ML20236L608
| ML20236L608 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 11/04/1987 |
| From: | Shell R TENNESSEE VALLEY AUTHORITY |
| To: | NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM) |
| References | |
| NUDOCS 8711100463 | |
| Download: ML20236L608 (7) | |
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TENNESSEE VALLEY AUTHORITY CHATTANOOGA TENNESSEE 374ot SN 157B Lookout Place I
NOV 041987
.U.S. Nuclear Regulatory Commission ATTN:
Document Contro) Dask Washington, D.C.
20555 Gentlemen:
In the Matter of
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Docket Nos. 50-327 Tennessee Valley Authority
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50-328
-SEQUOYAH NUCLEAR PLANT (SQN) RESPONSE TO NRC INSPECTION REPORT NOS.
50-327/87-50 AND 50-328/87-50
Reference:
~ NRC Inspection Report No. 50-327'84-24 from J. Nelson Grace to H. G. Parris dated March 7, 1985 1
On June 6 and July 22, 1985, TVA submitted its responses to violations 50-327/84-24-01 and 50-327/84-24-02.
As a result of concerns raised by NRC j
relative to that response, as indicated in Inspection Report Nos. 50-327/87-50
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and 50-328/87-50,- detail 12, dated September 29, 1987 we submit the enclosed evaluation.
The enclosure provides our evaluation of NRC's concerns relative to the above mentioned responses. We do not recognize any items described herein as commitments.
If you have'any questions,.please telephone M. R. Harding at 615/870-6422.
To the best of my knowledge, I declare the statements contained herein are J
complete and true.
Very truly yours, TENNESSEE VALLEY AUTHORITY I
R. H. Shell, Manager Regulatory Affairs Enclosure cc:
See page 2 8711100463 B71104 p
ADOCKOSOOfg7 PDR An Equal Opportunity Employer l
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~ U.S. Nuclear Regulat'ory Comission
{}}' j 4-cc (Enclosure): a 1 Mr. G. G. Zech,L Assistant Director l l forl Inspection Programs. ~ -l Of fice of. Special Projects .j U.S..-Nuclear. Regulatory Commission. 101 Marietta Street, NW,-Suite 2900 d ),, Atlanta, Georgia 30323 'Mr. J. A !Zwolinski,' Assistant Director-for Projectsi-Division of TVA Projects - Office of Special' Projects U.S. Nuclear Regulatory Commission ,1 4350 East-West ~ Highway -EW 322 Bethesda, Maryland.'20814
- Sequoyah Resident Inspector-
~.Sequoyah Nuclear Plant 2600 Igou Ferry Road Soddy Daisy,. Tennessee 37379 .I i i l 3 p \\\\ I L _a _. __ -
. c. 3 /- GR [f t . ENCLOSURE 3; . Violation-50-327/84-24 l NRC's comment'tc TVA's' violation response states:that the reason for violation l section does not address root cause for the failure of' plant personnel to j establish'and implement adequate procedures for the conduct of i ' ~ ".... equipment control, procedure review and approval, performance of maintenance, j radiation work permit access control, and access to containment." While it'is difficult to discuss root cause for such a. broad statement of violation, in' general terms the root causes can be addressed'as 1) failure to . provide sufficient management control to ensure. adherence to existing . procedures,_2)-insufficient control to ensure proper. work. planning',~and 3) t: . failure.to. exercise control'over the special' tools used in performing this I ' task. These causes are discussed in much greater detail under the " Examples of. Violation" sections. 'It-should be noted that, through analysis of operating experiences and ' feedback from personnel directly responsible for. operations and' maintenance.- l activities,: procedures that control these activities have improved since the time'of the seal. table spill event. While these. improvements may not.be q directly related to this event, cradit will be taken for the additional s . controls;that exist to-prevent recurrence of this type of event'as.a.-result of 4 lthese programmatic improvements. Example a
- As the' violation response noted, using Special Maintenance Instruction (SMI)-0-94-1 with-the reactor at power was a violation of that procedure.
The c , root cause of this event is considered to b'e a failure to provide adequate. 'l management control to ensure procedural adherence, j l
- Adherence to procedures is now required. in Administrative Iristruction (AI)-4.
