View source for RBG-31222, Responds to Violations Noted in Insp Rept 50-458/89-11 on 890315-0430.Corrective Actions:Retraining of Personnel, Revising of Tagging Procedure,Addl Classroom Training & Assigning Util Personnel to Oversee Contractor Clearances

{{Adams
| number = ML20246G256
| issue date = 07/07/1989
| title = Responds to Violations Noted in Insp Rept 50-458/89-11 on 890315-0430.Corrective Actions:Retraining of Personnel, Revising of Tagging Procedure,Addl Classroom Training & Assigning Util Personnel to Oversee Contractor Clearances
| author name = Deddens J
| author affiliation = GULF STATES UTILITIES CO.
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000458
| license number = 
| contact person = 
| document report number = RBG-31222, NUDOCS 8907140208
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE, UTILITY TO NRC
| page count = 8
}}

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* GULF STATES                      UTILITIES COMPANY mowemm         n u ot,c r et.x r-         a rwmm u muue. -
API A C M M;4      (IiG 6'.?94   346 Et L1 July 7, 1989 RBG- 31222 File Nos. G9.5, G15.4.1 U. S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Gentlemen:
River Bend Station - Unit 1 Refer to: Region IV Docket No. 50-458/ Report 89-11 Pursuant to 10CFR2.201, this letter provides Gulf States Utilities Company's (GSU) response to the Notice of Violation contained in NRC Inspection Report No. 50-458/89-11. The inspection was performed by Messrs. E. J. Ford and W.
B. Jones during the period of March 15 through April 30, 1989 of activities authorized by NRC Operating Licensing NPF-47 for River Bend Station - Unit 1.
GSU's response to the violation is divided into two parts for the sake of clarification and is provided in the attachments.                            GSU will provide a supplemental response to document the corrective actions taken by December 15, 1989.
Should you have any questions, pleasecontactMr.L.A,.Englandat(504) 381-4145.
Sincerel ,
J. C. Dedcens Sr. Vice President River Bend Nuclear Group FP/WH0/TCC/ F/ Kgch Attachments                                                                                                                4 1
cc:     U. S. Nuclear Regulatory Commission                                                                               ,
Region IV 611 Ryan Pla7a Drive, Suite 1000 Arlington, TX 76011 NRC Senior Resident Inspector P. O. Box 1051 St. Franc 4ville, LA 70775                                             g/
                                                                                                            /glgl e,907140208 890907                                                                          '/
PDR          ALOCK 05000458 O                         PDC

UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION-STATE OF LOUISIANA                                                )
PARISH OF WEST FELICIANA                                          )'
Docket No. 50-458 In the Matter'of                                                  )
GULF STATES UTILITIES COMPANY                                      )
(River Bend Station-- Unit 1)
AFFIDAVIT J. C.-  Deddens,                   being . duly     sworn,    states that he is a Senior Vice President of Gulf States Utilities Company; that he is authorized on the part of said company to sign and file with the' Nuclear Regulatory Commission the documents attached hereto;              and that all such documents are true and correct to the best of his knowledge, information and belief.
J. C. D6d7 dens Subscribed and sworn to before me, a Notary Public in and for the State and Parish above named, this                                         'I            day of to/Af                       , 19 79   . My Commission expires with Life.
V        b kl      D       . klGO Claudia F. Ilur5 t Notary Public in and for West Feliciana Parish, Louisiana

ATTACHMENT 1 Response to Notice of Violation 50-458/8911-01A i
A. REFERENCE                                                                      I l
Notice of Violation - Letter from L. J. Callan to J.      C. Deddens, dated May 31, 1989 VIOLATION Criterion XVI of Appendix B to 10CFR Part 50 requires that measures be established to assure that conditions adverse to quality are promptly identified and corrected.
Quality Assurance Directive QAD-16,        " Corrective Action," Section 4.3,  i states that procedures shall require that corrective action be promptly        '
initiated and adequately documented by the responsible department to correct the condition and to determine if action is necessary to preclude its recurrence.
River Bend Nuclear Procedure RBNP-0047,         " Corrective Action Program,"
Section 5.4, requires that corrective action be promptly initiated and adequately documented by the responsible department to correct the condition and to determine if action is necessary to preclude .its recurrence.
Contrary to the above, adequate corrective actions were not taken to prevent repeat violations       of Administrative Procedure ADM-0027,
                                                                     " Protective Tagging." During the period of March 18 through April 12, 1989, the licensee identified eleven procedural violations of ADM-0027.
The corrective actions taken did not determine the extent to which protective tagging program violations existed, l
REASON FOR VIOLATION GSU has rev$ewed the associated protective tagging program condition reports (CR) stated in Inspection Report 8911 and other related CRs initiated during the second refueling outage (RF2). GSU has reviewed the chronology presented in the Inspection Report and finds it accurate. The various problems identified from our review of CRs can be categorized into four major areas:
: 1. Individuals working without a clearance or a wrong clearance,
: 2. Tagging boundaries were violated,
: 3. Clearances were released without work being finished, or
: 4. Crews began work on the wrong train.
Several    root causes have been identified from GSU's review.             The contributing     causes were attributed to poor communication between Page 1 of 4

