ML17305A571

Responds to NRC 900123 Ltr Re Violations Noted in Insp Rept 50-528/89-50.Corrective Actions:Work Orders Amended & Work Reperformed & Documented & Review of Core Loading Pattern, Mba Transfer Sheet & Spent Fuel Pool Map Conducted

ML17305A571
Person / Time
Site:	Palo Verde
Issue date:	02/21/1990
From:	Conway W ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
102-01606-WFC-T, 102-1606-WFC-T, NUDOCS 9003150098
Download: ML17305A571 (12)

See also: IR 05000528/1989050

Text

ACCELERATED

DISTIGBUTION

DEMON>TINCTION

SYSIEM r~t i SUBJECT: Responds to NRC 900123 ltr re violations

noted in Insp Rept 50-528/89-50.

DISTRIBUTION

CODE: IE01D COPIES RECEIVED:LTR

ENCL SIZE: TITLE: General (50 Dkt)-Insp Rept/Notice

of Violation Response NOTES ,S 05000528 REGULATORY

INFORMATION

DISTRIBUTION

SYSTEM (RIDS)ESSION NBR 9003150098

DOC.DATE 90/02/21 NOTARIZED:

NO DOCKET N FACIL:STN-50-528

Palo Verde Nuclear Station, Unit 1, Arizona Publ'i 05000528., AUTH.NAME AUTHOR AFFILIATION

CONWAY,W.F.

Arizona Public Service Co.(formerly Arizona Nuclear Power RECIP.NAME

RECIPIENT AFFILIATION

Document Control Branch (Document Control Desk)R INTERNAL: RECIPIENT ID CODE/NAME PD5 PD ACRS AEOD/DEIIB

DEDRO NRR/DLPQ/LPEB10

NRR/DREP/PEPB9D

NRR/DRIS/DIR

NRR/PMAS/ILRB12

OGC/HDS 1 RES MORISSEAU i D COPIES LTTR ENCL'.1 1 2 2 1 1 1, 1 1'1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME PETERSON,S.

AEOD AEOD/TPAD NRR SHANKMAN,S

NRR/DOEA DIR 11 NRR/DREP/PRPB11

NRR/DST/DIR

8E2 NU QC-STRACT REG FI.'2 FILE 01 COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 EXTERNAL: LPDR NSIC NOTES 1 1 1 1 1 1 NRC PDR 1 1 D A b NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, e ROOM Pl-37 (EXT.20079)TO ELMINATE YOUR NAME FROM DISIRIBUTION

LISIS FOR DOCUMENTS YOU DON'T NEED!TOTAL NUMBER OF COPIES REQUIRED: LTTR26 ENCL 26

Arizona Public Service Company P.O.BOX 53999~PHOENIX.ARIZONA 85072-3999

WILLIAM F.CONWAY EXECUTIVE VICE PRESIDENT NUCLEAR 102-01606-MFC/TRB/JJN

February 21, 1990 U.S.Nuclear Regulatory

Commission

Document Control Desk Washington, DC 20555 Reference:

Letter from R.Zimmerman, Director, Division of Reactor Safety and Projects, NRC to W.F.Conway, Executive Vice President Nuclear, Arizona Public Service, dated January 23, 1990 Dear Sirs: Sub j ect: Palo Verde Nuclear Generating

Station (PVNGS)Unit 1 Docket No.STN 50-528 (License No.NPF-41)Reply to Notices of Violation-50-528/89-50-01

and 528/89-50-02

File: 90-070-026

This letter is provided in response to the inspection

conducted by Messrs.D.Coe, T.Polich, J.Ringwald, J.Sloan, W.Wagner, T.Meadows, and W.Ang.Based upon the results of the inspection, two (2)violations

of NRC requirements

were identified.

The violations

are discussed in Appendix A of the referenced

letter.A restatement

of the violations

and PVNGS's responses are provided in Appendix A and Attachment

1 respectively, to this letter.The referenced

letter noted that the violation involving failure to document completion

of steps of a procedure is similar to previously

identified

violations

and requires additional

management

attention.

APS has taken additional

actions since this occurrence

to assure that personnel adhere to procedures.

These actions are described in Attachment

l.The refer'enced

letter also noted that the events that occurred during the Unit 1 refueling operations

demonstrated

the need to improve communications

between the various levels of APS management.

In response to the event, a Human Performance

Evaluation

was conducted and the following corrective

actions were implemented.

The Unit 1 guideline"Communication

of Unit 1 Status and Events" was revised to include additional

guidance for potential refueling events which would require immediate notification

of the Plant Manager or designee.The Unit 1 Plant Manager discussed this event and importance

of prompt, accurate communication

with the Unit 1 managers.f0Q 3I 50Qq g t'&P goOZP I~ooo gal PDg

Document Control Desk Page 2 102-01606-WFC/TRB/J

JN February 21, 1990 Should you have any questions regarding this response, please contact me.Very truly yours, WFC/TRB/JJN/kj

Attachments

CC: J.B.Martin D.H.Coe T.L.Chan E.E.Van Brunt A.C.Gehr J.R.Newman

Document Control Desk Page 1 of 1 102-01606-WFC/TRB/3

JN February 21, 1990 APPENDIX A NOTICE OF VIOLATION Arizona Nuclear Power Project Palo Verde Unit 1 Docket Number 50-528 License Number NPF-41 During an NRC inspection

conducted on November 13 through December 17, 1989, several violations

of NRC requirements

were identified.

