ML20245H573
| ML20245H573 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 06/26/1989 |
| From: | William Cahill TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| TXX-89430, NUDOCS 8906300001 | |
| Download: ML20245H573 (7) | |
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' Log # TXX-89430-
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WJELECTR/C Ref. # 10CFR2.201-William J. Cahill, Jr.
Ehecutive Vice l' resident i
'U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C.,20555 SUBJECTr COMANCHE PEAK STEAM ELECTRIC STATION (CPSES)
. DOCKET NOS. 50-445 AND 50-446 RESPONSE TO NRC INSPECTION REPORT NOS.
50-445/89-24 AND 50-446/89-24 Gentlemen:
TV Electric has reviewed the NRC's letter' dated May 18, 1989, concerning the inspection conducted by Messrs. S. P. Burris and S. D. Bitter during the period April 5,~ 1989, through.May 2, 1989.-- This inspection covered activities authorized by NRC Construction Permits CPPR-126 and CPPR-127 for CPSES Units I and 2.. Attached to the.May 18, 1989, letter was a Notice of Violation.
Subsequent;to this. violation, other instances of procedural noncompliance and a lack of sensitivity to the documentation of deficient conditions have been identified by the NRC and TU Electric. Additional management actions as identified in the attachment to this letter will be implemented to address these concerns.
On June 19,'1989, in a discussion between Mr. J. S. Wiebe of the NRC and Mr. T. L.' Heatherly of TU Electric, it was agreed that TU Electric's response to Notice of Violation 445/8924-V-01 would be submitted by June 26, 1989. The response to the subject violation is attached to this letter.
Sincerely, E
1
~f William J. Cahill, Jr.
CBC/ddm c - Mr..R. D. Martin, Region IV Resident Inspectors, CPSES (3) 8906300001 890626 I
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1 Attachment to TXX-89430 June 26, 1989 Page 1 of 6 NOTICE OF VIOLATION j
(445/8924-V-01,446/892T-V-01) q i
10CFR50, Appendix 0, Criterion V, requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or l
drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures or drawings.
This violation is composed of four examples of failure to follow procedures.
These four examples are discussed as follows:
1.
CPSES Test Department Administration (TDA) Manual Procedure TDA-304, i
Revision 0, Section 6.2, states that the test engineer must obtain the shift supervisor's approval to initiate preoperational tests.
Furthermore, Section 6.1 requires the test engineer to obtain the shift supervisor's approval to implement changes to preoperational test procedures.
Contrary to these requirements, the shift test engineer (STE) who was performing Preoperational Test ICP-PT-01-02, "118 Volt Class 1E AC Inverters", discovered that he had f ailed to obtain. the shif t supervisor's permission to perform the test.
Furthermore, he had not obtained the shift supervisor's approval to implement three temporary procedure changes.
2.
CPSES TDA manual Procedure TDA-303, Revision 0, Section 6.2.7, requires that preoperational testing be performed in accordance with approved test procedures and instructions.
1 Contrary to these requirements, during the conduct of Preoperational Test J
Procedure ICP-PT-37-01, " Auxiliary Feedwater System (Motor-Driven Pump)",
4 the required test equipment (a comparator and associated equipment) was I
removed from the flow transmitter prior to completion of the required i
testing and before implementation of the restoration section.
3.
CPSES TDA Manual Procedure TDA-303, Revision 0, Section 6.2.7, requires that preoperational testing be performed in accordance with approved test procedures and instructions.
Contrary to this requirement, while attempting to perform Step 7.3.7 of Preoperational Test Procedure ICP-PT-64-03, " Turbine Runback and Reactor Control", a bistable switch was manipulated in the process control Cabinet No. 2 instead of in the process control Cabinet No. 1 as the procedure directed.
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Attachment to TXX-89430 June 26, 1989 Page 2 of 6 4.
CPSES Operations Department Administration (0DA) Manual Procedure ODA-407, Revision 1, Section 6.1, requires that plant systems and subsystems be o)erated in accordance with written approved procedures during normal, a> normal, and emergency conditions except as allowed by the procedure (00A-407).
Furthermore, Section 6.1 of ODA-407 requires that any individual who cannot follow an operating procedure as written, shall place the system or component into a safe or stable condition and notify the shift supervisor immediately.
Finally, Section 6.1 of ODA-407 states that if the desired or anticipated results in a step are not achieved, the individual should not proceed.
