View source for RBG-40935, Responds to Violations Noted in Insp Rept 50-458/94-18. Corrective Actions:Relief Valve 1E22 RVF039 Was Verified to Have Been Seated & Leak Tight by Evidence of Sys Pressure Observed on Other Valves within Test Boundary

{{Adams
| number = ML20076G376
| issue date = 10/14/1994
| title = Responds to Violations Noted in Insp Rept 50-458/94-18. Corrective Actions:Relief Valve 1E22 RVF039 Was Verified to Have Been Seated & Leak Tight by Evidence of Sys Pressure Observed on Other Valves within Test Boundary
| author name = Fisicaro J
| author affiliation = ENTERGY OPERATIONS, INC.
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000458
| license number = 
| contact person = 
| document report number = RBF1-94-0054, RBF1-94-54, RBG-40935, NUDOCS 9410190282
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE
| page count = 10
}}

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Entstry Opsr:tions, Inc.
River Bend Station -
5485 US Highway 61              .
RW                                                                    " "
* 2                         t St Francisvilio. LA 70775 ~     i (504) 336 6225                  ;
              ,                                                                                 FAX (504) 635 5008 JAMES J, FISICARo               !
Director                        {
Nuclear Safety _                ;
i October 14,1994                                                                                                    l U.S. Nuclear Regulatory Commission                                                                                 i Document Control Desk                                                                                              ;
Mail Stop PI-37                                                                                                    i Washington, D.C. 20555                                                                                             :