This requirement-includes a warning of-disciplinary action associated with willful violation of procedures. In addition, procedural adherence was a .l subject of an extensive training program for SQN personnel involved in writing.. revising, or performing procedures, conducted between March 2, 1987, . J and May 29, 1987. A total of 958 individuals from Chemistry Division of power System Operations (DPS0), Maintenance, Modifications, Operations, 'j Mechanical Test, Reactor and Systems Engineering Sections were trained via this course. The management controls and' training of personnel in the area of procedure adherence properly address the root cause of this event. Example b l NRC's comments to the TVA violation respcnse indicate that the proposed corrective action for this item does not preclude issuance and use of an inappropriate procedure. Failure to correct this root cause is suggested as a contributing factor in the reactor coolant system (RCS) spill of February 1, 1987 (Licensee Event Report (LER]-87-13-01, potential Reportable Occurrence (PRO]-1-87-056),
lC W l + . Example b~(continued) The root cause of these events is not that the procedure did not address ') ' performing the task under the existing plant condition.. The procedure. inadequacy was~ recognized.before. starting' work in both cases. In'the thimble ) c tube event, SMI-0-94-1 required the plant to be shut down for work.. Likewise, p. before'the RCS spill incident, the operator realized SI-166.3 and SI-166.8 wero-inadequate before atroking valve 1-FCV-63-1. 1 In'each' case, the root cause is the failure to obtain a proced*re change to perform the work under the specific plant conditions.which existed at that. l time.. The first line of defense against errors cf this type is the detailed ' review a procedure change receives via established review and approval process. Bypassing this administrative control.by failing to process a required procedure change allows a personnel error to go undetected. ,j As a' specific response to the RCS spill incident, Operations personnel were ' 1 provided specific procedure adherence training by senior plant management. ' Additionally, the procedure. preparation'and use training program' conducted' between March 2, 1987, and May 29, 1987,. stressed proper and complete procedure preparation. This training also emphasized step by step adherence. I to procedures and correction of procedural inadequacies before continuing work. .with the procedure. 4 AI-4. requires procedures to contain precautions appropriate to the task performed, as well,as limitations and action statements to control processes within established limits during procedure performance. In addition to the above SQN completed a comprehensive, review of-safety-related procedures. This project-included checksheets, procedure walkdowns in the field, independent quality assurance (QA) walkdowns, and an audit by observation of procedure performance. Further, SQN will ensure consistent procedure quality by using a TVA procedure writer's guide which is presently under development. Example c NRC's comments to the TVA violation response state that the proposed I corrective action implies that the violation was caused by unqualified reviewers of the maintenance request (MR), and indicates that training of a j "one-shot" nature will not ensure continuing recurrence contcol. l l The. root causes for this violation are a failure to provide sufficient management control to ensure procedural compliance and insufficient controls 1 to ensure proper work planning. j i a The restriction of work request (WR) reviewers to those designated by section j supervisors acts to provide greater consistency and more detail to the WR I review process. Further, in evaluating the corrective action for this violation, it must be recognized that the process for planning WRs is much -more tightly controlled than at the timo of the seal table spill event. j Sequoyah Standard practice (SQM)-2 now includes detailed checklists for the preparation of WRs. These checklists address determination of equipment i classification; guidance for proper incorporation of approved plant 'i instructions in workplans; instructions relating to propor QA review; and guidance on postmaintenance testing. i a
j i;; ,.1 .g ' - j Example c'(continued)' { ' Additionally,.the failure of the WR to comply'with the procedural requirements of..SQM-2 has been addressed via the procedure training held between March.2, 1987,.and May 29, 1987, described in the response to examples a and;b. These' controls will act to prevent recurrence of this condition. .j Example d ' TVA's' response to this example was' considered adequate by NRC.. r Example e NRC's comment-to.TVA's. violation response states that'listedLcorrective' action- - is inadequate,'and points to.the RCS spill-incident'of: February 1, 1987, as an example of an event with.a similar root cause. I In both cases', the root cause of-these violations is a failure to provide -sufficient management control to insure procedural compliance. In reviewing l . the clearance procedure-following the RCS spill of February 1,'~1987, it was determined that changes to;AI-3, " Clearance procedure," would be desirable. ~ In s'ome instances,: limited ability to. operate a device within a clearance is . required. :In the past, this had been handled by issuing the clearance to Operations personnel.