Contrary to these. requirements, while performing Steps 5.5.3.1 and 5.5.3.2 of CPSES System Operating Procedure 50P-304A, Revision 5, an equipment operator failed to perform these two steps in the specified order during realignment of the turbine driven auxiliary feedwater pump.
The procedure specifically states that the turbine driven auxiliary feedwater pump discharge valve be closed prior to opening the recirculation valve.
RESPONSE TO NOTICE OF VIOLATION T4578M-V-01, 446/8924-V-0IT We agree with the Violation and the requested information follows:
Reason for Violation To determine the reason that procedures were not followed in each of the cited examples, personnel involved were evaluated for their attentiveness, attitude i
and knowledge of requirements.
In addition, the procedures. violated were reviewed for clarity.
No reason common to all of the examples was found, but it is apparent to' Nuclear Operations' management from these and subsequent events, that a potentially generic problem with procedural noncompliance and sensitivity to documenting deficient conditions exists.
Reasons for each of the cited examples are discussed separately.
Example No. 1:
The System Test Engineer (STE) did fail to obtain the Shift Supervisor's i
signature on the System Functional test (1CP-PT-02-01 SFT).
The STE conducted a pretest briefing in accordance with STA-303, section 6.2.6.9, " Conduct of Testing", with the Shift Supervisor and test participants, during which he did obtain the Shif t Supervisor's approval as indicated in the Test Log.
- However, the STE was in violation of TDA-303, section 6.2.7, because he failed to have the Shift Supervisor sign the Test Procedure cover sheet.
This was an administrative error caused by lack of attention to detail.
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Attachment to TXX-89430 I
June 26, 1989 i
Page 3 of 6 The STE wrote Test Procedure Change (TPC) #1 prior to commencing the System Functional test.
The STE failed to obtain Shift Supervisor approval but did i
get the other approvals as required by TDA-304, section 6.1.6, prior to l
implementation.
The other two TPC's (TPC-2 and TPC-3) were discussed with the Shift Supervisor and the STE had his concurrence prior to implementation as l
described in the Test Log for ICP-PT-02-01 SFT, Rev. 1.
The STE also obtained approval signatures from other STE's qualified at Level IV and the lead q
Startup Engineer prior to implementation.
These were. administrative errors caused by lack of attention to detail.
i Example No. 2:
1 The Operations I&C Technicians disconnected the test equipment from the flow transmitter during a break in the test without notifying the responsible STE
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prior to its removal because of concern over equipment damage due to room congestion and construction activities in the area.
Example No. 3:
The example occurred due to human error.
The STE, who was familiar with the equipment, inadvertently went to the wrong process control cabinet.
Example No. 4:
This violation occurred due to misunderstanding of administrative controls by I
the Auxiliary Operator (A0).
The Control Room operator referenced procedure SOP-304A, section 5.5.3 for instructions on realigning the Turbine Driven Auxiliary Feedwater Pump to the test header.
This section instructs that Task i
i shall be to close IAFT-042 and Task 2 shall be to open 1AF-041. These tasks are numbered in the procedure which mandates they be performed in sequence.
The requirement that Task 1 and Task 2 be performed in sequence was not understood by the Auxiliary Operator.
Further review indicated that ODA-207, l
" Guidelines for the Preparation and Review of Operations Procedures," which discusses the procedural requirements for the sequence of performing tasks, was not used frequently by the Auxiliary Operators.
ODA-407, " Guidelines on Use of Procedures," which is used frequently by the Auxiliary Operators, did not contain the procedural requirements for the sequencing of tasks.
Corrective Steps Taken and Results Achieved:
Example No. 1:
When identified, the STE immediately documented the deficiencies on Test Deficiency Reports (TDRs). The immediate corrective action was to obtain
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Shif t Supervisor signatures on the 1CP-PT-02-01 SFT, Rev.1 cover sheet and TPC-1, TPC-2 and TPC-3.
Other test procedures were reviewed to assure compliance with the requirements of 1DA-303 and TDA-304 and no further discrepancies were found.
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Attachment to TXX-89430 i
June 26, 1989 Page 4 of 6 Example No. 2:
The STE immediately instructed I&C technicians to restore the test equipment in accordance with ICP-PT-37-01 SFT, Step 7.1.2.4 and documented the incident in the Test Log.
Example No. 3:
The STE performing the test reset the bistable and entered the occurrence in the Test Log.
The STE involved was counseled by Startup supervision on the i
requirements of TDA-303, " Conduct of Testing", and the care which is required to preclude possible automatic operation or damage to equipment if the incorrect devices are mistakenly operated during testing.
The STE documented the incident with a Test Deficiency Report (TOR).
