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See also: [[followed by::IR 05000244/1990031]]


=Text=
=Text=
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{{#Wiki_filter:A.L Uj"LCKH AZU ULDLM.DULAUlN LJZIVBJI.IDLLMLBJlN 3 I 8 LPIVJ.
BJlN 3 I 8 LPIVJ.t i REGULATORY
t i                     REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
INFORMATION
SSION NBR:9103210167             DOC.DATE: 91/03/08     NOTARIZED: YES         DOCKET CIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester                 G 05000244 AUTH. NAME             AUTHOR AFFILIATION MECREDY,R.C.
DISTRIBUTION
RECIP.NAME Rochester Gas        l'lectric RECIPIENT AFFILIATION Corp.
SYSTEM (RIDS)i SSION NBR:9103210167
Document Control Branch (Document         Control Desk)
DOC.DATE: 91/03/08 NOTARIZED:
 
YES DOCKET CIL:50-244
==SUBJECT:==
Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH.NAME AUTHOR AFFILIATION
Responds to NRC 910208           ltr re violations noted in Insp,Rept
MECREDY,R.C.
                ,50-244/90=31 on 901213-910103.Corrective a'ctions:dc distribution panel switch labels revised to clarify switch load/function & addi checklists will be developed.
Rochester Gasl'lectric Corp.RECIP.NAME
DISTRIBUTION CODE: IEOID             COPIES RECEIVED:LTR       ENCL   / SIZE:   /3 TITLE: General       (50 Dkt)-Insp Rept/Notice of Vio ation Response                         /
RECIPIENT AFFILIATION
NOTES:License Exp       date in accordance with 10CFR2,2.109(9/19/72).               05000244 RECIPIENT             COPIES            RECIPIENT          COPIES            D ID   CODE/NAME           LTTR ENCL        ID CODE/NAME      LTTR ENCL PD1-3 PD                     1      1    JOHNSON,A              1    1            D INTERNAL: AEOD                             1      1    AEOD/DEIIB              1    1 AEOD/TPAB                     1      1    DEDRO                  1    1 NRR MORISSEAU,D               1      1    NRR SHANKMAN,S          1    1 NRR/DLPQ/LPEB10               1      1    NRR/DOEA/OEAB          1    1 NRR/DREP/PEPB9D               1      1    NRR/DRIS/DIR            1    1 NRR/DST/DIR 8E2               1      1    NRR/PMAS/ILRB12        1    1 NUDOCS-ABSTRACT               1      1                            1    1 OGC/HDS1                     1      1    RG FIL          02      1    1 RGN1       FILE   01          1      1 EXTERNAL: EGGG/BRYCE, J. H.                 1      1   NRC PDR                1   1 NSIC                          1     1 D
Document Control Branch (Document Control Desk)SUBJECT: Responds to NRC 910208 ltr re violations
A D
noted in Insp,Rept ,50-244/90=31
D NOTE TO ALL "RIDS" RECIPIENTS:
on 901213-910103.Corrective
PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!
a'ctions:dc
TOTAL NUMBER OF COPIES REQUIRED: LTTR               22  ENCL   22
distribution
 
panel switch labels revised to clarify switch load/function
I ROCHESTER GAS AND ELECTRIC CORPORATION            ~  89 EAST AVENUE, ROCHESTER  N. Y. 14649-0001 ROBERT     C   MECREDY                                                               TELEPHONE Vice Precidenr AREA COOE 71B 646 2700 Cinna Nuclear Producrion March 8, 1991 U.S. Nuclear Regulatory Commission ATTN:         Document   Control Desk Washington,         DC   20555
&addi checklists
 
will be developed.
==Subject:==
DISTRIBUTION
Reply to   a Notice of Violation NRC   Inspection Report No. 50-244/90-31 R.E. Ginna Nuclear Power Plant NRC   Docket No. 50-244
CODE: IEOID COPIES RECEIVED:LTR
 
ENCL/SIZE:/3 TITLE: General (50 Dkt)-Insp Rept/Notice
==Dear       Sir:==
of Vio ation Response NOTES:License
 
Exp date in accordance
This       letter is in   response to the February       8, 1991       letter       from Thomas         T. Martin, Regional     Administrator, to Robert E. Smith, Senior Vice President,               Production and Engineering, which transmitted Notice of Violation from Inspection Report 90-31. In that letter, Violations A and B were identified. This letter provides the reply to the Notice of Violation, pursuant to 10 CFR 2.201.
with 10CFR2,2.109(9/19/72).
RESTATEMENT OF VIOLATIONS:
/05000244 RECIPIENT ID CODE/NAME PD1-3 PD INTERNAL: AEOD AEOD/TPAB NRR MORISSEAU,D
During an NRC inspection conducted between December 13, 1990 and January 3, 1991, violations of NRC requirements were identified.
NRR/DLPQ/LPEB10
In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, (1990),
NRR/DREP/PEPB9D
the particular violations are set forth below:
NRR/DST/DIR
A.         10 CFR Part 50, Appendix B, Criterion VI, "Document Control,"
8E2 NUDOCS-ABSTRACT
states in part, that measures shall be established to control the issuance of documents, such as procedures, including changes thereto, which prescribe all activities affecting quality.         These measures       shall assure that documents, including changes, are reviewed for adequacy.
OGC/HDS1 RGN1 FILE 01 EXTERNAL: EGGG/BRYCE, J.H.NSIC COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME JOHNSON,A AEOD/DEIIB
9103210167 910308 PDR         ADOCK 05000244
DEDRO NRR SHANKMAN,S
  ~~ j,Hi l.e ap U PDR
NRR/DOEA/OEAB
 
NRR/DRIS/DIR
Contrary to the above, in March 1989, a procedure affecting quality, namely, Procedure M-48.14, "Isolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing," was changed without an adequate review being performed. The specific change involved inclusion of a step in the procedure which allowed the disabling of Engineered Safety Feature Actuation System (ESFAS) instrumentation while the reactor was in any mode of operation,'ncluding power. The licensee's organizational measures for review, approval, and issuance of this procedure change, including the review by the Plant Operations Review Committee, did not assure that the change was adequately reviewed in that did not identify that implementation of the procedure change it in a mode other than cold shutdown condition would place the plant in a condition that was prohibited by Technical Specification 3.5.2.
NRR/PMAS/ILRB12
B. Technical Specification 6.8.1 requires establishment of the applicable procedures recommended in Appendix "A" of Regulatory Guide 1.33, November 1972, (Safety Guide 33)
RG FIL 02 NRC PDR COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D D NOTE TO ALL"RIDS" RECIPIENTS:
Appendix A, Section I, specifies that maintenance which can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.
PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO ELIMINATE YOUR NAME FROM DISTRIBUTION
Contrary to the above, on December 12, 1990, the licensee failed to adequately preplan and perform corrective maintenance on the A emergency diesel generator undervoltage circuit card. Specifically, maintenance procedure M-48.14, "Isolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing," was used to perform the corrective maintenance while the reactor was at 3 percent power during startup. Step 5.5.1 directed personnel to open DC circuit breakers for the A and B safeguards logic trains which disabled the automatic and manual (push button) sequencing of safeguards equipment.       This step was both unnecessary to perform the required work and inappropriate for the circumstances as it disabled the safeguards sequencing function at a time prohibited by plant technical specifications.     Additionally, use of M-48.14 proceeded despite indications that the procedure was inappropriate.
LISTS FOR DOCUMENTS YOU DON'T NEED!TOTAL NUMBER OF COPIES REQUIRED: LTTR 22 ENCL 22 A D D
Those indications included labels on the DC breaker panels warning of the possible safety injection consequences and the initiation of alarm annunciator L-31, "Safeguards DC Bus Failure."
Violations A and   B are classified in the aggregate at Severity Level III.   (Supplement 1)
I ROCHESTER GAS AND ELECTRIC CORPORATION
 
