RBG-40675, Responds to NRC Re Violations Noted in Insp Rept 50-458/94-08.Corrective Action:Individuals Were Counseled on Procedural & Adminstered Disciplinary Action

Responds to NRC Re Violations Noted in Insp Rept 50-458/94-08.Corrective Action:Individuals Were Counseled on Procedural & Adminstered Disciplinary Action

ML20070A055
Person / Time
Site:	River Bend
Issue date:	06/22/1994
From:	James Fisicaro ENTERGY OPERATIONS, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
RBG-40675, NUDOCS 9406280159
Download: ML20070A055 (10)

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June 22,1994 U.S. Nuclear Regulatory Commission Document Control Desk Washington D.C. 20555

Subject:

Reply to a Notice of Violation IR 94-08

Reference:

River Bend Station - Unit I / Docket 50-458/94-08 File Nos.: G9.5, G15.4.1 RBG-40675 Gentlemen:

Pursuant to 10CFR2.201, please find attached Entergy Operations, Inc's (EOI) response to two notices nf violation described in NRC Inspection Report (IR) 94-08, dated May 23,1994. The inspection was perfonned by Messrs. Ward Smith and Chris Skinner during March 13 through April 23,1994.

In the inspection report, you raised concerns regarding procedure compliance and management oversight. RBS management acknowledges these issues and has initiatives underway to address these concerns. As previously presented, the focal point of this effort is the Long Tenn Perfonnance Improvement Plan (LTPIP) which will be completed over a three year period. These LTPIP initiatives adbess the issues identified in your inspection repon in that they include programs to increase management oversight of work activities and pmcesses and improve the overall quality and effectiveness of situ procedures. Although these initiatives will not immediately resolve all issues, the progmms are beginning to address your concerns and improvements have been noted.

The LTPIP includes management initiatives to monitor LTPIP cffectiveness through completion. These management checks are identifying areas that have improved and areas that require additional attention. With close management involvement, the programs requiring added attention are quickly identified and adjustments made.

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l Reply to a Notice of Violation IR 94-08 June 22,1994 RBG-40675 Page 2 of 4 An example of this check-and-adjust philosophy is the EOI Operations Peer Group task force that was developed to evaluate and improve the clearance tagging process. EOI identiGed that this complex process was a contributor to human perfonnance errors and that improvements were desirable. The task force, made up of representatives fmm each of the EOI nuclear sites, is completing an evaluation of the clearance program and is expected to present its findings to the Operations Peer Group in the near future.

In addition, the Opemtions Peer Group is developing a computerized tagging program to provide a common base program for EOI plants. Upon completion of the base pmgram, each plant will customize the program for unique plant characteristics (such as component identification information). The pmpose of this effon is to produce an efficient protective tagging process that will reduce the potential for human error while maintaining a high degree of conGdence that the program can be safely and effectively implemented.

We are improving the effectiveness of management oversight activities by establishing management review groups as integral parts of key work processes and increasing management involvement and observation of work activities. For example, LTPIP initiatives have implemented management review groups such as the Condition Review Group (CRG), Corrective Action Review Board (CARB), Work Control Center and senior management meetings with supervisors.

The CRG is an upper management review group that conducts daily reviews of Condition Repons (CRs) to ensure that significant issues are brought to the attention of senior management. These issues are presented to the CARB, made up of senior management, which ensures that the root cause and corrective actions adequately address the issue.

The Work Management Center was established to provide a cental location, outside the control room, to manage and suppon plant work activities. This initiative allows increased focus on oversight and control of work activities without additional burden on the control room staff.

A final example of this increased oversight are the meetings that were held between senior management and supervisors to discuss initiatives concerning procedure compliance, work mies and responsibilities. This meeting included a review l

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l Reply to a Notice of Violation IR 94-08 June 22,1994 RBG-40675 Page 3 ef 4 of the current results of these initiatives and a discussion to detennine what can be dono to improve our effectiveness in these areas. The Vice Presideni - Operations took this opponunity to re-emphasize our expectations for management accountability and personal involvement with personnel. Our expectations for procedure, work mies, or responsibility issues are that supervisors will conduct a full investigation, detennine root cause and develop appropriate corrective actions. For significant issues, the supervisor and responsible individual will meet with the Vice President - Operations or the General Manager - Plant Operations to review the issue. These reviews will provide consistent messages and corrective actions for each event or issue.