f g                                 ,
[                                   - contractor work crews and their         supervisors,   contract    personnel l''                                  unfamiliarity.with RBS plant design, and failure of contract personnel to take adequate- precautions to follow details in RBS administrative procedure (ADM)-0027, " Protective Tagging". GSU determined the primary cause was inadequate training of contract personnel             to   ADM-0027 requirements.      In addition, the re-training provided as a corrective action was not adequate to preclude future occurrences.
CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND RESULTS ACHIEVED Numerous corrective actions were taken for each RF2 CR related to protective tagging.      GSU took additional actions after recognizing that previous corrective actions had not been adequate to prevent recurrence of additional tagging violations. Immediate corrective actions include:
: 1)    Contract personnel responsible for the tagging violations were re-trained,
: 2)    Tagging procedure (ADM-0027) was revised,
: 3)    Additional " Tool Box" and formal classroom training was conducted.
: 4)    Individuals involved in violations were removed from the " Authorized Requestor" list,
: 5)    GSU personnel were assigned to oversee and co-sign contractor clearances,.
: 6)   'A 100% review of open supplemental clearances and partial      releases as completed,
: 7)    GSU discontinued the use of supplemental clearances for RF-2,
: 8)    Operations Quality Assurance surveillance were increased for safety and non-safety related work activities for          review    of   work documentation and tagging, and
: 9)    Tagging officials were retrained and instructed to give closer attention to details prior to resuming duties.
The root causes mainly focused around contcactor personnel events; therefore, GSU believes the program implementation by GSU personnel is satisfactory. Supplemental clearances have been reinstituted, post outage, since the contractors involved are no longer performing work on site. Contractors will not be allowed as holders of clearances under ADM-0027 pending completion of task force review activities.
CRs are sent to a wide distribution, including but not limited to Quality Assurance, Licensing, and the Independent Safety Engineering Group (ISEG). CRs are now reviewed and trended daily in accordance uith a new procedure, RBNP-052,
* River Bend Station Trending Program", to determine adverse trends. The recently developed and approved trending program is designed to detect long term trends.       RBNP-0052 recommends that trend reports be issued at six month frequencies.            Short term trends are generally discovered through the various CR reviews and periodic trend reports issued to RBS management (typically every 1-2 weeks).
CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FUTURE VIOLATIONS Long term corrective action falls into two areas that are being addressed separately.
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A. GSU will enhance the existing program with the following actions:
l                                            1)   An' upper tier River Bend Nuclear Procedure (RBNP) is being             ]
developed to standardize root cause analysis based on INPO Good Practice OE-907, " Root Cause Analysis".
: 2)   Training will be provided to all licensee personnel required to provide root cause analysis for responses to condition reports and other nonconformance documents.
: 3)   Administrative Procedure, ADM-0019 " Initiation and Processing of Condition Reports" currently requires root cause analysis under the following conditions:
a)        Conditions classified Quality Class I or QA Program Applicable and result in significant conditions adverse to quality, b)        Conditions reportable to the NRC, or c)       Other conditions adverse to safety for which a root cause
                                                           . determination is made                                        j Additionally, all CRs are reviewed for potential deportability.
GSU also determines whether a root cause analysis is required for selected CRs other than~ safety related conditions utilizing the following guidelines:                                              i a)        Conditions irdicate repetitive problems, i
b)        Conditions impact the reliability of the plant, or c)        Conditions have an impact on the safety of personnel or the protection of equipment This root cause determination effort will continue. The root cause selection process will be evaluated to determine its effectiveness.          It is expected that the implementation of root cause analysis, given sufficient review time, will result in effective and timely corrective actions by GSU.
B. The following actions for the ADM-0027 tagging program will be performed:
: 1)       An RF-2 critique for lessons learned will be completed
: 2)       A task force will be developed to review the existing tagging program considering:
a)    Use of supplemental clearances (ALARA vs. safety considerations) b)    Differences between the RBS tagging program and the GSU corporate program, Page 3 of 4