ROBERT C MECREDY Vice Precidenr Cinna Nuclear Producrion
REPLY TO VIOLATION A:
~89 EAST AVENUE, ROCHESTER N.Y.14649-0001
THE REASONS FOR THE VIOLATION Rochester   Gas and   Electric (RG&E) concurs that the stated violation occurred.     Procedure M-48.14 was changed in March 1989, without an adequate review being performed.         There were two weaknesses     in Ginna's procedure development and change policy, which resulted in a technically incorrect procedure being approved.         As discussed by RG&E at the Enforcement Conference on January 29, 1991, these weaknesses occurred at the level of the "Responsible Manager" (RM) review, and in the lack of   a multi-disciplinary review of the proposed   change. In March 1989, the procedure development and change policy did not provide adequate guidance to an RM for . determining the operational impact of the proposed change.       Consequently,   the RM (using existing policy guidance) concluded that the proposed change was "minor" and did not have any operational impact, since the proposed change added a step that was deleted during the last revision.
TELEPHONE AREA COOE 71B 646 2700 March 8, 1991 U.S.Nuclear Regulatory
Therefore, the RM did not require a multi-disciplinary review.     The Plant Operations Review Committee (PORC),
Commission
acting on the recommendation of the RM, did not pursue this classification in sufficient detail and recommended approval of the proposed change.
ATTN: Document Control Desk Washington, DC 20555 Subject: Reply to a Notice of Violation NRC Inspection
: 2. THE CORRECTIVE STEPS     THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED RG&E   personnel, with active participation by senior management, performed a thorough investigation of the event, and promptly initiated extensive and comprehensive corrective actions. The Senior Vice President conducted a .series of meetings, with PORC members, procedure RMs and     all operating shifts to communicate management expectations for maintaining a questioning attitude and the need for attention to detail.
Report No.50-244/90-31
All plant procedures were screened for their impact on operability of safeguards equipment, resulting in numerous procedures being placed in a restricted status, such that
R.E.Ginna Nuclear Power Plant NRC Docket No.50-244 Dear Sir: This letter is in response to the February 8, 1991 letter from Thomas T.Martin, Regional Administrator, to Robert E.Smith, Senior Vice President, Production
    .the procedure could not be used without further review (quarantined). The procedure development and change policy was revised to require an operational review of ALL proposed procedure changes, and a structured procedure review checklist was developed for this 'review.       PORC and senior management reviewed the adequacy of these short term corrective actions, and Quality Performance department personnel performed an independent assessment of these actions. These actions were completed   prior to startup of the plant.
and Engineering, which transmitted
 
Notice of Violation from Inspection
A detailed   list of short term corrective actions (all of which have been completed) is at Attachment 1.'umerous corrective actions that are considered long term have also been completed.       These completed long term corrective actions are at Attachment 2.
Report 90-31.In that letter, Violations
Results of these actions assure a high level of detail and consistency during the performance of safety reviews. The need for a questioning attitude at all times has also been reinforced. A total of approximately 275 procedures were quarantined, and these procedures will remain unavailable for use until a thorough review for their operational impact has been performed. These actions have strengthened existing barriers (or created new barriers) within the procedure development and change policy, to assure that procedure changes are adequately reviewed.
A and B were identified.
THE CORRECTIVE   STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS RG&E personnel have established a detailed corrective action plan to strengthen the procedure development and change policy. Personnel will be trained on the lessons learned from this event. There will be periodic assessments of the adequacy of the proposed corrective actions, and of their continuing effectiveness. Ongoing evaluations will provide opportunities for changes to or reinforcement of these actions. The role of the RM in the procedure review process will be clarified. See LER 90-017 and NRC Inspection Report 90-31 for additional discussions of these long term actions.
This letter provides the reply to the Notice of Violation, pursuant to 10 CFR 2.201.RESTATEMENT
A detailed     list of these proposed corrective actions, including the current scheduled completion date, is at .
OF VIOLATIONS:
THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance with 10 CFR Part 50, Appendix B, Criterion VI was achieved prior to December 20, 1990. By that date, procedure quarantine had been completed, and the procedure development   and change policy had been formally changed to require   an operational. review of   all -proposed procedure changes.
During an NRC inspection
 
conducted between December 13, 1990 and January 3, 1991, violations
0
of NRC requirements
(
were identified.
  ~
In accordance
 
with the"General Statement of Policy and Procedure for NRC Enforcement
REPLY TO VIOLATION B.
Actions," 10 CFR Part 2, Appendix C, (1990), the particular
: 1. THE REASONS FOR THE VIOLATION Rochester Gas and Electric .concurs that the stated violation
violations
    'occurred.     A Human Performance   Enhancement System (HPES) evaluation determined that the following were co'ntributing causes for the violation:
are set forth below: A.10 CFR Part 50, Appendix B, Criterion VI,"Document Control," states in part, that measures shall be established
A. There was a lack of a formalized process for the operational review of work order packages.
to control the issuance of documents, such as procedures, including changes thereto, which prescribe all activities
B. Procedure M-48.14 was a   PORC approved procedure and was considered correct by     the   Planner, Scheduler, and Control   Room Foreman.
affecting quality.These measures shall assure that documents, including changes, are reviewed for adequacy.9103210167
C. Procedure M-48.14 had been previously used by the Planner to successfully implement corrective maintenance.
910308 PDR ADOCK 05000244 PDR~~j,Hi l.e ap U  
(However, the plant was at cold shutdown in that instance.)
Contrary to the above, in March 1989, a procedure affecting quality, namely, Procedure M-48.14,"Isolation
D. Confidence   in the validity of the PORC approved M-48.14 and the Planner's stated previous experience implementing M-48.14 outweighed the Control Room Foreman's questioning attitude in his decision making to follow the procedure instructions.
of Bus 14 Undervoltage
In addition, other indications were inadequate in informing the operators that use of M-48.14 was inappropriate under these circumstances:
System for Maintenance, Troubleshooting, Rework and Testing," was changed without an adequate review being performed.
A. Switch labelling within the DC distribution panels lacked adequate information in describing the switch/load function.
The specific change involved inclusion of a step in the procedure which allowed the disabling of Engineered
B. Required Actions in Alarm Response Procedure AR-L-31, (Safeguards DC Bus Failure) were not comprehensive.
Safety Feature Actuation System (ESFAS)instrumentation
 
while the reactor was in any mode of operation,'ncluding
l THE CORRECTIVE STEPS       THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED The   following corrective steps have         been taken to address the contributing causes:
power.The licensee's
A. RG&E   has developed and implemented a           detailed work package review requirement for Safety             Re'lated   and Safety Significant work. This includes work package reviews for technical adequacy, proper isolation/holds, operational impact, adequate testing, conformance to technical specifications and quality concerns.               The Technical (Discipline) and Operational Reviews are performed   utilizing     a . detailed checklist to ensure consistency in the reviews.
organizational
B. Rochester   Gas   and Electric Senior Management           has communicated     ,their expectations for maintaining' questioning attitude and attention to detail to Operations Personnel,           PORC   Members,   and Station "planning staffs.
measures for review, approval, and issuance of this procedure change, including the review by the Plant Operations
C. Selected plant procedure groups were screened for their impact on operability of safeguards equipment.             Those requiring changes or additional information were quarantined from use until the changes are completed.
Review Committee, did not assure that the change was adequately
A total of approximately 275 plant procedures               were quarantined.
reviewed in that it did not identify that implementation
D. DC Distribution     Panel   switch labels were revised to clarify switch load/function.
of the procedure change in a mode other than cold shutdown condition would place the plant in a condition that was prohibited
E. Procedure AR-L-31 (Safeguards DC Bus Failure) was revised to incorporate enhanced Required Actions.
by Technical Specification
F. Operations management issued formal guidance to the operators, stating management expectations for work package review prior to release             of equipment to maintenance.
3.5.2.B.Technical Specification
A detailed list of short term corrective actions (all of which, have been completed)     is at Attachment 1. Numerous corrective actions that are considered long term have also been completed. These completed long term corrective actions are at Attachment 2.
6.8.1 requires establishment
 