Regarding RBS procedure quality, interim procedure improvement initiatives are being developed as a subset of the long tenn Procedures Upgrade Project (PUP) Plan (see LTPIP, Chapter 18) to provide an immediate focus on improvement of site procedures.

The interim improvement initiatives focus on those procedures most important to continued safe operation and establish the foundation for implementation of the PUP.

Details of these interim measures will be provided to your office in a future letter.

River Bend Station management understands the significance of the issues that you have identified and is taking the necessary steps to resolve your concerns. We are confident that the corrective actions we have implemented will effectively resolve your concems.

Should you have any questions, please contact Mr. O. P. Bulich at (504) 336-6251. '

Sincerely,

,W .] W James J. Fisicaro Director - Nuclear Safety RMM enclosures f

9 Reply to a Notice of Violation IR 94-08 June 22,1994 RBG-40675 Page 4 of 4 cc: U.S. NRC Regional Administrator, Region IV 611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011 NRC Senior Resident Inspector P.O. Box 1051  ;

St. Francisville, LA 70775 i

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ATTACIIMENT A REPLY TO NOTICE OF VIOLATION IR 458/94-08-01 EliFERENG Notice of Violation - letter from A. B. Beach to J. R. McGaha dated May 23,1994.

YlOLATION

" Technical Specification 6.8.1 requires, in part, that written procedures shall be implemented covering the applicable pmcedures recomnwnded in Appendix A of Regulatory Guide 1.33, Revision 2, Febmary 1978."

l " Regulatory Guide 1.33, Appendix A, states, in pan, that equipment control (e.g., locking and tagging) should be perfonned in accordance with written administrative procedures."

" Administrative Procedure ADM-0027, " Protective Tagging," Revision 12, Section 7.2.1.4, stated, in pan, that positioning of valves and breakers shall be according to the positioning action specified and placed on clearance."

" Contrary to the above, on April 21,1994, after Clearance RB-94-1573 was completed and verified, Division II Station Battery Breaker ENB' BAT 01B was found opened but not racked out, as required by clearance."

REASON FO1GIE VIOLATION Entergy Operations agrees with the above characterization of this violation. We believe the not cause of the event was inattention to detail and failure to self-check for both the designated opemtor and the verifying opemtor.

On April 21,1994 two operators were assigned clearance RB 94-1573 which required that Switchgear ENB*SWG01B, Breaker ACB-581, be opened and racked out. While reviewing the clearance package, the operators noticed a sticker on the folder stating "Do not hang this clearance until ENB charger is in service". This special condition was discussed with the Tagging Official and the Work Management Supervisor. The Work Management Supervisor subsequently provided approval for the installation of the clearance.

The operators pmceeded to the Division II switchgear room where the clearance was to be placed. The designated operator verified the switchgear and breaker label with the clearance infonnation and opened the breaker. As the designated opemtor hung the tag, the second operator verified the correct switchgear and breaker label infonnation with the clearance I infonnation. i l

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. l Initial confusion surrounding the special conditions required the operators to research the caution note requirements to conGnn that the breaker could be opened as required by the clearance. Both operators displayed a questioning attitude concerning the caution note.

However, both operators failed to discern the clearance requirement to rack the breaker out. It is believed that the operators were distracted by the caution note on the clearance folder and became involved with detennining if they were allowed to open the breaker.

The designated operator failed to self-check his actions to ensure that the breaker was properly tagged-out in accordance with clearance RB 94-1573 and clearance procedure ADM-0027,

" Protective Tagging." In addition, the verifier did not adequately perfonn a concurrent verincation as required by procedure ADM-0027 and in acconlance with ADM-0076, "Verincation Program," which provides general veriGcation direction.

It is general practice to open and rack-out an electrical breaker (breakers similar to ACB-581 that are capable of being racked-out) during clearance tagging. This requirement provides redundancy in ensuring that the requirements of the clearance are met. Opening the breaker isolated the system as intended by the cleanmcc but did not provide the desired level of redundant protection.

CORRECllVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED Upon identification of the discrepancy, the breaker was racked-out to meet the requirements of ADM4)027. In addition, the opemtors involved with the incident were counseled on management expectations for strict procedural compliance and administered disciplinary action.

F ADM-0027 (Section 7.5.4) was revised to incorporate a requirement for independent verification of proper tag placement. Concurrent veriGcation of tag placement is allowed only when tags are to be placed in High Radiation Areas and then only with the approval of the Operations Superintendent.

CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS The revision to ADM4)027 which implemented the formal requirement to independently verify tag placement should reduce the likelihood for future violations of this nature. However, additional actions are planned to streamline the cleamnce process.

Specifically, ADM4)027 will be revised to present the program requirements in a simplified fonnat. This revision will result in a more effective procedure and a sepamte " Tagging Guide" containing much of the detailed, "how to" infonnation currently contained in ADM-0027. The current procedure includes descriptive infonnation on how to install and remove  ;

cleamnces for specific components (e.g. AOV isolation, MOV isolation, and electrical breaker isolation). This descriptive infonnation will be moved from the procedure to the Tagging Guide. The revised procedure will contain the speciGc program execution requirements.

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A commercially-available training program for operators is currently being evaluated to provide additional guidance with regard to self-checking as a means to reduce human perfonnance related errors. As currently envisioned, this training will help operators manage distractions to increase focus on work activities, maintain alenness, and effectively manage the time constraints associated with operations work activities.

Chapter 13 of the LTPIP provides initiatives to improve the overall effectiveness of human perfonnance at RBS. These initiatives establish programs to increase employee ownership and accountability. The programs utilize proven industry methods that have been effective in reducing human error by assuring that work is done correctly the Drst time and by identifying and solving the root causes of human perfonnance errors. These initiatives also include the removal of human perfonnance " traps" such as procedure qua'ity and compliance which are being addressed as part of the Procedures Upgrade Project (PUP) Plan (LTPIP Chapter 18). ,

pATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance was achieved when River Bend Station personnel racked out the breaker in compliance with the establi.ched tagging requirements. ADM-0027 has been revised to incorpomte a requirement for independent verification of proper tag placement. Other initiatives that are currently being evaluated are 1) a revision to ADM-0027 to simplify procedure content, and 2) development of a computerized tagging program to impmve the effectiveness of the overall program. An Operations Peer Group task force is also currently evaluating the program for additional improvements. LTPIP initiatives will be implemented  ;

and completed in accordance with the schedules outlined in the plan (Refer to EOI submittal RBG-40428, dated March 28,1994).

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REPLY TO NOTICE OF VIOLATION IR 458/94-08-02 EEFERENCE Notice of Violation - Letter from A. B. Beach to J. R. McGaha dated May 23,1994.

VIOLATION

" Technical Specification 6.8.1.d requires, in part, that written procedures shall be implemented covering surveillance and test activities of safety-related equipment."

" Surveillance Test Procedure STP-257-4502, " Primary Containment Purge Isolation Radiation-Ifigh Activity Monitor Monthly Channel Functional (RMS*RE21B)," Revision 6, Section 5.12, stated, in part, that the Keithly Programmable Current Source required a 1-hour wann-up time to achieve its required accuracy. Prerequisite Section 6.10 states, " Ensure the current source has been energized for at least I hour"."

"Contmry to the above, on April 14, 1994, licensee personnel commenced the procedure section of Procedure STP-257-4502 without energizing the current source, as required by Prerequisite Section 6.10, and failed to energize the current source for at least I hour prior to use, as required by Step 7.1.6.1."

A clarification should be noted in the above statement concerning Section 6.10 of STP-257-4502, Revision 6. Section 6.10 states to " Energize the current source to allow it to wann up."

BEASON FOR Tile VIOLATION Entergy Operations agrees with the above characterization of this violation. We believe the root cause of the event was the technician's lack or adequate knowledge of the equipment wann-up requirements.

The Keithly Progmmmable Current Source, Model 220 (PCS-001 A), used to perfonn ,

Surveillance Test Procedure (STP) STP-257-4502, described above, was energized (warmed-up) in the Instnmientation and Control (I&C) Shop for one hour prior to performing the test.

After the warm-up, PCS4)01 A was taken to the control building to perform the test and approximately one hour later, was plugged in at the test site. Approximately 30 minutes later, -

the technician reached STP step 7.1.6 which states to " Ensure the current source has been energized for at least one hour

• The intent of this requirement is to energize the current source for one hour without power intermption. However, the technician did not follow proceduml requirements and inappropriately took credit for the one hour shop wann-up and signed-off the step as being satisfied.

