfer, which automatically initiated an SI, occurred at a pressure of 702 psig, pressurizer level near thirty-four percent, and about 100 F subcooling.
At this point the operators had full control of the stabilized plant.
' Enclosure 2
November 3, 1986
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t Contributing Causes of the Event - The underlying cause of this event was the failure to specify in the Design Control documents that the mode of control of the S/G PORV controllers at the AFWPTCP had been changed.
This, in turn, led to a failure by station personnel to change procedures and to train operators on this modification.
The situation was further exacerbated by human engineering deficiencies introduced by the modifications.
As a consequence, the staff assigned to perform the test did not understand the function and interaction of controls on the shutdown panels.
This lack of understanding led to a pretest setup of the panels that ensured that the PORVs would open on transfer and that attempts to shut them would be futile.
Other human engineering factor failures led to reducing charging pump flow and flow to the reactor. coolant pump seals by the very attempts to increase flow.
Although the main control room PORV controllers were replaced with safety-related controllers, the licensee chose not to replace or modify the AFWPTCP controllers.
Also, no human engineering deficiency review (HED) was performed on the shutdown panels.
Other contributing factors to this event included inadequate training on the shutdown panel instruments and controls, inconsistencies in labeling of instruments and controls, lack of termination test criteria, and reluctance by the control room crew to assist the shutdown panel crew for fear of invalidating l
the test.
Actions Taken to Prevent Recurrence - A Confirmation of Action Letter was issued to Catawba Unit 2 on July 3, 1986.
The licensee management agreed to develop a detailed restart plan which deals with the corrective actions necessary to correct deficiencies identified in the following areas:
i 1.
HUMAN FACTORS k
2.
PROCEDURES 3.
EQUIPMENT LABELING n
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4.
RETRAINING l
5.
EQUIPMENT REPAIR In addition, licensee management agreed that the " Loss of Control Room Functional Test" would be rerun after the requisite power rating was attained to adequately demonstrate that the plant can be safely shut down and cooled down from the auxiliary shutdown station following evacuation of the control room.
NRC - An Augmented Inspection Team (AIT) was dispatched to the site from Tegion II and made their inspection from June 28 through July 2.
The AIT was initiated to inspect the events surrounding the June 27, 1986, test for Loss of Control Room and the subsequent transient.
An enforcement conference was held between NRC Region II and the licensee on August 11, 1986.
Escalated enforcement is proposed for:
(1) the required human factors review of any design change to control room functions was not done as required; (2) the operators did not know of the change in function as neither the controller nor its labeling was changed; (3) training was inadequate; and (4) startup procedures were inadequate.
l Enclosure 3
November 3, 1986 N
The event began with the test requiring the tripping of the reactor which caused
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a normal cooldown and pressure decrease and then transferring of control to the remote shutdown panels from the control room.
A design change to the remote shutdown panels had removed the pressure control auto function from the steam generator power operated relief valves (SGPORV) and made them position-only I
controllers.
The transfer of control caused the SGPORVs to open and the operator continued to increase the setpoint which he thought would cause the valves to close and which caused the valves to open further.
The cooldown of the primary j
system increased and, as safety injection is auto blocked by design whenever the transfer is made, the pressure reduced to 702 psig and the temperature dropped 95 F before the test was terminated and the plant stabilized.
No Technical Specification or Operating License safety limits were exceeded.
1 l
86-XX, Management Deficiencies at Turkey Point Nuclear Power Station Date and Place - On August 12, 1986, the NRC forwarded to Florida Power and Light Company a Confirmatory Order and Notice of Violation and Proposed Imposition of i
Civil Penalties (N0V) for the Turkey Point Nuclear Power Station, which contained six Severity Level III violations, each with multiple examples and each assessed a civil penalty of $50,000.
The violations involved the Design Control Program, Safety Evaluations in Accordance with 10 CFR 50.59, Violation of Limiting Conditions for Operation (LCO), Procedural Controls, Load Testing of Station j
Batteries, and Failure to take Prompt Corrective Action on several occasio~ns.
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u Nature, Probable Consequences, and Causes - While much of the NRC inspection j
involved in this enforcement action addressed the Auxiliary Feedwater (AFW) 1 System design, maintenance, and testing, other issues and events inspected over
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a nine-month period were included.
Item I of the NOV involves significant weaknesses identified in the design control program.
These violations indicate that the licensee had not exercised adequate control to ensure that changes required as a result of system modifications were.
b
. appropriately translated into operating procedures, drawings, system descriptions, i
[
and design basis documents.
Most of these violations affected the AFW and back-up f
nitrogen systems.
The NRC staff considers these violations significant because l
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operability of the back-up nitrogen ::ystem is essential to ensure that the AFW l
j can perform its intended function upon the loss of the non-safety grade instrument air system.
The program weaknesses identified could lead to degradation or complete loss of the safety functions of these systems.
Item II of the NOV involves the failure to satisfy the requirements of 10 CFR 50.59.
In several cases, adequate safety evaluations were not performed for the effects of:
(1) changes made which could have led to AFW steam supply vent failure at low steam pressure conditions; (2) temporary system alterations pertaining to the removal of the AFW governor speed control system; and (3) temporarily adding loads to an engineered safety features electrical bus which could have overloaded the emergency diesel generator supplying that bus.