of the applicable
~'
procedures
3 ~ THE CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Corrective steps that will be taken to avoid further violations are oriented toward strengthening barriers and a more formalized work package review and approval process.
recommended
Additional checklists will be developed for work package reviews performed by non-Maintenance personnel.                 A detailed list of these proposed corrective actions, including                     the current scheduled completion date, is at Attachment 3.
in Appendix"A" of Regulatory
4 ~ THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance with Technical Specification 6.8.1 and Appendix "A" of Regulatory Guide 1.33, November 1972 occurred on December 20, 1991 with the implementation of the additional reviews for Safety Related and Safety Significant work packages.
Guide 1.33, November 1972, (Safety Guide 33)Appendix A, Section I, specifies that maintenance
Very   truly       yours, Robert     C. Mec           dy RCM dp                                 Subscribed and sworn to before me Attach. (3)                             on this 8th day of March, 1991 xc: Mr. Thomas T. Martin Regional Administrator Region 1 475 Allendale Road King of Prussia, PA 19406                     v'AMES C. McGUIRE NTAAYPUBUC, Stats of Nsat Yctft Thomas Moslak                                   OuaFOIinhheos Carly MfCNtatfaahn Expha Osc.2tt, $ 9+4 USNRC Senior Resident Inspector Ginna Station 1503 Lake Road Ontario, NY 14519
which can affect the performance
 
of safety-related
Page No.'TTACHMENT                 1 LIST OF SHORT TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)
equipment should be properly preplanned
ITEM       DESCRIPTION OF THE ACTION, WHICH NUMBER    WAS COMPLETED   IN 1990.
and performed in accordance
                                                              /
with written procedures, documented
01         Senior Management to meet with all operating shifts (prior to startup except for one shift) to communicate management expectations for questioning attitude and attention to detail.
instructions, or drawings appropriate
02      , Management to meet with the maintenance planning staff to communicate management expectations for questioning attitude and attention to detail.
to the circumstances.
03        Management   to meet with PORC members and procedure "Responsible Managers" to communicate management expectations for questioning attitude and attention to detail.
Contrary to the above, on December 12, 1990, the licensee failed to adequately
04        Prepare and issue a more detailed operations policy on the importance of following through on procedure concerns.
preplan and perform corrective
05        Prepare and issue a policy for station planners on the importance of identifying operational consequences for planned activities involving safeguards equipment.
maintenance
06        Involve the Operations shift in the development of corrective actions for the HPES on crew performance.
on the A emergency diesel generator undervoltage
07        Perform preliminary HPES evaluation for the issue of crew performance.
circuit card.Specifically, maintenance
08        Perform screening of all plant procedure categories, to determine which categories require review for quarantine.
procedure M-48.14,"Isolation
09        Identify all current "M", "EM", and "CP" procedures that could involve safeguards manipulation, Tech. Spec.'concerns, or A-52.4 concerns.
of Bus 14 Undervoltage
10        Identify all other current plant procedures that could involve safeguards manipulation, Tech. Spec. concerns, or A-52.4 concerns.
System for Maintenance, Troubleshooting, Rework and Testing," was used to perform the corrective
Based on the results of screening performed, quarantine any proce'dures that meet for quarantining.          the'riteria 12        Independent check of the identification of procedures for quarantining.
maintenance
Establish interim policy for the review of infrequently used procedures as part of the work package planning process.
while the reactor was at 3 percent power during startup.Step 5.5.1 directed personnel to open DC circuit breakers for the A and B safeguards
i4        Determine the previous uses of M-48.13 and M-48;14, and identify any other times they were used inappropriately.
logic trains which disabled the automatic and manual (push button)sequencing
15        Review AR procedures to ensure the appropriate level of significance is imparted, and the appropriate response to the annunciator is clearly stated.
of safeguards
 
equipment.
Page No.
This step was both unnecessary
ATTACHMENT 1 LIST OF SHORT TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)
to perform the required work and inappropriate
ITEM      DESCRIPTION OF THE ACTION, WHICH NUMBER    WAS COMPLETED IN 1990.
for the circumstances
16       Revise those AR procedures that have significant deficiencies.
as it disabled the safeguards
17        Upgrade labelling of the two DC distribution panels and two individual DC switches in the Main Control Board.
sequencing
18        Determine any other AC or DC distribution panels in the Control Room that require operator / training awareness, and/or upgraded labelling.
function at a time prohibited
19        Perform immediate read and acknowledge training on the functions of all DC switches, including SI-A1 and SI-B1, in, the 1A and 1B DC Distribution Panels.
by plant technical specifications.
20        Provide improved direction or additional requirements for operational and pre-PORC review of changes to procedures.
Additionally, use of M-48.14 proceeded despite indications
Review the specific training histories and operating experience of those operators directly involved in this event.
that the procedure was inappropriate.
22        PORC review of the adequacy of short term corrective actions, and evaluation of readiness for plant startup.
Those indications
23        Perform a senior management review of the adequacy of short term actions completed, prior to plant startup.
included labels on the DC breaker panels warning of the possible safety injection consequences
24        Initiate TCR for training on DC distribution panels in the Main Control Board.
and the initiation
25        Initiate TCR for long term training requirements.
of alarm annunciator
 
L-31,"Safeguards
Page No.
DC Bus Failure." Violations
ATTACHMENT 2, LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990 AND ALREADY COMPLETED)
A and B are classified
DESCRIPTION OF THE ACTION, WHICH                       ACTUAL HAS ALREADY BEEN COMPLETED                             COMPLETION DATE Evaluate the safety significance on accident           02/22/91 analyses, for both trains of SI initiation being disabled.
in the aggregate at Severity Level III.(Supplement
Perform complete HPES evaluation on the issue         '01/28/91 of crew performance, and identify recommended
1)  
  'corrective actions.
REPLY TO VIOLATION A: THE REASONS FOR THE VIOLATION Rochester Gas and Electric (RG&E)concurs that the stated violation occurred.Procedure M-48.14 was changed in March 1989, without an adequate review being performed.
Determine the priority and schedule for the             02/04/91 corrective actions resulting from the HPES evaluation of crew performance.
There were two weaknesses
Management to meet with any remaining                   03/05/91 licensed operators, training staff, etc., as needed, to communicate management expectations for questioning attitude and attention to detail.
in Ginna's procedure development
Conduct training on the planner policy                 03/08/91 regarding the importance of identifying operational consequences for planned activities involving safeguards equipment.
and change policy, which resulted in a technically
Provide training on Operations policy                   02/15/91 regarding Importance of following through on procedure concerns, and provide feedback to Operations management.
incorrect procedure being approved.As discussed by RG&E at the Enforcement
Perform Root Cause Analysis of the approval             01/28/91 and use of M-48.14 (the PCN process), and identify any failed barriers. Recommend corrective actions.
Conference
Perform Barrier Analysis on the work planning           01/28/91 process, and identify any failed barriers.
on January 29, 1991, these weaknesses
Recommend corrective actions.
occurred at the level of the"Responsible
Review recommended corrective actions from               02/04/91 the HPES evaluations, and develop a long term action plan to improve the process.
Manager" (RM)review, and in the lack of a multi-disciplinary
Review results of actions .taken, HPES                   02/12/91 evaluations, and commitments from LERs 90-015, 90-016, and 90-017, and add actions
review of the proposed change.In March 1989, the procedure development
~
and change policy did not provide adequate guidance to an RM for.determining
to this plan.
the operational
Prepare a detailed action plan for the review           02/04/91 and release of procedures from quarantine.
impact of the proposed change.Consequently, the RM (using existing policy guidance)concluded that the proposed change was"minor" and did not have any operational
Notify the industry via NUCLEAR NETWORK of               01/11/91 this event.
impact, since the proposed change added a step that was deleted during the last revision.Therefore, the RM did not require a multi-disciplinary
Initiate long term improvements in the                   01/16/91 requirements for review of Maintenance Work Order packages.
review.The Plant Operations
NSARB to review the adequacy of the long term           03/05/91 Corrective Action Plan.
Review Committee (PORC), acting on the recommendation
Issue formal guidance to the operators for               01/29/91 management expectations for release of equipment to maintenance.
of the RM, did not pursue this classification
 