In accordance

with the"General Statement of Policy and Procedure for NRC Enforcement

Actions," 10 CFR Part 2, Appendix C (1989), the violations

are listed below: Technical Specification 6.8.1 states, in part: "Written procedures

shall be established, implemented

and maintained

covering...the recommendations

in Appendix A'of Regulatory

Guide 1.33, Revision 2, February 1978 Regulatory

Guide 1.33, Revision 2, February 1978 recommends"Procedures

for Performing

Maintenance." Regulatory

Guide 1.33, Revision 2, February 1978, is implemented

in part by ANPP procedure 30DP-9MPOl, Revision 0, entitled"Conduct of Maintenance," Section 3.8, which states in step 3.8.6: "Work instruction

steps, sections of steps and data sheets shall be properly documented

at the time of performing

the step or as soon thereafter

if conditions

do not permit." Contrary to the above, on November 14, 1989, Unit 1 Train"B" containment

spray pump motor maintenance

work order 362320 had progressed

from Step 3.2.1 to Step 4.5 without corresponding

documentation

at the time of performing

the step, under conditions

which permitted such documentation.

This is a Severity Level IV violation applicable

to Unit 1 (Supplement

I).B.10 CFR Part 50, Appendix B, Criterion V, states in part that activities

affecting quality shall be prescribed

by documented

instructions, procedures, or drawings, of a type appropriate

to the circumstances

and shall be accomplished

in accordance

with these instructions, procedures, or drawings.Contrary to the above, on September 30, 1989, the licensee issued Special:Nuclear Material Transfer Set 1-3-1 to reload the Unit 1 reactor core, which was not appropriate

to the circumstance

in that it contained an error which directly resulted in partially inserting a fuel assembly in the core in other than its analyzed location.This is a Severity Level IV violation applicable

to Unit 1 (Supplement

I).l

Document Control Desk Page 1 of 8 102-01606-WFC/TRB/J

JN February 21, 1990 ATTACHMENT

1 Re 1 to Notice of Violation 50-528 89-50-01 A.I.REASON FOR VIOLATION On November 14, 1989, work to inspect motor terminal lugs on the Unit 1"B" train safety injection pumps.began in accordance

with Work Orders 362318 and 36320.Since the work areas were potentially

contaminated, working copies of the original work orders were made.After the assistant shift supervisor's

approva1 was" obtained to start work, the original work orders were left in the electric shop and the electricians

and a QC inspector proceeded to the work area with the working copies.Terminal lug inspection

was in progress and almost complete on Work Order 362320 when the NRC inspectors

observed that both the electrician

and the QC inspector had not been signing off completed work instruction

steps as the steps were performed on the working copy.The reason for the violation was cognitive error by the personnel involved.The electricians

were interviewed

following the event.Both electricians

had thoroughly

reviewed the work order preceding the actual work.The electricians

were aware of the requirement

to sign-off the steps in the work order while performing

the work however, contrary to APS administrative

requirements, the electricians

periodically"checked-off" the steps on the working copy

Document Control Desk Page.2 of 8 102-01606-WFC/TRB/J JN February 21, 1990 of the work order.The QC inspector was interviewed

following the event.The QC inspector had completed the General Inspector Indoctrination

Training, which included discussions

of APS's requirement

to sign-off steps as work was completed.

However, the QC inspector had been on site for only three weeks and was unsure of the procedural'equirements

to sign-off work steps as they are completed.

A.II CORRECTIVE

STEPS TAKEN AND RESULTS ACHIEVED The NRC inspectors

informed the responsible

Work Group Supervisor

about the violation of APS administrative

requirements.

The Work Group, Supervisor

immediately

directed the electricians

to stop work on Work Orders 362318 and 362320.Prior to continuing

with the lug inspection, the work orders were amended to require a complete re-performance

of the work.The work was re-performed

and properly documented.

No discrepancies

were identified

indicating

improper performance

of previous work.The steps in the amended work orders were properly signed-off

as each step was completed.

No further discrepancies

were identified

during the performance

of the work.

Document Control Desk Page 3 of 8 102-01606-'WFC/TRB/JJN

February 21, 1990 The individual

electricians

involved in the event were disciplined

for not adhering to APS administrative

control requirements (i.e., signing off on the work order as each step was complete).

Additionally, maintenance

personnel were briefed on the use of 30DP-9MPOl,"Conduct of Maintenance," which, in part, requires'roper

documentation

of completed steps at the time of performance.

An effectiveness

review of QC Inspector indoctrination

training was performed immediately

following the event.Interviews

were conducted with other new QC Inspectors.

