NRC Generic Letter 1985-13
or .:-. -~ I n - b- 4.. -asAd TO ALL REACTOR LICENSEES AND APPLICANTS
Gentlemen:
SUBJECT: TRANSMITTAL OF NUREG-1154 REGARDING TO THE DAVIS-BESSE LOSS
OF MAIN AND AUXILIARY FEEDWATER EVENT (Generic Letter No. 85 - 13)
On June 9, 1985, Toledo Edison Company's Davis-Besse Nuclear Power Plant experienced a loss of all feedwater event while the plant was operating at 90%
power. Shortly after the event, the NRC Executive Director for Operations directed that an NRC Team be sent to Davis-Besse, in conformance with the staff-proposed Incident Investigation Program, to investigate the circumstances of this event.
The NRC Team has now completed its investigation and has documented the factual information and their findings and conclusions associated with the event (see enclosed NUREG-1154, entitled "Loss of Main and Auxiliary Feedwater Event at the Davis-esse Plant on June 9, 1985"). You should review the information for applicability to your facility.
In addition, you should ensure that the information in NUREG-1154 is made available to your plant staff as part of your training program in connection with the Feedback of Operating Experience to Plant Staff (TMI Action Plan Item I.C.5.).
This generic letter is provided for information only, and does not involve any reporting requirements. Therefore, no clearance from the Office of Management and Budget is required.
Hugh L. Thompson, Jr., Director Division of Licensing Enclosure:
NUREG-1154 SL:ORAB:DL M dfiDL A D/DL
JHannon:cl GHolahan DCr cfield HThompson
7 et 85 7 JA /85 . / .85 / /85
K IWGO 5 io
-2- On August 5, 1985, the Executive Director for Operations (EDO) identified and assigned responsibility for generic and plant-specific actions resulting from the investigation of the Davis-Besse event. Some of the generic actions may be applicable to your facility. A copy of the EDO memorandum is included for your information.
This generic letter isprovided for information only, and does not involve any reporting requirements. Therefore, no clearance from the Office of Management and Budget isrequired. The enclosed report is currently under NRC review.
Any generic requirements stemming from the report will be transmitted at a later date following completion of the appropriate procedural steps.
Original Signed By:
Hugh L. Thompson, Jr., Director Division of Licensing Enclosures:
1. NUREG-1154
2. EDO Memorandum of August 5, 1985
3. List of Generic Letters
- PREVIOUS CONCURRENCE SEE DATE
SL:ORAB:DL* C:ORAB:DL* AD/SA:DL* D/D ip JHannon:cl GHolahan DCrutchfield HTh mpson
7/24/85 7/24/85 7/25/85 8 85
UNITED STATES
NUCLEAR REGULATORY COMMISSION
WASHINGTON, D. C. 20555 AUG o 5 S98 MEMORANDUM FOR: Harold R. Denton, Director, NRR
James M. Taylor, Director, IE
Robert B. Minogue, Director, RES
C. J. Heltemes, Jr., Director, AEOD
James G. Keppler, Regional Administrator, RIII
FROM: William J. Dircks Executive Director for Operations SUBJECT: STAFF ACTIONS RESULTING FROM THE INVESTIGATION
OF THE JUNE 9 DAVIS-BESSE EVENT (NUREG-1154)
An advance copy of the subject report was transmitted to you by memorandum dated July 22, 1985 from the Davis-Besse Team Leader, C. E. Rossi. The report documents the Team's efforts in identifying the circumstances and causes of the June 9, 1985 event, together with findings and conclusions which form the basis for identifying follow-on actions.
You will note from the report that the licensee has not completed trouble- shooting and the determination of root causes for all equipment failures or malfunctions. Consequently, the results of future troubleshooting or analysis activities may form the basis for additional follow-on actions. The identifi- cation of these additional actions is a responsibility of the normal program office. The responsibility for the followup and reporting on the licensee's continued troubleshooting and determination of root cause for equipment failures is Region III.