in sufficient
Page No.
detail and recommended
ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT-YET COMPLETED)
approval of the proposed change.2.THE CORRECTIVE
DESCRIPTION OF THE ACTION                  GROUP        SCHEDULED ASSIGNED  'OMPLETION DATE Evaluate the impact of use of              MAINT        05/01/91 M-48.13/.14 during power operations, for other Technical Specification concerns.
STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED RG&E personnel, with active participation
Establish a working group to                OPER        06/30/91 perform task identification of infrequently performed operational activities.
by senior management, performed a thorough investigation
Develop  training for lessons              TRN-SYSTEM  09/01/91 learned from this event.
of the event, and promptly initiated extensive and comprehensive
For each Ginna "pre-PORC" group,            SGP          07/01/91 establish a pre-PORC review checklist or review criteria'or review of procedures.      (This should similar to the review criteria
corrective
                                          -'e developed for the Operations.
actions.The Senior Vice President conducted a.series of meetings, with PORC members, procedure RMs and all operating shifts to communicate
group.)
management
Revise remaining AR procedures that        OPER        03/31/91 have deficiencies.
expectations
Assess the adequacy    of the              OPER        12/01/91 administrative controls established as a result of the event..
for maintaining
Evaluate the training conducted for        TRN-SYSTEM  10/14/91 changes to A-503 (Procedure Adherence), for possible weaknesses in that training.
a questioning
Notify the NRC of RGRE's policy for          PM-MGMT      04/01/91 declaration of an event, and of the requirement to notify the NRC, and to subsequently evaluate the need to notify the state and counties.
attitude and the need for attention to detail.All plant procedures
Evaluate the guidance in the                 GMNP-EP      05/01/91 Emergency Plan and EPIP's, for declaration of an event and/or notification to the NRC and state
were screened for their impact on operability
~
of safeguards
and counties, after the condit'ions for the event no longer exist.
equipment, resulting in numerous procedures
Curriculum Committees to review the         TRN-GINNA    07/01/91 LER's,  HPES  evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.
being placed in a restricted
Curriculum Committees to review the         TRN-MAINT    07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.
status, such that.the procedure could not be used without further review (quarantined).
 
The procedure development
1 tl 0
and change policy was revised to require an operational
l'
review of ALL proposed procedure changes, and a structured
 
procedure review checklist was developed for this'review.PORC and senior management
Page No.
reviewed the adequacy of these short term corrective
ATTACHMENT 3 LIST    OF                LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDUL'ED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED
actions, and Quality Performance
'DESCRIPTION OF THE ACTION                                    GROUP      SCHEDULED ASSIGNED  COMPLETION DATE Curriculum Committees to review the                          TRN-SYSTEM 07/01/91 LER's, HPES  evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.
department
Clarify the role of the Responsible                          SGP       04/01/91 Managers in the procedure review process,,to ensure that the distinction  between "major" and "minor" changes is and that 10CFR50.59 consistently'pplied, "consequential" changes are properly evaluated.
personnel performed an independent
Clarify the role of the Responsible                          SGP        04/01/91 Managers in the procedure review process, to ensure that accountability for the adequacy and accuracy of procedures is designated.
assessment
Revise procedure A-601 to clarify                            SGP        07/01/91 the role of the Responsible Managers, and provide reinforcement of management expectations to Responsible Managers and other appropriate personnel.
of these actions.These actions were completed prior to startup of the plant.  
Consult with other utilities, to                              PM-MGMT    06/01/91 obtain information on how they accomplish similar activities.
A detailed list of short term corrective
Provide a plan to assure the                                  GMNP-MGMT  04/01/91 of the long term                      'dequacy corrective actions.
actions (all of which have been completed)
Perform a review of policies issued                          QC-ADMIN  05/01/91 (or procedures changed) as a result of this event, to ensure they are consistent with previously existing policies and/or procedures.
is at Attachment
Incorporate the policies for long                            MAINT      05/01/91 term improvements in the Maintenance Work Order process into formal administrative controls.
1.'umerous
Ensure formal guidance is                                     OPER      07/01/91 incorporated into administrative procedures.
corrective
Ensure appropriate training is                                TRN-GINNA  09/01/91 conducted on the formal guidance incorporated into procedures.
actions that are considered
 
long term have also been completed.
Page No.
These completed long term corrective
ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED)
actions are at Attachment
DESCRIPTION OF THE ACTION                GROUP        SCHEDULED ASSIGNED    COMPLETION DATE Implement  training to all                TRN-GINNA    12/01/91 applicable portions of the nuclear organization.
2.Results of these actions assure a high level of detail and consistency
Implement training to all                TRN-MAINT    12/01/91 applicable portions of the nuclear organization.
during the performance
Develop a policy for, the use or          OPER        09/01/91 reference to procedures to respond to Annunciator alarms.
of safety reviews.The need for a questioning
Conduct follow up evaluations on         PM-MGMT      06/30/91 the effectiveness of the short term corrective actions.
attitude at all times has also been reinforced.
Conduct effectiveness reviews of         OAC          12/01/91 the long term corrective actions.
A total of approximately
Determine the need for added              PM-MGMT      01/01/92 reinforcement of the short term corrective actions.
275 procedures
NSARB to review the preliminary          GMNP-MGMT    06/15/91 results of effectiveness reviews.
were quarantined, and these procedures
NSARB to review the final results        GMNP-MGMT    01/01/92 of effectiveness reviews.
will remain unavailable
 