- If work is performed under such a clearance, the noted violation occurs. 1 This concern'is presently. addressed by AI-3, revision 35, section 3.1.8, which allows'the use_of. caution orders for. personnel safety and plant equipment protection. This step requires..very explicit instructions.on what, steps are required-before, operating a tagged device. Observation of these requirements - will allow required operational flexibility, while providing plant protection and personnel-safety. Additionally, open RCS Work now requires a clearance review by the' responsible supervisor / engineer with the Assistant Shift - Engineer-(ASE) and Unit Operator (UO) in accordance with Maintenance Instruction 3.2. 1 A different arrangement-for control of clearances on the incore detector exists in'AI-8. This method will be described under example f. - The enhancements to the clearance procedure AI-3, combined vith the procedure adherence training described earlier, will prevent recurrence of this violation. . Example f ' NEC's comment to TVA's violation response states that corrective action described.for this violation appears adequate, but evidence of corrective s \\ action comp,'etion cannot be found. The root cause of this violation is a failure to supply sufficient management control to ensure adherence to procedures. I i L ____ - ___ _ ___-_. -
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- Example f (continued).
) .t. While the intent of the stated' corrective action was. satisfied.by the' action t Ltaken, the' radiation work permit'(RWP) cover sheet'was not revised..'AI-8, ' " Access.to Containment," was revised '(revision 13) to require the Shiftt Engineer.(SE).to initiate a hold order clearance'on the incore flux detector i ' drives. : 1This, clearance must be issued to RadiationfControl (RC) Shift f Supervisor, by title,'before allowing personnel. access'into;the' lower a containment. : This. clearance can only. be released.for work requiring. incore. . flux detector system operation. RCI-14, section:V.9 (revision 3), states that "all containment entries will be made in accordance with AI-8. In this manner, the responsibility for this, concern has been shifted from the worker to the SE z>, and RC shift supervisor. ;By controlling the procers at this level of management,-recurrence of this violation will be prevented. 'No evidence was found'of these controls being removed inadvertently through-revision,'and these procedural-controls are in the revisions of.AI-8 and RCI-14'in effect on October 21. 1987. { VIOLATION 50-327/84-24-02 ,? ',l NRC's comment.to TVA's violation' response statesLthat the listed cause does not,sti~pulate whether ' the personne1' error was. that of an. individual or a i ' collective failure of the Plant Operations Review Committee (PORC). Additional comments on the corrective action section of this paragraph indicate that the actions specified do not match the stated reason for the violation and are therefore inadequate. 'There are two separate violations noted, and each has a root cause. 1 The failure of PORC to review the. procedure is a direct result of an-individual's failure to'peciess a procedure revision, as' required by AI-4. The procedure adherence training, discussed in response to Notice of Violation 50-327/84-24-01, addreases this root cause. The approval of'a procedure, which'did not adequately address postmaintenance inspection or QA requirements, can be attributed to a weakness in the PORC-review process in effect at that time. The listed corrective action, training for PORC members. addresses that concern. Additionally, AI-43 now provides detailed guidance for review by qualified reviewers. This review function is.part of a recent technical specification change. The noted corrective actions will prevent recurrence of this violation. The qualified reviewer is now required to be trained in an established training t program,'which will hava a yearly decertification requirement. le..
~ !? s -(; a. i Assurance of' Adequate Root Cause Analysis- 'l TVA has taken action to ensure that problems are adequately analyzed for root cause in order that appropriate corrective actions are identified. .SQA-186i " Root Cause; Assessment For Adverse Actions / Conditions," was ~ implemented on September.2, 1986~ to aid in'the determination'and documentation ~of significant. coot cause' events. This procedure provides a -standardized format and detailed guidance so that consistent techniques and terminology will be'used_in root'cause analysis (RCA). )l The RCA evaluation.can be performed for any plant condition or event. It can -l .be used in addition to,_or in conjunction with, SQA-84.(pros), and AI-12, l " Condition Adverse To Quality Reports (CAQRs)," evaluations. j 8 1 i _}}