==Subject:==
River Bend Station - Unit 1                                                                 l Docket No. 50-458                                                                           l License No. NPF-47                                                                          }
Reply to Notices of Violation Described in Inspection Report 50-458/94-18, dated September 16,1994                                     ,
i File No.:              G9.5, G15.4.1                                                                               ,
RBG-40935                                                                                                          [
RBF1-94-0054                                                                                                       i Gentlemen:                                                                                                         I l
Pursuant to 10CFR2.201, attached is Entergy Operations, Inc.'s response to notices of '                            f violation described in NRC Inspection Report (IR) 50-458/94-18.                                                    ;
In the Inspection Report, the Staff expressed concems regarding the three violations. The                          f first concern deals with failure to properly implement a corrective action committed to in a                     .j Licensee Event Report. River Bend Station (RBS) management certainly understands that                            .j any condition adverse to quality warrants technically sound and comprehensive corrective                           i actions. Entergy is committed to making improvements in this area through initiatives                              [
such as the Long Term Perfonnance Improvement Plan (LTPIP). As you know, the.                                      l LTPIP includes procedure related initiatives which should reduce the potential for a similar                       t occurrence in the future.                                                                                          ;
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  -4 Reply t'o Notice of Violation IR 94-18 October 14,1994                                                                               ,
RBG-40935 RBF1-94-0054 Page 2 or 3 The Staff's second concern relates to a local leak rate test procedure that was performed     -
and signed-off as being complete, when in fact, other valves in the isolated boundary were not tested. You also requested that Entergy Operations address actions taken or planned to ensure that there are no additional surveillance test procedures (STPs) signed off as completed if they are not. Our review of the circumstances surrounding violation 9418-02 suggests that any potential vulnerability in this area is limited to those STPs which implement 10CFR50, Appendix J requirements. As discussed in the attached response, a review of these STPs did not reveal any discrepancies.                                        ;
As previously communicated to you, we recognize that our procedure quality mquires improvement and, as communicated earlier, we have implemented a Procedures Upgrade            :
Project for that purpose. As part of this project, we recently issued a major revision to the upper-tier procedure that governs control and use of RBS procedures. This revision will l
strengthen the processes we use for revising, cancel'ing, eviewing and approving procedures, including all STPs. Specifically, the re ised process does not pennit changes to procedure scope or intent without multiple reviews.
Your final concern mgarding two valves that wem found out of their required position is an    ;
issue that EOI is striving to eliminate. We have determined that the most probable root cause of the mispositioned valves is personnel error. A review of our condition report database suggests that valve misposition is a relatively uncommon occurrence. We              i recognize the imponance of human perfonnance and will continue to pursue the related          !
initiatives in the LTPIP.                                                                     j Should you have any questions, please contact Mr. T. W. Gates at (504) 381-4866.
f Sincerely,
[          A-
[
JJF/kvm                                                                                       !
attachments i
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Reply to Notice of Violatica IR 94-18 October 14,1994 RBG-40935                                                                                                                                  i REF1-94-0054 Page 3 or 3 cc:    U.S. Nuclear Regulatory Commission Region IV 611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011 NRC Resident Inspector                                                                                                             i i                          P.O. Box 1051 St. Francisville, LA 70775 Mr. D.L. Wigginton U.S. Nuclear Regulatory Commission Mail Stop Ol3-H-3 Washington, DC 20555 i
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                  .                                                                                     Attachment 1    l
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l Reply to Notice of Violation                                        '
94-18-01                                              ]i VIOLATION                                                                                          '
10 CFR Part 50, Appendix B, Criterion XVI states, in pan, that conditions' adverse to quality     :
and nonconfonnances shall be promptly identified and corrected to preclude repetition.             -
In Licensee Event Report 458-92-012, the licensee identified that containment isolation
* Thennal Relief Valves IE22*RVF039, IE12*RVF036, IE12*RVF030, and IE12*RVF005 were not leak rate tested as required by Technical Specification 3.6.4. The licensee's corrective actions included revising and implementing surveillance test procedures to test the four valves with a water leak test.                                                                :
Contmry to the above, as of August 18,1994, a condition adverse to quality was not corrected in that Thennal Relief Valve IE22*RVF039 was never tested because of a valve lineup error made while revising Surveillance Test Procedure STP-203-3829, "High Pressure Core Spray Valve Leak Rate Test (water)."
i REASON FOR TIIE VIOLATION Entergy Operations, Inc. admits this violation and believes the reason for the violation was personnel error made during the procedure revision process, in that the revised surveillance procedure did not receive an adequate technical review.                                            l Surveillance Test Procedure (STP)-203-3829, "High Pressure Core Spray Valve Leak Rate Test (Water)," was revised to extend its test boundary to include Thennal Relief Valve             i lE22*RVF039 for testing during RF-4. This valve, along with three other valves, was added to the test pmgram to comply with technical specification requirements as discussed in River       !
Bend LER-92-012. During the procedure revision process, the applicable valve lineup data sheet was revised to change the test boundary to close condensate storage tank return valve IE22*MOVF011. STP-203-3829 was later issued and implemented during RF-4.
Following RF-5, it was discovered that relief valve IE22*RVF039 was not tested because no specific step had been added to the STP to open valve IE22*MOVF010, wif.ch would have              l allowed valve IE22*RVF039 to be tested. Review of the STP (and P& ids) revealed that the valve lineup data sheet should have been revised to not only close condensate return valve         -
;                   IE22*MOVF011, but also to open valve IE22*MOVF010. The primary purpose of the                      ;
i procedure revision was to include valve IE22*RVF039 within the test boundary of the STP;           j however, personnel revising the procedure did not perfonn an adequate review of required            j document (including P& ids) to ensure that valve 1E22*RVF039 would be tested.                     _
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      .                                                                                    Attachment 1 Page 2 of 2 l
_C_ORRECTIVE STEPS TIIAT HAVE BEEN TAKEN AND TIIE RESULTS ACIIIEVED The following corrective steps were taken in response to this event:
: 1. A Condition Report (CR 94-1035) was written to document this condition and to facilitate disposition and implementation of corrective actions.
: 2.      Relief Valve IE22*RVF039 was verified to have been seated and leak tight by evidence of system pressure observed on other valves within the test boundary.
: 3. Surveillance Test Procedures for the remaining 17 valves referenced in LER 92-012 j              requiring water leak rate tests were reviewed. All required testing for these valves was   '
I              verified to be complete.
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: 4.      A review of all low pressure leak rate test procedures (and a representative sample of air test procedures) was perfonned to ensure the technical adequacy of each procedure.
The review consisted of an assessment of previously perfonned procedures and of P& ids to confinn correct valve lineup, system test configuration, test method, and compliance with technical specification requirements.
: 5.      The personnel involved in this event are no longer employed at RBS. As such, no specific personnel related corrective action is necessary.
CORRECTIVE STEPS TIIAT WILL BE TAKEN TO AVOID FURTIIER VIOLATION Entergy Operations, Inc. will continue to implement initiatives to improve human perfonnance. As discussed in previous correspondence to the staff, these initiatives allow increased focus on oversight, control of work activities, and personnel accountability.
DATE WIIEN FULL COMPLIANCE WILL BE ACIIIEVED Full compliance has been achieved.
                                                                                                         ]