for use until a thorough review for their operational
    't I
impact has been performed.
T}}
These actions have strengthened
existing barriers (or created new barriers)within the procedure development
and change policy, to assure that procedure changes are adequately
reviewed.THE CORRECTIVE
STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS
RG&E personnel have established
a detailed corrective
action plan to strengthen
the procedure development
and change policy.Personnel will be trained on the lessons learned from this event.There will be periodic assessments
of the adequacy of the proposed corrective
actions, and of their continuing
effectiveness.
Ongoing evaluations
will provide opportunities
for changes to or reinforcement
of these actions.The role of the RM in the procedure review process will be clarified.
See LER 90-017 and NRC Inspection
Report 90-31 for additional
discussions
of these long term actions.A detailed list of these proposed corrective
actions, including the current scheduled completion
date, is at Attachment
3.THE DATE WHEN FULL COMPLIANCE
WILL BE ACHIEVED Full compliance
with 10 CFR Part 50, Appendix B, Criterion VI was achieved prior to December 20, 1990.By that date, procedure quarantine
had been completed, and the procedure development
and change policy had been formally changed to require an operational.
review of all-proposed procedure changes.  
0 (~  
REPLY TO VIOLATION B.1.THE REASONS FOR THE VIOLATION Rochester Gas and Electric.concurs that the stated violation'occurred.
A Human Performance
Enhancement
System (HPES)evaluation
determined
that the following were co'ntributing
causes for the violation:
A.B.There was a lack of a formalized
process for the operational
review of work order packages.Procedure M-48.14 was a PORC approved procedure and was considered
correct by the Planner, Scheduler, and Control Room Foreman.C.D.Procedure M-48.14 had been previously
used by the Planner to successfully
implement corrective
maintenance.(However, the plant was at cold shutdown in that instance.)
Confidence
in the validity of the PORC approved M-48.14 and the Planner's stated previous experience
implementing
M-48.14 outweighed
the Control Room Foreman's questioning
attitude in his decision making to follow the procedure instructions.
In addition, other indications
were inadequate
in informing the operators that use of M-48.14 was inappropriate
under these circumstances:
A.Switch labelling within the DC distribution
panels lacked adequate information
in describing
the switch/load
function.B.Required Actions in Alarm Response Procedure AR-L-31, (Safeguards
DC Bus Failure)were not comprehensive.  
l  
THE CORRECTIVE
STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED The following corrective
steps have been taken to address the contributing
causes: A.RG&E has developed and implemented
a detailed work package review requirement
for Safety Re'lated and Safety Significant
work.This includes work package reviews for technical adequacy, proper isolation/holds, operational
impact, adequate testing, conformance
to technical specifications
and quality concerns.The Technical (Discipline)
and Operational
Reviews are performed utilizing a.detailed checklist to ensure consistency
in the reviews.B.Rochester Gas and Electric Senior Management
has communicated ,their expectations
for maintaining'
questioning
attitude and attention to detail to Operations
Personnel, PORC Members, and Station"planning staffs.C.Selected plant procedure groups were screened for their impact on operability
of safeguards
equipment.
Those requiring changes or additional
information
were quarantined
from use until the changes are completed.
A total of approximately
275 plant procedures
were quarantined.
D.DC Distribution
Panel switch labels were revised to clarify switch load/function.
E.Procedure AR-L-31 (Safeguards
DC Bus Failure)was revised to incorporate
enhanced Required Actions.F.Operations
management
issued formal guidance to the operators, stating management
expectations
for work package review prior to release of equipment to maintenance.
A detailed list of short term corrective
actions (all of which, have been completed)
is at Attachment
1.Numerous corrective
actions that are considered
long term have also been completed.
These completed long term corrective
actions are at Attachment
2.  
~'  
3~THE CORRECTIVE
STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS
Corrective
steps that will be taken to avoid further violations
are oriented toward strengthening
barriers and a more formalized
work package review and approval process.Additional
checklists
will be developed for work package reviews performed by non-Maintenance
personnel.
A detailed list of these proposed corrective
actions, including the current scheduled completion
date, is at Attachment
3.4~THE DATE WHEN FULL COMPLIANCE
WILL BE ACHIEVED Full compliance
with Technical Specification
6.8.1 and Appendix"A" of Regulatory
Guide 1.33, November 1972 occurred on December 20, 1991 with the implementation
of the additional
reviews for Safety Related and Safety Significant
work packages.Very truly yours, Robert C.Mec dy RCM dp Attach.(3)xc: Mr.Thomas T.Martin Regional Administrator
Region 1 475 Allendale Road King of Prussia, PA 19406 Thomas Moslak USNRC Senior Resident Inspector Ginna Station 1503 Lake Road Ontario, NY 14519 Subscribed
and sworn to before me on this 8th day of March, 1991 v'AMES C.McGUIRE NTAAY PUBUC, Stats of Nsat Yctft OuaFOIinhheos
Carly Mf CNtatfaahn
Expha Osc.2tt,$9+4
Page No.'TTACHMENT
1 LIST OF SHORT TERM CORRECTIVE
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)ITEM NUMBER DESCRIPTION
OF THE ACTION, WHICH WAS COMPLETED IN 1990.01 02 03 04 05 06 07 08 09 10 12i4 15/Senior Management
to meet with all operating shifts (prior to startup except for one shift)to communicate
management
expectations
for questioning
attitude and attention to detail., Management
to meet with the maintenance
planning staff to communicate
management
expectations
for questioning
attitude and attention to detail.Management
to meet with PORC members and procedure"Responsible
Managers" to communicate
management
expectations
for questioning
attitude and attention to detail.Prepare and issue a more detailed operations
policy on the importance
of following through on procedure concerns.Prepare and issue a policy for station planners on the importance
of identifying
operational
consequences
for planned activities
involving safeguards
equipment.
Involve the Operations
shift in the development
of corrective
actions for the HPES on crew performance.
Perform preliminary
HPES evaluation
for the issue of crew performance.
Perform screening of all plant procedure categories, to determine which categories
require review for quarantine.
Identify all current"M","EM", and"CP" procedures
that could involve safeguards
manipulation, Tech.Spec.'concerns, or A-52.4 concerns.Identify all other current plant procedures
that could involve safeguards
manipulation, Tech.Spec.concerns, or A-52.4 concerns.Based on the results of screening performed, quarantine
any proce'dures
that meet the'riteria
for quarantining.
Independent
check of the identification
of procedures
for quarantining.
Establish interim policy for the review of infrequently
used procedures
as part of the work package planning process.Determine the previous uses of M-48.13 and M-48;14, and identify any other times they were used inappropriately.
Review AR procedures
to ensure the appropriate
level of significance
is imparted, and the appropriate
response to the annunciator
is clearly stated.  
Page No.ITEM NUMBER ATTACHMENT
1 LIST OF SHORT TERM CORRECTIVE
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)DESCRIPTION
OF THE ACTION, WHICH WAS COMPLETED IN 1990.16 17 18 19 20 22 23 24 25 Revise those AR procedures
that have significant
deficiencies.
Upgrade labelling of the two DC distribution
panels and two individual
DC switches in the Main Control Board.Determine any other AC or DC distribution
panels in the Control Room that require operator/training awareness, and/or upgraded labelling.
Perform immediate read and acknowledge
training on the functions of all DC switches, including SI-A1 and SI-B1, in, the 1A and 1B DC Distribution
Panels.Provide improved direction or additional
requirements
for operational
and pre-PORC review of changes to procedures.
Review the specific training histories and operating experience
of those operators directly involved in this event.PORC review of the adequacy of short term corrective
actions, and evaluation
of readiness for plant startup.Perform a senior management
review of the adequacy of short term actions completed, prior to plant startup.Initiate TCR for training on DC distribution
panels in the Main Control Board.Initiate TCR for long term training requirements.  
Page No.ATTACHMENT
2, LIST OF LONG TERM CORRECTIVE
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990 AND ALREADY COMPLETED)
DESCRIPTION
OF THE ACTION, WHICH HAS ALREADY BEEN COMPLETED ACTUAL COMPLETION
DATE Evaluate the safety significance
on accident analyses, for both trains of SI initiation
being disabled.Perform complete HPES evaluation
on the issue of crew performance, and identify recommended
'corrective
actions.Determine the priority and schedule for the corrective
actions resulting from the HPES evaluation
of crew performance.
Management
to meet with any remaining licensed operators, training staff, etc., as needed, to communicate
management
expectations
for questioning
attitude and attention to detail.Conduct training on the planner policy regarding the importance
of identifying
operational
consequences
for planned activities
involving safeguards
equipment.
Provide training on Operations
policy regarding Importance
of following through on procedure concerns, and provide feedback to Operations
management.
Perform Root Cause Analysis of the approval and use of M-48.14 (the PCN process), and identify any failed barriers.Recommend corrective
actions.Perform Barrier Analysis on the work planning process, and identify any failed barriers.Recommend corrective
actions.Review recommended
corrective
actions from the HPES evaluations, and develop a long term action plan to improve the process.Review results of actions.taken, HPES evaluations, and commitments
from LERs 90-015, 90-016, and 90-017, and add actions~to this plan.Prepare a detailed action plan for the review and release of procedures
from quarantine.
Notify the industry via NUCLEAR NETWORK of this event.Initiate long term improvements
in the requirements
for review of Maintenance
Work Order packages.NSARB to review the adequacy of the long term Corrective
Action Plan.Issue formal guidance to the operators for management
expectations
for release of equipment to maintenance.
02/22/91'01/28/91 02/04/91 03/05/91 03/08/91 02/15/91 01/28/91 01/28/91 02/04/91 02/12/91 02/04/91 01/11/91 01/16/91 03/05/91 01/29/91  
Page No.ATTACHMENT
3 LIST OF LONG TERM CORRECTIVE
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT-YET COMPLETED)
DESCRIPTION
OF THE ACTION GROUP SCHEDULED ASSIGNED'OMPLETION
DATE Evaluate the impact of use of M-48.13/.14
during power operations, for other Technical Specification
concerns.Establish a working group to perform task identification
of infrequently
performed operational
activities.
Develop training for lessons learned from this event.For each Ginna"pre-PORC" group, establish a pre-PORC review checklist or review criteria'or
review of procedures.(This should-'e similar to the review criteria developed for the Operations.
group.)Revise remaining AR procedures
that have deficiencies.
Assess the adequacy of the administrative
controls established
as a result of the event..Evaluate the training conducted for changes to A-503 (Procedure
Adherence), for possible weaknesses
in that training.Notify the NRC of RGRE's policy for declaration
of an event, and of the requirement
to notify the NRC, and to subsequently
evaluate the need to notify the state and counties.MAINT 05/01/91 OPER 06/30/91 TRN-SYSTEM
09/01/91 SGP 07/01/91 OPER OPER 03/31/91 12/01/91 PM-MGMT 04/01/91 TRN-SYSTEM
10/14/91 Evaluate the guidance in the Emergency Plan and EPIP's, for declaration
of an event and/or notification
to the NRC and state~and counties, after the condit'ions
for the event no longer exist.GMNP-EP 05/01/91 Curriculum
Committees
to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate
incorporation
into training programs.Curriculum
Committees
to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate
incorporation
into training programs.TRN-GINNA 07/01/91 TRN-MAINT 07/01/91  
1tl 0 l'  
Page No.ATTACHMENT
3 LIST OF LONG TERM CORRECTIVE
ACTIONS (THOSE ACTIONS SCHEDUL'ED
TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED'DESCRIPTION
OF THE ACTION GROUP ASSIGNED SCHEDULED COMPLETION
DATE Curriculum
Committees
to review the LER's, HPES evaluation, and Root Cause evaluations, for appropriate
incorporation
into training programs.Clarify the role of the Responsible
Managers in the procedure review process,,to
ensure that the distinction
between"major" and"minor" changes is consistently'pplied, and that 10CFR50.59"consequential" changes are properly evaluated.
Clarify the role of the Responsible
Managers in the procedure review process, to ensure that accountability
for the adequacy and accuracy of procedures
is designated.
Revise procedure A-601 to clarify the role of the Responsible
Managers, and provide reinforcement
of management
expectations
to Responsible
Managers and other appropriate
personnel.
Consult with other utilities, to obtain information
on how they accomplish
similar activities.
Provide a plan to assure the'dequacy of the long term corrective
actions.Perform a review of policies issued (or procedures
changed)as a result of this event, to ensure they are consistent
with previously
existing policies and/or procedures.
Incorporate
the policies for long term improvements
in the Maintenance
Work Order process into formal administrative
controls.Ensure formal guidance is incorporated
into administrative
procedures.
Ensure appropriate
training is conducted on the formal guidance incorporated
into procedures.
TRN-SYSTEM
07/01/91 SGP 04/01/91 SGP 04/01/91 SGP 07/01/91 PM-MGMT 06/01/91 GMNP-MGMT 04/01/91 QC-ADMIN 05/01/91 MAINT 05/01/91 OPER 07/01/91 TRN-GINNA 09/01/91
Page No.ATTACHMENT
3 LIST OF LONG TERM CORRECTIVE
ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED)
DESCRIPTION
OF THE ACTION GROUP ASSIGNED SCHEDULED COMPLETION
DATE Implement training to all applicable
portions of the nuclear organization.
Implement training to all applicable
portions of the nuclear organization.
Develop a policy for, the use or reference to procedures
to respond to Annunciator
alarms.Conduct follow up evaluations
on the effectiveness
of the short term corrective
actions.Conduct effectiveness
reviews of the long term corrective
actions.Determine the need for added reinforcement
of the short term corrective
actions.NSARB to review the preliminary
results of effectiveness
reviews.NSARB to review the final results of effectiveness
reviews.TRN-GINNA 12/01/91 TRN-MAINT 12/01/91 OPER 09/01/91 PM-MGMT 06/30/91 OAC PM-MGMT 12/01/91 01/01/92 GMNP-MGMT 06/15/91 GMNP-MGMT 01/01/92
't I T
}}