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o 3 The Keitiily Prognunmable Current Source Instmetion Manual states that, "If the instrument has been subjected to extreme temperature, allow sufficient time for internal temperatures to reach nonnal operating conditions....". The manual defines normal operating conditions as 18  ;

C to 28 C (64.4 F to 82.4 F) and less than 70% noncondensing humidity. The manual also states that, " Typically, it takes one hour to stabilize a unit that is 10 C(18 F) out of the specified range." The current source was stored, used and subsequently tested in the Control Building where the environment is controlled within these conditions. Typically these instmments are not used where environmental conditions would exceed those specified by the vendor. An interview with the technician iuvolved with the incident confirmed that the instmment was not exposed to extreme conditions at any time.

The technician believed he could satisfy the wann-up requirements of the STP by wanning up the instmment in the I&C Shop prior to field use. The technicians inadequate knowledge of the equipment warm up requirements led improper use of the instrument as required by procedure.

CORRECTIVE STEPS TilAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED PCS-001 A was taken to the Standards Laboratory to verify its accuracy with less than one hour wann-up. At the Standants Laboratory, PCS-001 A was energized for 15 minutes and tested.

The instrument remained within the tolerances specified in the vendor's instmetion manual.

The instmment remained energized and was tested again in 30 minutes. It was again found within acceptable tolerance. The checks verified the current source was within tolerance during perfonnance of STP-257-4502. Therefore, the as-tested STP data was detennined to be acceptable. Since the environmental conditions where these instruments are typically used is within the requirements specified in the vendor technical manual, the test methodology (shop wann-up) used by the technician was technically acceptable.

The technician involved with the incident was counseled on the proper interpretation of test equipment wann-up requirements and management expectations for strict procedural compliance. In addition, a group meeting was held to discuss lessons leamed with other I&C technicians. Observations indicate that personnel are properly utilizing the Keithly current source as required by procedure.

CQERIICTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTIIER VIOLATIONS A comprehensive exam is being developed for I&C technicians and first line supervisors to l identify areas that can be improved and detennine if application of the exam is needed for l other maintenance disciplines. The exam, to be developed by June 30,1994, will address many functional areas including fundamentalI&C knowledge requirements, surveillance testing perfonnance, and knowledge of M&TE equipment requirements. Corrective actions to address the areas needing improvement will be evaluated to incorporate additional training into 1 the continuing tmining program or improve I&C pmcedures. I l

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N Chapter i3 of the LTPIP provides initiatives to improve the overall effectiveness of human '

perfonnance at RBS. These initiatives establish programs to increase employee ownership and accountability. The programs utilize proven industry methods that have been effective in reducing human error by assuring that work is done correctly the Grst time and by identifying and solving the root causes of human perfonnance errors. These initiatives also include the removal of human perfonnance " traps" such as procedure quality and compliance which are being addressed as part of the Procedures Upgrade Project (PUP) Plan.

The PUP is being developed to implement the LTPIP Chapter 18 procedure improvement initiatives. The PUP Project Plan reflects the procedural goals and commitments identiGed in the LTPIP but provides additional details and speciGe program requirements. The plan will include an evaluation to detennine the level of detail required for procedures and work instmetions to achieve the appropriate balance between the training based knowledge of the user and written direction included in the documentation. This initiative is directed to improve the quality and use ability of procedures and reduce the human perfonnance error rate associated with procedural compliance. Interim measures that will support implementation of this plan are currently being implemented. Details of this plan will be provided to your ofGce in a future letter.

Management expectations for strict regulatory and procedural compliance has been conveyed to RBS site personnel through "all hands" meetings presented by the Vice President Operations and through memoranda presented by the General Manager - Plant Operations. Section 1.5 of  ;

LTPIP Chapter 18 provides initiatives to continue to convey management expectations for l strict procedural compliance. These initiatives will pre /Me training to all procedure users to emphasize the linportance of procedure adherence and os ,N the improved mechanisms l available to change procedures. I DATE WilEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance was achieved upon completion of the instrument accuracy test performed on May 3,1994 which verified the acceptability of the STP test data. A comprehensive exam for I&C Technicians and first line supervisors will be developed by June 30,1994.

Implementation of this exam is expected to begin in August,1994 and should be completed in October,1994. The Gndings of this exam will be evaluated and any necessary actions needed as renected by the test results will be incorpomted into the I&C continuing training programs and procedures. The LTPIP initiatives will be implemented and completed in accordance with  !

the goals and schedules outlined in the plan (Refer to EOI submittal RBG-40428, dated March 28, 1994).

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