i Attachment 2 Page 1 of 2 Reply to Notice of Violation 94-18-02 NOTICE OF VIOLATION Technical Specification 6.8.1.d states, in part, that written procedures shall be implemented and maintained covering surveillance and test activities of safety-related equipment.
Surveillance Test Procedure (STP)-204-3831, " Residual Heat Removal Loop B Valve Leak Rate Test (Water)," Revision 3, includes Valves lE12*MOVF004B, IE12*MOVF064B, and IE12*RVF017B within the test boundary.
Contrary to the above, on May 15, 1994, the system test valve lineup was altered, removing test pressure from the above three valves. The procedure was signed off as having satisfactorily tested the valves when, in fact, they were not.
REASON FOR THE VIOLATION Entergy Operations, Inc. believes that the reason for the violation was personnel error in that valve IE12*RVF030 was removed from the test boundary of the STP and an adequate technical review was not perfonned to detennine if other valves would be affected by the change.
During RF-5, test personnel were in the process of perfonning an 18-month leak rate test of Residual Heat Removal (RHR) Loop "B" containment isolation valves when they discovered             T that Relief Valve IE12*RVF030 was unseated and leaking by. A maintenance work order was initiated to repair the relief valve. Due to the time involved in reworking the leaking relief valve (IE12*RVF030), and in an effort to ensure that the remaining valves within the scope of STP-204-3831 were tested, test personnel were instmeted to perform a partial performance of the STP. (Procedures allow for panial perfonnance of components during testing, as necessary.) A change notice was initiated to include relief valve IE12*RVF030 within the test boundary of another su: illance procedure to meet post-maintenance retest requirements. The test boundary for STP-204-3831 was reduced in order to isolas - relief valve IE12*RVF030             )
and to complete the STP.
l As reflected in NRC IR 94-18, a post-outage review of STP-204-3831 revealed that as a result         i of isolating relief valve IE12*RVF30, motor operated valves IE12*MOVF004B, IE12*MOV064B, and relief valve IE12*RVF017B were also isolated from the intended test               ;
boundary of STP-204-3831. These valves were subsequently signed-off as being satisfactorily tested when, in fact, they had not been tested. The inadvenent isolation of these valves occurred because test personnel did not perfonn the necessary technical review to ensure that when removing valve lE12"RVF030 from the test boundary of the STP, no other valves would be impacted. Additionally, if an independent review of the change had been perfonned

    .                                                                                                          l Attachment 2
                                                                                                               ]
Page 2 of 2 by LLRT personnel prior to implementing the modified STP, valves IE12*MOVF004B, IE12*MOVF064B, and IE12*RVF017B would have been included within the test boundary of                i STP-204-3831 and therefore, the signatures would have been valid.
CORRECTIVE STEPS TIIAT IIAVE BEEN TAKEN AND TIIE RESULTS ACIIIEVED The following corrective steps were taken in response to this event:
: 1. A maintenance history review was conducted of work activities associated with valves IE12*MOVF004B,1E12*MOVF064B, and IE12*RVF017B since their last comprehensive perfonnance test (July 10, 1993). The purpose of this review was to detennine if the valves' integrity had been compromised. Results indicated that the valves would meet their design safety function.
: 2.      A complete perfonnance of STP-205-3831 was scheduled and satisfactorily completed on September 20,1994. This test was perfonned to provide additional assurance that valves IE12*MOVF004B, IE12*MOVF064B, and IE12*RVF017B would perfonn as designed.
: 3.      A review of all low pressure water leak nite test procedures (and a representative sample of air test procedures) was perfonned to ensure the technical adequacy of each procedure. The review consisted of an assessment of previously perfonned procedures and P& ids to confinn correct valve lineup, system test configuration, test method and compliance with technical specification requirements. This process confirmed that the criteria for detennining satisfactory perfonnance had been attained and no additional surveillance test steps had been signed-off as being complete without actually being perfonned.
: 4.      The personnel involved in this event are not longer employed at River Bend Station.
As such, no specific personnel related corrective action is necessary.
CORRECTIVE STEPS TIIAT WILL BE TAKEN TO AVOID FURTHER VIOLATION Surveillance Test Procedures (STPs) that implement 10CFR50, Appendix J requirements will be revised to require an independent (second party) review of changes (in scope or boundary) required during testing. Procedure revisions will be accomplished prior to their next perfonnance, i.e., RF-6.
IMTE WIIEN FULL COMPLIANCE WILL BE ACIIIEVED River Bend Station is in full compliance.

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       ..                                                                                      Attachment 3     l Page 1 of 3   l Reply to Notice of Violation 94-18-03 NOTICE OF VIOLATION                                                                                  j Technical Specification 6.8.1.b states, in part, that written procedures shall be implemented        l covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33,               l Revision 2, February 1978.                                                                           j i
Regulatory Guide 1.33, Appendix A, states, in part, that procedures shall be implemented covering the operation of safety-related boiling water reactor systems.                              j System Operating Procedure (SOP)-0034, "MSIV Sealing System (Positive Leakage Control)," Revision 5, Attachment 1, requires the position of Valve IMSI*V84 to be closed and the position of valve IMSI*V85 to be open after the valve lineup is completed.
Contrary to the above, on June 30,1994, Valve IMSI*V84 was found in the open position and Valve IMSI*V85 was found in the closed position. The valve lineup was completed on June 26,1994.
i REASON FOR TIIE VIOLATION                                                                            ;
Entergy Operations, Inc. (EOI) admits this violation and has detennined that the most probable       ;
root cause for the mispositioned valves is personnel error.
An extensive review of perfonnance data for inservice testing, leak rate testing, and instrument     l calibration procedures associated with valves IMSI*V84 and IMSI*V85, provided no                     .
evidence to suggest that the valves had been positioned incorrectly during these evolutions.
5 MSIV Sealing System valves 1MSI*V84 and IMSI*V85 did not comply with System Operating Procedure (SOP)-0034 for correct valve position. The root cause for this event could not be detennined; however, the most probable cause is personnel error.                        j i
CORRECTIVE STEPS TIIAT IIAVE HEEN TAKEN AND TIIE RESULTS ACIIIEVED                                   t t
A.         The below actions were taken as an immediate response to this violation:                  l
: 1. Valve IMSI*V85 was scaled open and its position independently verified by          l operations personnel. The Division II ponion of Surveillance Test Procedure        ;
(STP) 208-0601, "MSIV Position Leakage Control System Functional Test,"
was reperfonned with satisfactory results.
: 2. System Operating Procedure (SOP)-0034 was reperfonned in its entirety to verify the system was in the correct standby lineup position. Valve IMSI*V84       l was closed and independently verified at that time.                                !