Latest revision as of 08:48, 29 October 2019

Responds to NRC 910208 Ltr Re Violations Noted in Insp Rept 50-244/90-31 on 901213-910103.Corrective Actions:Dc Distribution Panel Switch Labels Revised to Clarify Switch Load/Function & Addl Checklists Will Be Developed
ML17309A458
Person / Time
Site: Ginna Constellation icon.png
Issue date: 03/08/1991
From: Mecredy R
ROCHESTER GAS & ELECTRIC CORP.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9103210167
Download: ML17309A458 (23)
v • d • e


Text

A.L Uj"LCKH AZU ULDLM.DULAUlN LJZIVBJI.IDLLMLBJlN 3 I 8 LPIVJ.

t i REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

SSION NBR:9103210167 DOC.DATE: 91/03/08 NOTARIZED: YES DOCKET CIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH. NAME AUTHOR AFFILIATION MECREDY,R.C.

RECIP.NAME Rochester Gas l'lectric RECIPIENT AFFILIATION Corp.

Document Control Branch (Document Control Desk)

SUBJECT:

Responds to NRC 910208 ltr re violations noted in Insp,Rept

,50-244/90=31 on 901213-910103.Corrective a'ctions:dc distribution panel switch labels revised to clarify switch load/function & addi checklists will be developed.

DISTRIBUTION CODE: IEOID COPIES RECEIVED:LTR ENCL / SIZE: /3 TITLE: General (50 Dkt)-Insp Rept/Notice of Vio ation Response /

NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72). 05000244 RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD1-3 PD 1 1 JOHNSON,A 1 1 D INTERNAL: AEOD 1 1 AEOD/DEIIB 1 1 AEOD/TPAB 1 1 DEDRO 1 1 NRR MORISSEAU,D 1 1 NRR SHANKMAN,S 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PEPB9D 1 1 NRR/DRIS/DIR 1 1 NRR/DST/DIR 8E2 1 1 NRR/PMAS/ILRB12 1 1 NUDOCS-ABSTRACT 1 1 1 1 OGC/HDS1 1 1 RG FIL 02 1 1 RGN1 FILE 01 1 1 EXTERNAL: EGGG/BRYCE, J. H. 1 1 NRC PDR 1 1 NSIC 1 1 D

A D

D NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

TOTAL NUMBER OF COPIES REQUIRED: LTTR 22 ENCL 22

I ROCHESTER GAS AND ELECTRIC CORPORATION ~ 89 EAST AVENUE, ROCHESTER N. Y. 14649-0001 ROBERT C MECREDY TELEPHONE Vice Precidenr AREA COOE 71B 646 2700 Cinna Nuclear Producrion March 8, 1991 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555

Subject:

Reply to a Notice of Violation NRC Inspection Report No. 50-244/90-31 R.E. Ginna Nuclear Power Plant NRC Docket No. 50-244

Dear Sir:

This letter is in response to the February 8, 1991 letter from Thomas T. Martin, Regional Administrator, to Robert E. Smith, Senior Vice President, Production and Engineering, which transmitted Notice of Violation from Inspection Report 90-31. In that letter, Violations A and B were identified. This letter provides the reply to the Notice of Violation, pursuant to 10 CFR 2.201.

RESTATEMENT OF VIOLATIONS:

During an NRC inspection conducted between December 13, 1990 and January 3, 1991, 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, (1990),

the particular violations are set forth below:

A. 10 CFR Part 50, Appendix B, Criterion VI, "Document Control,"

states in part, that measures shall be established to control the issuance of documents, such as procedures, including changes thereto, which prescribe all activities affecting quality. These measures shall assure that documents, including changes, are reviewed for adequacy.