The purpose of this memorandum is to identify and assign responsibility for generic and plant-specific actions resulting from the investigation of the Davis-Besse event (documented in NUREG-1154). In this regard, you are requested to review the enclosure which specifies staff actions resulting from the investigation of the June 9 Davis-Besse event. You are requested to determine the actions necessary to resolve each of the items in your area of responsibility and, where appropriate, identify additional staff actions or revisions as our review and understanding of this event are refined.
Plant-specific actions required for plant restart should receive priority attention.
Although the NRC Team that investigated the Davis-Besse event did not identify major NRC deficiencies, nonetheless this event provides an opportunity to learn from experience and to feed back the pertinent lessons into our activities.
Consequently, all responsible program managers should conduct an in-depth and searching reappraisal of the effectiveness of their programs and the lessons of the Davis-Besse event. In sum, how can we make our programs more effective
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-2- and the NRC a better regulatory agency? For example, what actions are needed when a utility continues to receive low SALP ratings; what impediments or procedures are delaying decisions regarding needed plant upgrades; how can effective corrective action be achieved when plants have a history of maintenance deficiencies; and what should be done when voluntary licensee improvement programs prove less than satisfactory? We need to reflect on these and similar questions and identify further, perhaps more focused actions to gain needed improvements.
In view of the importance of this subject, I intend to have periodic progress review meetings. The first meeting will be in September, and at that time you should be prepared to: (1) discuss the schedule and status of each item with- in your responsibility listed in the enclosure or that you have identified;
and (2) provide a written summary of those actions you have identified for achieving improvements in your program areas. Further, I request that you prepare a written status report on the disposition of your items (and anticipated actions for uncompleted items) within six months. -Every effort should be made to dispose of these items promptly.
The enclosure is based directly on the NRC Team's report. Accordingly, it does not include all licensee actions, nor does it cover NRC staff activities associated with normal event followup such as authorization for restart, plant inspections, or possible enforcement items. These items are expected to be defined and implemented in a routine manner. Overall lead responsibility for staff actions relating to facility restart is separate from this effort and rests with NRR. Additionally, NRR is responsible for coordinating and promptly communicating the staff's requirements which must be resolved before operations at Davis-Besse may be resumed. Other offices involved in plant-specific actions are to coordinate their efforts with NRR.
Separately from this action, I will be discussing with you further how we may improve the IIT procedures based upon the experience with the Davis-Besse Team.
William Drcks Executive Director for Operations Enclosure:
As Stated cc w/enclosure:
J. Davis, NMSS
T. Murley, RI
J. N. Grace, RI!
R. Martin, RIV
J. Martin, RV
STAFF ACTIONS RESULTING FROM THE INVESTIGATION
OF THE JUNE 9 DAVIS-BESSE EVENT
(Reference: NUREG-1154)
1. Item 1: Adequacy of the licensee's management and maintenance practices.
(Reference: Conclusion Section 8)
Action Responsible Office iCategory (a) Evaluate and take action on NRR Plant-specific the licensee's response to findings relating to corrective actions and preventive main- tenance problems (including testing, root cause determina- tion of equipment misoperation and operating experience).
Region III I Plant-specific (b) Evaluate and take action on the licensee's response to findings concerning management practices (e.g., control of maintenance programs and post-trip reviews).
2. Item: Completion of analyses for loss of feedwater events.
(Reference: Section 7)
Action Responsible Office Category Evaluate the time margins and NRR Plant-specific consequences of alternative sequences for a loss of feed- water event at Davis-Besse.
3. Item: Adequacy of the Steam Feedwater Rupture Control System (SFRCS).
(References: Section 5.2.2 and Finding 6)
Action Responsible Office Category Review the design basis for SFRCS NRR Plant-specific and the susceptibility of the SFRCS
to: a) spurious actuations involving such items as MSIV closure; and b)
single failures.
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4. Item: Interaction of plant security features and operator actions.