Attachment 3
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: 3. An investigation into the cause of valves IMSI*V84 and IMSI*V85 being                   ;
mispositioned was initiated via the RBS condition report process.                       i B. The below actions were taken as part of the investigation into this event:
: 1. SOP-0034 valve lineup procedure was reviewed to detennine when the system               j lineup was last perfonned. Records indicated that the valve lineup was                  I perfonned and independently verified by licensed reactor operators on June 26, l')94, i
: 2. The perfonnance dates for other procedures which may have manipulated these valves were also reviewed. In-service testing, leak rate testing, and instnnnent calibration procedures perfonned after the SOP lineup was completed were l
reviewed to detennine if the valves could have been mispositioned while                 !
perfor.ning these processes.                                                           i l
: a.       Surveillance Test Procedure (STP)-208-3600, " Main Steam Isolation              ,
Valve and Penetration Ixakage Control System Leakage Rate Test," was            I perfonned on June 26,1994. This procedure did not require manipulation of valves IMSI*V84 and IMSI*V85.
: b.      Surveillance Test Procedure (STP)-208-6701, "MSIV Leakage Control Valve Opembility," was performed on June 28,1994. While portions of this procedure require IMSI*V84 to be opened and uncapped, the                -
sections perfonned on this date did not.
: c.       Surveillance Test Procedure (STP)-208-4208 was last perfonned on July 10, 1994, with the 18 month perfonnance completed on April 6,1994.
Since the valve lineups were completed after this date, it is not likely that the problem occurred during perfonnance of this procedure.
: d.       Surveillance Test Pmeedure (STP)-208-3605, " Leak Rate Testing of Main Steam System Valves Scaled by MS-PLCS," (which does manipulate IMS!*V84 and IMSI*V85) was last performed on June 13, 1994. The valve lineup was completed after this time.
: 3. In addition to the surveillance procedures listed above, other references werc         !
checked to detennine when the valve position may have been changed. The                  l control room log, manipulated device log, and the hydro procedure were                   l checked and no reference to operation of IMSI*V84 or IMSI*V85 was                        l recorded.
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      .                                                                                     Attachment 3 '  l
   ,.                                                                                         Page 3 of 3
: 4.      The protective equipment tagging log was also reviewed. Although several            .l clearances were put in place and subsequently cleared on components during            l this time frame, valves IMSI*V84 and IMSI*V85 were not included in those              ;
dearances. No clearances could be located which manipulated the two valves in         .
question.                                                                            l
: 5.      Interviews were conducted with system engineers working on the MSIV Positive -       ;
Leakage Control System (LSV system), operators involved with IST procedure           j implementation, and system engineering suppon personnel perfonning LLRTs,           j as well as operators who perfonned the system lineups. No reason could be identified for the mispositioned valves.                                              ,
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: 6.      In August / September of 1994, a unique training seminar was presented to            !
Operations Depanment personnel. This two-day course was designed to help             i the operators be observant about abnonnal conditions, alert about emerging          -I failures, aware of conditions that are conducive to human error, and                 I knowledgeable about techniques to reduce their own human errors.
                                                                                                           ]t The course introduced several effective human error reduction techniques which       I were designed to improve the quality and reliability of daily task performance,      i t
CORRECTIVE STEPS THAT WILL llE TAKEN TO AVOID FURTIIER VIOLATIONS                                   ;
A review of current programs governing valve testing and manipulation did not identify any weaknesses in those areas. Therefore no programmatic deficiencies exist that would have             l contributed to this violation. No further actions are required.
Entergy Operations, Inc. will continue to implement initiatives to improve human perfonnance. As discussed in previous correspondence to the staff, these initiatives allow increased focus on oversight, control of work activities, and personnel accountability.             l I
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED                                                          l Full compliance has been achieved.
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