9103210167 910308 PDR ADOCK 05000244

~~ j,Hi l.e ap U PDR

Contrary to the above, in March 1989, a procedure affecting quality, namely, Procedure M-48.14, "Isolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing," was changed without an adequate review being performed. The specific change involved inclusion of a step in the procedure which allowed the disabling of Engineered Safety Feature Actuation System (ESFAS) instrumentation while the reactor was in any mode of operation,'ncluding power. The licensee's organizational measures for review, approval, and issuance of this procedure change, including the review by the Plant Operations Review Committee, did not assure that the change was adequately reviewed in that did not identify that implementation of the procedure change it in a mode other than cold shutdown condition would place the plant in a condition that was prohibited by Technical Specification 3.5.2.

B. Technical Specification 6.8.1 requires establishment of the applicable procedures recommended in Appendix "A" of Regulatory Guide 1.33, November 1972, (Safety Guide 33)

Appendix A,Section I, specifies that maintenance which can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.

Contrary to the above, on December 12, 1990, the licensee failed to adequately preplan and perform corrective maintenance on the A emergency diesel generator undervoltage circuit card. Specifically, maintenance procedure M-48.14, "Isolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing," was used to perform the corrective maintenance while the reactor was at 3 percent power during startup. Step 5.5.1 directed personnel to open DC circuit breakers for the A and B safeguards logic trains which disabled the automatic and manual (push button) sequencing of safeguards equipment. This step was both unnecessary to perform the required work and inappropriate for the circumstances as it disabled the safeguards sequencing function at a time prohibited by plant technical specifications. Additionally, use of M-48.14 proceeded despite indications that the procedure was inappropriate.

Those indications included labels on the DC breaker panels warning of the possible safety injection consequences and the initiation of alarm annunciator L-31, "Safeguards DC Bus Failure."

Violations A and B are classified in the aggregate at Severity Level III. (Supplement 1)

REPLY TO VIOLATION A:

THE REASONS FOR THE VIOLATION Rochester Gas and Electric (RG&E) concurs that the stated violation occurred. Procedure M-48.14 was changed in March 1989, without an adequate review being performed. There were two weaknesses in Ginna's procedure development and change policy, which resulted in a technically incorrect procedure being approved. As discussed by RG&E at the Enforcement Conference on January 29, 1991, these weaknesses occurred at the level of the "Responsible Manager" (RM) review, and in the lack of a multi-disciplinary review of the proposed change. In March 1989, the procedure development and change policy did not provide adequate guidance to an RM for . determining the operational impact of the proposed change. Consequently, the RM (using existing policy guidance) concluded that the proposed change was "minor" and did not have any operational impact, since the proposed change added a step that was deleted during the last revision.

Therefore, the RM did not require a multi-disciplinary review. The Plant Operations Review Committee (PORC),

acting on the recommendation of the RM, did not pursue this classification in sufficient detail and recommended approval of the proposed change.

2. THE CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED RG&E personnel, with active participation by senior management, performed a thorough investigation of the event, and promptly initiated extensive and comprehensive corrective actions. The Senior Vice President conducted a .series of meetings, with PORC members, procedure RMs and all operating shifts to communicate management expectations for maintaining a questioning attitude and the need for attention to detail.

All plant procedures were screened for their impact on operability of safeguards equipment, resulting in numerous procedures being placed in a restricted status, such that

.the procedure could not be used without further review (quarantined). The procedure development and change policy was revised to require an operational review of ALL proposed procedure changes, and a structured procedure review checklist was developed for this 'review. PORC and senior management reviewed the adequacy of these short term corrective actions, and Quality Performance department personnel performed an independent assessment of these actions. These actions were completed prior to startup of the plant.

A detailed list of short term corrective actions (all of which have been completed) is at Attachment 1.'umerous corrective actions that are considered long term have also been completed. These completed long term corrective actions are at Attachment 2.

Results of these actions assure a high level of detail and consistency during the performance of safety reviews. The need for a questioning attitude at all times has also been reinforced. A total of approximately 275 procedures were quarantined, and these procedures will remain unavailable for use until a thorough review for their operational impact has been performed. These actions have strengthened existing barriers (or created new barriers) within the procedure development and change policy, to assure that procedure changes are adequately reviewed.

THE CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS RG&E personnel have established a detailed corrective action plan to strengthen the procedure development and change policy. Personnel will be trained on the lessons learned from this event. There will be periodic assessments of the adequacy of the proposed corrective actions, and of their continuing effectiveness. Ongoing evaluations will provide opportunities for changes to or reinforcement of these actions. The role of the RM in the procedure review process will be clarified. See LER 90-017 and NRC Inspection Report 90-31 for additional discussions of these long term actions.

A detailed list of these proposed corrective actions, including the current scheduled completion date, is at .

THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance with 10 CFR Part 50, Appendix B, Criterion VI was achieved prior to December 20, 1990. By that date, procedure quarantine had been completed, and the procedure development and change policy had been formally changed to require an operational. review of all -proposed procedure changes.

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REPLY TO VIOLATION B.

1. THE REASONS FOR THE VIOLATION Rochester Gas and Electric .concurs that the stated violation

'occurred. A Human Performance Enhancement System (HPES) evaluation determined that the following were co'ntributing causes for the violation:

A. There was a lack of a formalized process for the operational review of work order packages.

B. Procedure M-48.14 was a PORC approved procedure and was considered correct by the Planner, Scheduler, and Control Room Foreman.

C. Procedure M-48.14 had been previously used by the Planner to successfully implement corrective maintenance.

(However, the plant was at cold shutdown in that instance.)

D. Confidence in the validity of the PORC approved M-48.14 and the Planner's stated previous experience implementing M-48.14 outweighed the Control Room Foreman's questioning attitude in his decision making to follow the procedure instructions.

In addition, other indications were inadequate in informing the operators that use of M-48.14 was inappropriate under these circumstances:

A. Switch labelling within the DC distribution panels lacked adequate information in describing the switch/load function.

B. Required Actions in Alarm Response Procedure AR-L-31, (Safeguards DC Bus Failure) were not comprehensive.

l THE CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED The following corrective steps have been taken to address the contributing causes:

A. RG&E has developed and implemented a detailed work package review requirement for Safety Re'lated and Safety Significant work. This includes work package reviews for technical adequacy, proper isolation/holds, operational impact, adequate testing, conformance to technical specifications and quality concerns. The Technical (Discipline) and Operational Reviews are performed utilizing a . detailed checklist to ensure consistency in the reviews.

B. Rochester Gas and Electric Senior Management has communicated ,their expectations for maintaining' questioning attitude and attention to detail to Operations Personnel, PORC Members, and Station "planning staffs.

C. Selected plant procedure groups were screened for their impact on operability of safeguards equipment. Those requiring changes or additional information were quarantined from use until the changes are completed.

A total of approximately 275 plant procedures were quarantined.

D. DC Distribution Panel switch labels were revised to clarify switch load/function.

E. Procedure AR-L-31 (Safeguards DC Bus Failure) was revised to incorporate enhanced Required Actions.

F. Operations management issued formal guidance to the operators, stating management expectations for work package review prior to release of equipment to maintenance.

A detailed list of short term corrective actions (all of which, have been completed) is at Attachment 1. Numerous corrective actions that are considered long term have also been completed. These completed long term corrective actions are at Attachment 2.

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3 ~ THE CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS Corrective steps that will be taken to avoid further violations are oriented toward strengthening barriers and a more formalized work package review and approval process.

Additional checklists will be developed for work package reviews performed by non-Maintenance personnel. A detailed list of these proposed corrective actions, including the current scheduled completion date, is at Attachment 3.