(References: Section 3.6 and Finding 9)
Action Responsible Office Category Evaluate the effect of security NRR Plant-specific features (locked doors, locked Generic equipment, etc.) on the operator's ability to gain prompt access to equipment required to perform safety actions outside the control room in accordance with emergency procedures.
S. Item: Availability of the Shift Technical Advisor (STA)
(References: Section 6.1.3 and Finding 14)
Action Responsible Office Category Evaluate the time available and NRR Plant-specific role for STA assistance during Generic complex operating events.
6. Item: Reliability of the AFW containment isolation valves and other safety-related valves.
(References: Section 5.2.5 and Findings 4, 5, 6, and 15)
Action Responsible Office Category (a) Monitor the licensee's Region III Plant-specific troubleshooting activities.
(b) Evaluate the licensee's engineer- NRR Plant-specific ing report on root cause analysis and proposed corrective actions.
(c) Determine if the safety function NRR Plant-specific of the ANE containment isolation valves has been properly specified, i.e., are the valves required to open as well as close for design basis events.
(d) Verify that these valves constitute NRR Plant-specific a single failure point for the ANE
system for certain design basis events.
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Acticon Responsible Office (e) Determine that the procedures for Region III Plant-specific adjustments of the AFW isolation valves such as torque switch bypass switches are clear and proper, and that.the associated training programs are adequate. Confirm that adjust- ment settings are consistent with plant procedures.
(f) Determine if the engineering NRR Plant-specific basis for the specification of the adjustments for safety- related valves such as the torque switch and torque switch bypass switch settings are adequate for all design basis events.
(g) Evaluate the test program for NRR Plant-specific the AFN containment isolation valves to confirm operability for all design basis events.
(h) Evaluate whether other safety- NRR Plant-specific related valves in Davis-Besse may be subject to the same type/
cause of failure.
(1) Conduct a review of failures of AEOD Generic safety-related motor-operated valves and provide an assessment of pertinent failure modes affecting valve performance under design basis conditions.
(j) Determine if further generic corres- IE Generic pondence, such as an NRC Bulletin, is warranted on this type/cause of failure of safety-related valves.
7. Item: Adequacy of emergency notifications.
(References: Section 6.1.4 and Finding 12)
Action Responsible Office Category (a) Verify the adequacy of the Region III Plant-specific licensee's procedures and training for reporting of events to the NRC Operations Center.
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(b) Review the adequacy of NRC IE Generic guidance for determination of severity levels when plant conditions vary and may be stable when the licensee has an opportunity to report.
Cc) Review the adequacy of shift IE Generic staffing for assuring that knowledgeable individuals will be available for properly implementing the emergency plan during complex and long operational events.
8. Item: Reliability of the AFW pump turbines.
(References: Sections 5.2.4 and 6.2.4 and Findings.4, 8, and 15)
Action Responsible Office Category (a) Monitor the licensee's Region III Plant-specific troubleshooting activities including possible hot plant operation to confirm failure mode.
(b) Evaluate the licensee's engineer- NRR Plant-specific ing report on root cause analysis and proposed corrective actions.
(c) Evaluate the licensee's response NRR Plant-specific and corrective actions relating to the unreliability of the auxiliary feedwater system (including the need for a third pump and turbine trip reset capability).
(d) Verify that the AFW system has Region III Plant-specific been adequately tested to con- firm system configuration involved with design basis events.
(e) Review the implementation of Region III Plant-specific the operator training program to assure proper operator actions, such as resetting of trip throttle valve.
(f) Conduct a review of past AEOD Generic operating experience and determine the causes for overspeed turbine trips.
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'g)- Determine the need for further IE Generic I generic correspondence on this
'failure mode/cause.
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9. 'Item: Reliability of the PORV.
(References: Sections 5.2.8 and 6.2.1 and Findings 10 and 13)
Action Responsible Office Category (a) Monitor the licensee's Region III . Plant-specific troubleshooting activities.