I Example No. 4:
The Reactor Operator immediately directed that recirculation valve 1AF-042 be closed to restore auxiliary feedwater flow to the steam generator.
The Auxiliary Feedwater System was realigned to the requirements of procedure SOP-304A.
Subsequently PIR-110 was written to document this event.
4 Corrective Steps That Will be Taken to Avoid Further Violations:
Examples No. 1, 2 and 3:
All STE's and Group Leads will be required to read this NOV and response and review TDA-303,." Conduct of Testing".
This review will be documented on a-Test Engineer Indoctrination Record and placed on the Test Engineer's qualification / training record.
In each of these examples, the personnel who were involved were counseled at.
the time by Startup management on the importance of compliance with TDA-303,
" Conduct of Testing".
Example No. 4:
The Manager, Operations, met with the operating crew involved and counseled them on procedure usage and procedure compliance.
00A-407 was changed to state that all procedure steps are to be performed in sequence except as allowed by 1) ODA-407, 2) E0P rules of usage, or 3) Shif t Supervisor approval and documentation of the deviation.
Clear direction concernir.g the performance of procedure steps in sequence will be maintained in ODA-407 or any superseding procedure on the use of procedures.
ODA-407 allows the Auxiliary Operators to perform certain routine tasks without the applicable procedures being available or referenced due to the experience of the operator or the familiarity of the operation.
ODA-407 identified which sections of 50P-304A could be performed without the
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. Attachment to TXX-89430
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m Page 5 of 6, applicable procedures being available or. referenced.. In the subject event t' e h
Lappilcable sections of SOP-304A were available and referenced even-though not required by 0DA-407..As a preventative measure,.0DA-407;has been changed tol q
require"all. sections of 50P-304A to be available 'and referenced when 'used.
l The Shift Operations Manager also'develo)ed and implemented an action: plan to reduce the number of operator errors. Tie action plan provided for the
- following:
a.
Generating a memo'on procedure compliance to the Shift Supervisors (who in turn has discussed the memo with their.-respective crew,' at length).
.b.
The Manager, Operations, and/or Shift Operations Manager met and J
-discussed the-memo (Item a. above) with each crew after the Shift-Supervisor completed _his discussion.
- c. - A workshop was held'by the Manager, Operations, with all Operations Department Senior. Reactor Operators (Shift Supervisors, Unit Supervisors, Shift Technical Advisors and Staff) including Training and Plant Evaluation personnel, to discuss procedure compliance.and'
-deficiency reporting.
d.
.in the future, should a Plant Incident. Report-(PIR)', operator error orL procedure violation. occur, a critique session with the. responsible -
Operations department individual will be held and documented.
Additional Steps to Avoid Further Violations:-
Subsequent to'this violation, other. instances of procedural noncompliance and a lack of. sensitivity to the documentation of deficient conditions have~been-identified in the Nuclear Operations area by the NRC and TV Electric. As a result, TV Electric management directed that additional actions should be
. implemented to ensure procedural compliance in'the entire Nuclear Operations organization,.and to avoid future violations.
These measures are in addition to those previously planned for these examples.
To reinforce the fact that-all examples of procedural noncompliance are unacceptable to TU Electric management, the following actions will be taken:
o The Vice President, Nuclear Operations has directed that a workshop be developed and administered by Nuclear Operations departmental managers to their respective supervisors.
The workshop curriculum will be approved by the Vice President Nuclear Operations and include a i
discussion of this violation, in addition to:
1 1.
Emphasis on procedural compliance in all areas.
2.
Responsiveness to NRC questions and concerns.
3.
Documentation of deficient conditions.
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. Attachment'to TXX-89430 June 26, 1989 4
.Page 6:of.6 o
The workshop curriculum will be administered by the supervisor to each employee reporting to him/her.
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. The Plant Evaluation-Manager will incorporate these and other similar j
events concerning procedural compliance, into a " lessons learned" documentary training film.
This film will be viewed by Nuclear Operations personnel who are subject to procedure compliance.
Date of Full Compliance:
All STE's and Group Leaders in Startup will read the response.to this.
1 violation and review the requirements of T0A-303, " Conduct of Testing", by July 15,.1989 (including documenting the review and updating the training:
records).
Procedural compliance workshop training for departmental supervisors will be complete by. July 15, 1989.
Procedural compliance workshop treining for departmental employees will be
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comolete by August 1, 1989..
The video " lessons learned" training documentary will be completed and viewed by Nuclear Operati.ons employees by October 1, 1989.
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