View source for BVY-93-105, Summarizes Findings & Corrective Actions That Will Be Implemented Prior to Resuming Fuel Handling Activities,As Followup to Recent Discussions W/Nrc Region I Re Two Fuel Incidents on 930903 & 09

{{Adams
| number = ML20057C359
| issue date = 09/20/1993
| title = Summarizes Findings & Corrective Actions That Will Be Implemented Prior to Resuming Fuel Handling Activities,As Followup to Recent Discussions W/Nrc Region I Re Two Fuel Incidents on 930903 & 09
| author name = Reid D
| author affiliation = VERMONT YANKEE NUCLEAR POWER CORP.
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000271
| license number = 
| contact person = 
| document report number = BVY-93-105, NUDOCS 9309280267
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE
| page count = 2
}}

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VERMONT YANKEE NUCL, EAR POWER CORPORATION
         ,.q               Ferry Road, Brattleboro, VT 05301-7002 s    )                                                                          ENGINE I i OFFICE i
580 MAIN S1REET BOLTON. MA 01740              ,
(508) 779 C.711             j September 20,1993                                     !
BVY 93-105 United States Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555

==Reference:==
a)       License No. DPR-28 (&[c . No. 50-271) 1

==Dear Sir:==

I l          

==Subject:==
Summary of Fuelllandling Incidents and Corrective Actions 1
As a followup to our recent discussions with NRC Region 1 concerning two fuel handling                        j incidents at our site, the following summarizes our findings and corrective actiens that will be                         :
implemented prior to resuming fuel handling activities. The root cause has been identified in both cases i          to be human error. Although there were other contributing causes, this conclusion is based on the fact that each crew had made many successful fuel moves prior to the occurrence of each incident.                             I l
For the first incident, which occurred on September 3,1993, the bridge operator and the Senior Reactor Operator (SRO) did not properly execute various steps of the procedure that could have ensured that the fuel bundle was properly grappled. The second incident, which occurred on September 9,1993, was caused by the bridge operator acknowledging an order to raise the fuel assembly but, improperly, going to lower. Additionally, the operator did not verify that the initial motion was in the correct direction.
l Comprehensive corrective actions were taken after the September 3 incident. Additional training l
both in the classroom and on-the-job was conducted for all crews. Command and control was significantly improved including requiring the same high standards of performance on the refuel floor as                 j practiced in the control room. The refueling procedure was revised. Two modifications were made to                       i the refueling platform controls to improve human factors. Subsequent self-assessment initiatives in the fuel handling area revealed that the corrective actions were targeted in the right areas, effective in the areas related to the first incident, and positively received and implemented. These actions did not preclude the second incident from occurring because the second incident was primarily caused by human error.
Following the second event, a senior management task force chaired by the Plant Manager and including the Quality Assurance Director and an engineer experienced in human factors, was formed to t          thoroughly investigate the circumstances of the two fuel handling incidents. Additional corrective actions l           now in the process of being implemented include a seccmd revision of the fuel handling procedure to clearly delineate the responsibilities of each member of the refueling crew. The SRO's responsibilities             ;
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U.S. Nuclear Regulatory Commission September 20,1993 l       Page 2 l
in the areas of ensuring procedure compliance, briefing the crew before each crew change and directly overseeing the critical phases of any fuel move will be emphasized. A human factors review of the refueling equipment will result in a change to the orientation of the joystick and a change to the color of the grapple closed indicating light. Additional classroom and hands-on crew training will be conducted before resuming fuel moves. This training will focus on equipment modifications, procedure changes and managements' expectations for self-checking, procedural compliance and teamwork.
In addition to the immediate corrective actions, long term corrective actions will be pursued.
Training will be enhanced to place more emphasis on safety significant infrequent operations and to require cognizant engineer verification of design change training materials. A comprehensive human factors review of the entire refueling process will be conducted. The QA and self-assessment processes will emphasize the need to focus on infrequently performed safety-significant activities.
l                It is our iment to discuss these items in more detail when we meet with you on Tuesday, l       September 21,1993. We assure you that all issues will be fully resolved before resuming fuel moves at Vermont Yankee.
I Very truly yours, Vermont Yankee Nuclear Power Corporation A-                O Donald A. Reid Vice President, Operations cc:      USNRC Region I Administrator USNRC Resident inspector - VYNPS USNRC Project Manager - VYNPS l
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