                                 ,6 c)   A tagging computer program will be evaluated for use and recommendations will be provided - to include training, d)   Tagging programs in use at other nuclear facilities will be surveyed for recommended changes, e)   Current tagging       forms  will   be  reviewed  for simplification and improvement.
: 3)   ADM-0027 may be revised based on the recommendations of the task force.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED:
The RBNP to standardize root cause analysis will be approved by September 30, 1989. A supplemental response will be submitted by December 15,-1989 to document all corrective actions after Final Task Force actions are     1 identified.
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                                                                                                                                                      ' ATTACIMENT 2 Response to Notice of Violation (NOV) 50-458/8911-01B
                      'B. REFERENCE
                           . Notice. of ' Violation - Letter from L. J. Callan to J.                                                                                                               C.. Deddens, dated May.31, 1909 1
VIOLATION cg'                          Criterion XVI of Appendix B to 10CFR Part.50 requires that measures be established to assume that conditions adverse to quality are promptly identified and corrected.
1; U                            Quality Assurance Directive QAD-016, " Corrective Action," Secticn 4.3; states that procedures shall require that corrective action be.promptly
                           . iuitiated and. adequately documented by the responsible department to.
correct the condition and to determine if action is necessary to preclude its recurrence.
River Bend Nuclear' Procedure RBNP-0047, " Corrective Action Pr6 gram,"
Section 5.4, requires that corrective action be promptly initiated and
                           -adequately documented by the responsible department to correct the condition and to de termine if action is necessary to preclude its recurrence.
Contrary to the above, corrective actions described in Licensee -Event Report (LER) 87-029, " Residual . Heat Removal System Isolation Due to Inadvertent Jumper tirounding," were not adequately documented in that no procedural            changes were implemented to prohibit the practice of taping together two short jumper wires rather than using a jumper of the appropriate length. As a result, the unit underwent a loss.cf shutdown cooling for six minutes on April 27, 1989, when a taped jumper separated during a surveillance test.
l                           REASON FOR VIOLATION To address the second part of NOV 8911-01, the corrective action stated in Licensee Event Report (LER) 87-029 included prohibiting the practice of taping jumper wires together for use inside control room cabinets.
This corrective action would have been sufficient; however, no mechanism was in place to ensure that the corrective action would remain intact.
As a result of this omission, on April 27,                                                                                                        1989, a second incident involving the separation of taped jumper wires caused an electrical transient inside a control room cabinet leading to e temporary !oss of residual heat removal (RHR) system shutdown cooling. GSU determined the root cause to be inadequate corrective actions to revise ADM-015
                              " Station Surveillance Test Program", to ensure continued compliance.
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CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND RESULTS ACHIEVED
: 1.                 Instrumentation and Controls                        (I&C) technicians were briefed about this l                  incident and were cautioned to                            exercise    care    while performing surveillance testing.                      In addition, techniques for employing more secure test connections are being used within the I&C Department to prevent similar incidents. While the unit was in mode 5, the RHR shutdown cooling. isolation logic was removed to prevent further isolations of shutdown cooling. The logic was restored to service prior to draining the upper fuel pools to less than 23 feet above the top of the reactor pressure vessel flange.
Temporary change notice (TCN) 89-0898 was issued and approved against ADM-0015 to prevent the use of taped jumpers as well at alligator-type clips 09 jumpers within the control room.
CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FUTURE VIOLATIONS The TCN incorporated into ADM-0015 also requires a generic statement concerning'the use of taped jumpers ano alligator-type clips be added to all I&C and electrical surveillance test procedures during their next revision. I&C and electrical technicians will                              receive training on TCN 89-0898.
DATE W;fN FULL COMPLIANCE WILL BE ACHIEVED I&C and electrical technicians will receive training on TCN 89-0898 by August 30, 1962                       I &'. red electrical,        control    room  applicable, surveillance test procedures (STPs) will be re.: sed during their next two year revision cyc"? by adding a generic statement on the use of secure test connections. The revision cycle for all subject STPs ends during July, 1991.
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