These examples are considered significant because of the repetitive weaknesses i
demonstrated in this area including three previous escalated enforcement actions involving 10 CFR 50.59 review deficiencies.
It is apparent that the previous corrective actions taken in this area were not adequate.
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8 Enclosure 4
November 3, 1986
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I Item III of the NOV involves two significant violations of Technical Specification (TS) Limiting Conditions for Operation.
On January 2,1986, radiography personnel identified three AFW steam supply stop check valves as unacceptable per the acceptance criteria of Test Request 001-86. These valves were then inoperable and the system should have been declared inoperable.
The operability of the valves was not adequately evaluated and an LC0 was not entered l
as required by TS 3.8.5.
On January 7,1986, an NRC inspector questioned the i
operability of the valves.
At that time, the valves were acknowledged to be I
d inoperable.
Unit 3 was then shut down and Unit 4 was placed in a 72-hour LC0 as required by TS 3.8.5.
Unit 4 was subsequently shut down on January 10, 1986.
This violation is considered particularly significant in that all functions of i
the valves should have been questioned when the problem was initially identified
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on January 2,1986.
It was not until January 7,1986, that the licensee's engineering organization evaluated the radiographic report and determined that the disc guide studs were bent or broken.
The second Technical Specification violation occurred when on February 12, 1986, the Unit 3 reactor was taken i
critical with only three safety injection pumps operable instead of four as l
required by TS 3.4.1.4.
l Item IV of the NOV identifies weaknesses in the licensee's procedural control l
program.
These involve failures to establish or implement adequate procedures and to properly control the revision and distribution of safety-related procedures.
These examples indicated that the procedural cnntrol program was not fully effective.
Item V of the NOV involves the failure to conduct adequate load capacity testing and monthly surveillance tests of safety-related batteries as required and the failure to conduct adequate preoperational load capacity tests of these same i
batteries.
This violation is significant because surveillance and preoperational testing did not demonstrate the operability of the batteries as required by TS 3.7.
In addition, examples of weaknesses involving the corrective action program were identified in the performance of maintenance activities.
This is significant as previous problems were also identified in this area.
Item VI of the NOV involves failures to take prompt and comprehensive corrective actions once deficiencies were identified by the licensee and the NRC.
Inadequate corrective actions were taken with regard to:
(1) the adjustment of l
cooling water flow to heat exchangers due to low flow problems without an i
ovaluation of the resulting change in flow to other components also served by the cooling water system; (2) the potential for an intake cooling water valve a
not to close as intended on a loss of power or control air which was identified in November 1984 but was not properly evaluated until February 14, 1986, at the urging of the NRC; and (3) the misinstallation of component cooling water (CCW) piping for the Unit 4 safety injection pump coolers which caused these coolers to be dependent on the Unit 3 CCW trains.
Adequate safety evaluations and administrative controls were not established to assure that the Unit 3 CCW system operated with sufficient redundancy when Unit 4 was operating and Unit 3 was shut down.
As a result of these failures to perform adequate evaluations and to take adequate corrective actions in response to identified deficiencies, systems did not satisfy their design requirements under certain conditions.
These examples indicate that although the licensee has shown great initiative in identifying potential safety problems, they must demonstrate the same degree of initiative in evaluating and correcting problems once they are identified.
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e e
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Enclosure 5
November 3, 1986 i
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l Actions Taken to Prevent Recurrence j
j Licensee Actions - Since early 1984, the licensee has corrected performance
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problems in several major systems; e.g., switchyard design change, auxiliary
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feedwater system upgrades, instrument power supply replacement and upgrade.
Since early 1984. the utility has embarked on a massive performance enhancement program (PEP).
The program covered mostly operational and control problems and people problems, but also addressed major site physical improvements that were j
thought to be important tc staff performance.
This closely managed program has 1
been updated twice as improvements allowed a clearer view of other problems or i
causes of problems.
The results include new buildings which enhance staff performance, a new simulator being ordered, submittal of updated Technical Specifications almost complete, enlargement of the on-site staff, and strengthened organization.
The new human factored procedures are more effective and are being followed more consistently.
The equipment is better maintained.
l These add up to a condition where significant transients are rare and of smaller magnitude with fewer intersystem interactions.
The licensee has recently responded to the Notice of Violation with enhancements in the design control process, engineering, and the maintenance procedure area i
as well as numerous additional specific corrective actions.
I NRC Actions - The NRC recognized that the licensee had initiated extensive actions to examine all safety systems and to identify and correct problems at d
Turkey Point.
Indeed, some of the violations cited in this package were identified as a result of these actions.
The NRC was encouraged by the programs the licensee had recently instituted and believed these measures were necessary to improve operations at the Turkey Point facilities.
The purpose of the Confirmatory Order was to update the original two year old Order and to incorporate the new initiatives being pursued by the licensee.
It facilitated control and review of the new activities.
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Since the spring of 1986, the NRC has conducted several inspections in addition l
to the standard program inspections.
These included inspection of the licensee's 4
phase 1 and phase 2 selected safety system reviews, the operator requalification program, accelerated requalification training, emergency operating procedures, 3
l emergency diesel generator (EDG) loading safety evaluations, EDG load modification, and several preoperational tests.
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The licensee submits quarterly reports on programs and meets with the Regional management at least quarterly.
These will continue for the duration of the Confirmatory Order.
Region II has augmented the standard inspection program.
This will continue for the foreseeable future.
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