ML20238C542

Responds to NRC Re Violations & Deviations Noted in Insp Rept 50-285/87-15.Corrective Actions:Pressure Gauge & Associated Tubing Immediately Removed from Containment Sump Discharge Line

ML20238C542
Person / Time
Site:	Fort Calhoun
Issue date:	09/02/1987
From:	Andrews R OMAHA PUBLIC POWER DISTRICT
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LIC-87-599, NUDOCS 8709100187
Download: ML20238C542 (7)

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Omaha Public Power District 1623 Harney Omaha, Nebraska 68102 2247 402/536 4000 l September 2, 1987 LIC-87-599 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555

References:

1. Docket No. 50-285

2. Letter from NRC (J. E. Gagliardo) to OPPD (R. L. Andrews) l 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, pase do not hesitate to contact us.

Sincerely, "fj R. L. Andrews Division Manager Nuclear Production RLA:rge Attachment c: LeBoeuf, Lamb, Leiby & MacRae 1333 New Hampshire Ave., W. W.

Washington, DC 20036 i

Mr. R. D. Martin, NRC Regional Administrator, Region IV Mr. A. Bournia, NRC Project Manager Mr. P. H. Harrell, NPC Senior Resident Inspector 8709100187 870902 G

PDR ADOCK 05000295 PDR g&o /

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j.{h ATTACHMENT A RESPONSE TO NOTICE OF VIOLATION During an NRC inspection conducted on June 1 through July 15, 1987, a violation of NRC requirements was identified. The violation involved the failure to <

provide appropriate instructions for the modification of a safety-related system. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, (1987), the violation is listed below:

Criterion V of Appendix B to 10 CFR Part 50 requires that activities affect- .

ing quality shall be prescribed by-documented instructions, procedures, or  !

drawings, of a type appropriate to the circumstances and shall be accom- i plished in accordance with these instructions, procedures, or drawings.

Section 5.I, " Control of Plant Design and Modifications," of the licensee's Quality Assurance Manual and Procedure S0-G-21, " Station Modification Con-trol," have been established to implement requirements of Appendix B and require that modification of equipment be performed in accordance with written procedures.

Contrary to the above, during the 1987 refueling outage, the licensee l performed a modification to the containment sump discharge line b; in- l stallation of a pressure gage and tubing without the use of a r:ritten and '

approved procedure.

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

OPPD'S RESPONSE THE REASON FOR THE VIOLATION IF ADMITTED OPPD admits the violation occurred. Investigation into the alleged failure to provide appropriate instructions for the modification of a safety-related system (i.e., pressure gauge and associated tubing found installed in the containment sump discharge line) revealed that no documentation could be located supporting the installation of the modification. i THE CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTT ACHIEVED The pressure gauge and associated tubing were immediately removed from the con-tainment sump discharge lira 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.

THE CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Based upon reviews done, the situation does not appear to be indicative of a generic problem, so no changes to plant procedures were deemed necessary.

ATTACHMENT A PAGE 2 l THE CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER VIOLATIONS l

(continued)

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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0 ATTACHMENT B 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 1 Policy and Procedure for NRC Enforcement Actions," 10 CFR'Part 2, Appendix C (1987), the deviation is listed below: 1 The licensee issued LER 87-001 on February 7,1987, to describe an event 1 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 l during performance of Surveillance Test Procedure ST-ESF-2. In LER 87-001, l the licensee stated that Procedure ST-ESF-2 had been revised to designate the responsibility for ensuring no equipment was inoperable to the shift i 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 l THE REASON FOR THE DEVIATION. IF ADMITTED l The deviation in question resulted from a statement made in an LER sent in l

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 I

ATTACHMENT B I 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 RESV_LTSS ACHIEVED As stated in the Notice of Deviation, the procedure cite'd.in the LER was revised to conform to the LER statement. This action was taken after notification by the NRC of the inconsistency. ,

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From a generic perspective, the circumstances surrounding this. deviation were q l investigated. OPPD found this item particularly disturbing because the.

I 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 J 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 l proven successful over the past 3 years for these types of submittals. The i 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 l of mechanisms exist to assure assigned responsibility,. completeness, and i accuracy. However, in some cases, a report or submittal to the NRC is' required I 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 one for acceptability in terms of corporate philosophy, management overview, and tone. Technical accuracy is not.the primary reason  ;

for this review as it is 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." i Additionally, LERs are currently being written within one group. This practice reduces the problems associated with their being written by individuals with no experience in formal written communication with the NRC. As experience level warrants, other groups may also be responsible for LER writing, but the primary responsibility now lies with the Shift Technical Advisor group.

ATTACHMENT B PAGE 3 CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND THE RESVLTS ACHIEVED (continue

~.2 r 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 i

Licensing group for final processing. Additionally, a certification process

} will be implemented for Special Res orts (as necessary), and other categories of unsolicited submittals to the Commission. This process will include a .2 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 1987.

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

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