These inspectors

stated that training adequately

addressed the procedural

requirement

to document the completion

of the work steps after the work step had been completed.

An examination

was administered

to another group of new QC Inspectors

regarding proper documentation

of work and administrative

controls for conduct of maintenance.

Based upon the test results, APS concluded that the requirements

discussed above were adequately

emphasized.

As a result of the training effectiveness

review, APS concluded that training was adequate and the problem was an isolated occurrence

limited to the QC Inspector.

The QC inspector (contractor)

was released from his duties with the PVNGS QC Department.

Additionally, applicable

indoctrination

QC training was enhanced to include testing to validate effectiveness

of the indoctrination

training and the competence

of the individual.

Document Control Desk Page 4 of 8 102-01606-WFC/TRB/J

JN February 21, 1990 In addition to the corrective

action's taken specifically

in response to the event, APS has taken a number of steps to reemphasize

to plant personnel the importance

of strict adherence to procedures.

A number of such steps are described in a letter to the NRC from J.N.Bailey, APS, dated November 17, 1989.A,III.CORRECTIVE

STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS

APS believes the actions taken as described above are adequate to prevent recurrence.

A.IV.~~DATE WHEN FULL COMPLIANCE

WILL BE ACHIEVED Full compliance

was achieved on November 14, 1989, when Work Orders 362318&362320 were completed with the appropriate

steps signed.

Document Control Desk Page 5 of,8*102-01606-WFC/TRB/J JN February 21, 1990 Re 1 to Notice of Violation 50-528 89-50-02 B.l.REASON FOR VIOLATION On September 29, 1989", PVNGS/APS Reactor Engineering

personnel completed and approved the Material Balance Area (MBA)transfer sheet for movement of fuel and ultimately, the reload of the Unit 1 reactor core.The Reactor Engineering

personnel reviewed the planned core loading pattern to determine the appropriate

assembly for each location in the core, and entered the assembly designator

on the MBA transfer sheet.They also identified

the location of the assemblies

on the Spent Fuel Pool (SFP)map and entered the SFP location designator

on the MBA transfer sheet.During the preparation

of the MBA transfer, sheet, the SFP location of one assembly was improperly

transcribed.

Assembly PlD303 was stored in SFP location P28.However, during the preparation

of the MBA transfer sheet for step 667, the SFP location of PID003 was entered as P38.The completed MBA transfer sheets were reviewed and approved by the responsible

Reactor Engineer.However, the Reactor Engineer did not verify every entry on the MBA transfer sheets.The applicable

procedure did not specifically

require such detailed verification.

Document Control Desk Page 6 of 8 102-01606-WFC/TRB/JJN

February 21, 1990 B.II.CORRECTIVE

STEPS TAKEN AND RESULTS ACHIEVED On November 16, 1989, while fuel loading was in progress, mimic boards of the SFP and reactor core in the control room were updated to reflect current assembly position.When the assembly from SFP location P38 (P1E004)was being inserted into the reactor core, reactor engineering

personnel observed that the mimic placard on the mimic board represented

a new fuel assembly and should have been located on the periphery of the core.Reactor engineering

personnel immediately

directed that the fuel movement be stopped.An immediate review of core loading pattern, the MBA transfer sheet, and the Spent Fuel Pool map was conducted.

The transcription

error on the MBA transfer sheet was identified

as the cause of this event.The MBA transfer sheets were revised to place assembly P1E004 into an intermediate

location outside of the reactor core.Assembly PlD303 was retrieved from the SFP and inserted into the proper core location.Following discussions

of the event, the cause and the additional

procedural

steps with the Operations.

Shift Supervisor, fuel movement recommenced.

Subsequent

to the event, on November 27, 1989, procedure 72AC-NF01"Control of SNM Transfer and Inventory" was revised to require independent

verification

of the MBA transfer sheets.This

Document Control Desk Page 7 of 8 102-01606-WFC/TRB/JJN

February 21, 1990 requirement

was added to clarify that the existing requirement

for approval included a 100 percent independent

verification.

To assess the potential safety significance

if the fuel transfer error had not been detected promptly, an analysis was performed assuming that the fuel assembly had been completely

inserted.The analysis demonstrated

that adequate shutdown margin would have existed.Additionally, the PVNGS Updated Final Safety Analysis Report provides the analysis for the misloading

of two assemblies

in the event that the final fuel loading verification

process did not identify a misloading

of fuel assemblies.

Therefore this event had no adverse effect on the health and safety of the public.The Unit 1 Plant Manager discussed this incident with the Unit 1 Managers to reemphasize

management's

intention that senior management

be promptly advised of such occurences.

B.III.CORRECTIVE

STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS

APS believes the actions taken as described above are adequate to prevent recurrence.

Document Control Desk Page 8 of 8 102-01606-WFC/TRB/JJN

February 21, 1990 B.IV.DATE WHEN FULL COMPLIANCE

WAS ACHIEVED Full compliance

was achieved on November 16, 1989'hen the MBA transfer sheets were revised and the fuel assemblies

were placed in the proper locations.