- (b)-'Evaluate the-licensee' s - NRR Plant-specific engineering report on root cause analysis and proposed corrective actions.
(c) Determine the need for a NRR Generic test program to establish reliability.
(d) Determine if surveillance tests NRR Generic are necessary to confirm opera- tional readiness. -i .
(e) Determine if additional NRR Generic protection against PORV
failure is necessary, i.e.,
automatic block valve closure.
10. Item: Adequacy of control room instrumentation and controls.
(References: Sections 6.1.1, 6.1.2, and 6.2.2 and Findings
10, 11, 17, and 18) I
Action Responsible Office Category (a) Evaluate the adequacy of - NRR Plant-specific the SFRCS actuation controls and associated training program.
(b) Evaluate the adequacy of NRR Plant-specific the installed control room instrumentation to allow operators to make the necessary and prompt determination for procedure conformance and PORV position.
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IAction Responsible Office Category (c) Determine if NRC requirements NRR Plant-specific should be revised regarding: Generic
(1) SPDS availability; and
(2) the need for plant- specific simulator.
11. Item: Need for isolation of the startup feedwater pump.
(References: Section 5.1.3 and Finding 7)
Action Responsible Office Category Reassess acceptability of the NRR Plant-specific provisions which resulted in the inability to place the startup feedwater pump in service from the control room.
12. Item: Resolution of equipment deficiencies.
(References: Section 5 and Table 5.1)
Action 'Responsible Office Category (a) Monitor the licensee's Region III Plant-specific troubleshooting activities.
(b) Evaluate the licensee's NRR Plant-specdfic engineering report on the root cause analysis and corrective aiction for the equipment listed'on Table 5.1 and not addressed by other items in this action plan.
(c) Determine the need for IE Generic generic correspondence on equipment problems.
13. Item: Adequacy of plant procedures.
(References: Sections 6.1.1 and 6.1.2.,and Findings 10 and 17)
Action Responsible Office Category Verify that plant procedures NRR Generic involving 'drasticw actions are required to be sufficiently precise and clear to ensure prompt implementation.
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14.i Itm
14 , I tem: Adequacy of safety system testing.
(Reference: Finding 15)
Action Responsible Office Category Evaluate the NRC requirements NRR Generic and guidance to assure that safety systems are tested in all configurations required by the design basis analysis.
15. Item: Acceptability of current safety assessment methods.
(References: Findings 1 and 2)
Action Responsible Office Category Assess the implications of RES Generic multiple independent and common mode failures as they relate to departures from design assumptions and specifications used in probabilistic safety analyses.
LIST OF RECENTLY ISSUED GENERIC LETTERS
GENERIC
LETTER NO. SUBJECT DATE
85-01 Fire Protection Policy Steering Committee Report 1/9/85
85-02 Staff Recommended Actions Stemming From NRC
Integrated Program for the Resolution of Unresolved Safety Issues Regarding Steam Generator Tube Integrity 4/15/85
85-03 Clarification of Equivalent Control Capacity 1/28/85 For Standby Liquid Control Systems
85-04 Operator Licensing Examinations 1/29/85
85-05 Inadvertent Boron Dilution Events 1/31/85
85-06 Quality Assurance Guidance for ATWS
Equipment that is not Safety-Related 4/16/85
85-07 Implementation of Integrated Schedules 5/02/85 for Plant Modifications
85-08 10 CFR 20.408 Termination Reports - Format 5/23/85
85-09 Technical Specifications for Generic Letter 83-28, Item 4.3 5/23/85
85-10 Technical Specifications for Generic Letter 83-28, Items 4.3 and 4.4 5/23/85
85-11 Completion of Phase II of "Control of 6/28/85 Heavy Loads at Nuclear Power Plants"
85-12 Implementation of TMI Action Item II.K.3.5,
"Automatic Trip of Reactor Coolant Pumps" 6/28/85
85-13 Transmittal of NUREG-1154 Regarding the Davis Besse Loss of Main and Auxiliary Feedwater Event 8/5/85