4 ~ THE DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance with Technical Specification 6.8.1 and Appendix "A" of Regulatory Guide 1.33, November 1972 occurred on December 20, 1991 with the implementation of the additional reviews for Safety Related and Safety Significant work packages.

Very truly yours, Robert C. Mec dy RCM dp Subscribed and sworn to before me Attach. (3) on this 8th day of March, 1991 xc: Mr. Thomas T. Martin Regional Administrator Region 1 475 Allendale Road King of Prussia, PA 19406 v'AMES C. McGUIRE NTAAYPUBUC, Stats of Nsat Yctft Thomas Moslak OuaFOIinhheos Carly MfCNtatfaahn Expha Osc.2tt, $ 9+4 USNRC Senior Resident Inspector Ginna Station 1503 Lake Road Ontario, NY 14519

Page No.'TTACHMENT 1 LIST OF SHORT TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)

ITEM DESCRIPTION OF THE ACTION, WHICH NUMBER WAS COMPLETED IN 1990.

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01 Senior Management to meet with all operating shifts (prior to startup except for one shift) to communicate management expectations for questioning attitude and attention to detail.

02 , Management to meet with the maintenance planning staff to communicate management expectations for questioning attitude and attention to detail.

03 Management to meet with PORC members and procedure "Responsible Managers" to communicate management expectations for questioning attitude and attention to detail.

04 Prepare and issue a more detailed operations policy on the importance of following through on procedure concerns.

05 Prepare and issue a policy for station planners on the importance of identifying operational consequences for planned activities involving safeguards equipment.

06 Involve the Operations shift in the development of corrective actions for the HPES on crew performance.

07 Perform preliminary HPES evaluation for the issue of crew performance.

08 Perform screening of all plant procedure categories, to determine which categories require review for quarantine.

09 Identify all current "M", "EM", and "CP" procedures that could involve safeguards manipulation, Tech. Spec.'concerns, or A-52.4 concerns.

10 Identify all other current plant procedures that could involve safeguards manipulation, Tech. Spec. concerns, or A-52.4 concerns.

Based on the results of screening performed, quarantine any proce'dures that meet for quarantining. the'riteria 12 Independent check of the identification of procedures for quarantining.

Establish interim policy for the review of infrequently used procedures as part of the work package planning process.

i4 Determine the previous uses of M-48.13 and M-48;14, and identify any other times they were used inappropriately.

15 Review AR procedures to ensure the appropriate level of significance is imparted, and the appropriate response to the annunciator is clearly stated.

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ATTACHMENT 1 LIST OF SHORT TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED IN 1990)

ITEM DESCRIPTION OF THE ACTION, WHICH NUMBER WAS COMPLETED IN 1990.

16 Revise those AR procedures that have significant deficiencies.

17 Upgrade labelling of the two DC distribution panels and two individual DC switches in the Main Control Board.

18 Determine any other AC or DC distribution panels in the Control Room that require operator / training awareness, and/or upgraded labelling.

19 Perform immediate read and acknowledge training on the functions of all DC switches, including SI-A1 and SI-B1, in, the 1A and 1B DC Distribution Panels.

20 Provide improved direction or additional requirements for operational and pre-PORC review of changes to procedures.

Review the specific training histories and operating experience of those operators directly involved in this event.

22 PORC review of the adequacy of short term corrective actions, and evaluation of readiness for plant startup.

23 Perform a senior management review of the adequacy of short term actions completed, prior to plant startup.

24 Initiate TCR for training on DC distribution panels in the Main Control Board.

25 Initiate TCR for long term training requirements.

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ATTACHMENT 2, LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990 AND ALREADY COMPLETED)

DESCRIPTION OF THE ACTION, WHICH ACTUAL HAS ALREADY BEEN COMPLETED COMPLETION DATE Evaluate the safety significance on accident 02/22/91 analyses, for both trains of SI initiation being disabled.

Perform complete HPES evaluation on the issue '01/28/91 of crew performance, and identify recommended

'corrective actions.

Determine the priority and schedule for the 02/04/91 corrective actions resulting from the HPES evaluation of crew performance.

Management to meet with any remaining 03/05/91 licensed operators, training staff, etc., as needed, to communicate management expectations for questioning attitude and attention to detail.

Conduct training on the planner policy 03/08/91 regarding the importance of identifying operational consequences for planned activities involving safeguards equipment.

Provide training on Operations policy 02/15/91 regarding Importance of following through on procedure concerns, and provide feedback to Operations management.

Perform Root Cause Analysis of the approval 01/28/91 and use of M-48.14 (the PCN process), and identify any failed barriers. Recommend corrective actions.

Perform Barrier Analysis on the work planning 01/28/91 process, and identify any failed barriers.

Recommend corrective actions.

Review recommended corrective actions from 02/04/91 the HPES evaluations, and develop a long term action plan to improve the process.

Review results of actions .taken, HPES 02/12/91 evaluations, and commitments from LERs90-015, 90-016, and 90-017, and add actions

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to this plan.

Prepare a detailed action plan for the review 02/04/91 and release of procedures from quarantine.

Notify the industry via NUCLEAR NETWORK of 01/11/91 this event.

Initiate long term improvements in the 01/16/91 requirements for review of Maintenance Work Order packages.

NSARB to review the adequacy of the long term 03/05/91 Corrective Action Plan.

Issue formal guidance to the operators for 01/29/91 management expectations for release of equipment to maintenance.

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ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT-YET COMPLETED)

DESCRIPTION OF THE ACTION GROUP SCHEDULED ASSIGNED 'OMPLETION DATE Evaluate the impact of use of MAINT 05/01/91 M-48.13/.14 during power operations, for other Technical Specification concerns.

Establish a working group to OPER 06/30/91 perform task identification of infrequently performed operational activities.

Develop training for lessons TRN-SYSTEM 09/01/91 learned from this event.

For each Ginna "pre-PORC" group, SGP 07/01/91 establish a pre-PORC review checklist or review criteria'or review of procedures. (This should similar to the review criteria

-'e developed for the Operations.

group.)

Revise remaining AR procedures that OPER 03/31/91 have deficiencies.

Assess the adequacy of the OPER 12/01/91 administrative controls established as a result of the event..

Evaluate the training conducted for TRN-SYSTEM 10/14/91 changes to A-503 (Procedure Adherence), for possible weaknesses in that training.

Notify the NRC of RGRE's policy for PM-MGMT 04/01/91 declaration of an event, and of the requirement to notify the NRC, and to subsequently evaluate the need to notify the state and counties.

Evaluate the guidance in the GMNP-EP 05/01/91 Emergency Plan and EPIP's, for declaration of an event and/or notification to the NRC and state

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and counties, after the condit'ions for the event no longer exist.

Curriculum Committees to review the TRN-GINNA 07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.

Curriculum Committees to review the TRN-MAINT 07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.

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ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDUL'ED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED

'DESCRIPTION OF THE ACTION GROUP SCHEDULED ASSIGNED COMPLETION DATE Curriculum Committees to review the TRN-SYSTEM 07/01/91 LER's, HPES evaluation, and Root Cause evaluations, for appropriate incorporation into training programs.

Clarify the role of the Responsible SGP 04/01/91 Managers in the procedure review process,,to ensure that the distinction between "major" and "minor" changes is and that 10CFR50.59 consistently'pplied, "consequential" changes are properly evaluated.

Clarify the role of the Responsible SGP 04/01/91 Managers in the procedure review process, to ensure that accountability for the adequacy and accuracy of procedures is designated.

Revise procedure A-601 to clarify SGP 07/01/91 the role of the Responsible Managers, and provide reinforcement of management expectations to Responsible Managers and other appropriate personnel.

Consult with other utilities, to PM-MGMT 06/01/91 obtain information on how they accomplish similar activities.

Provide a plan to assure the GMNP-MGMT 04/01/91 of the long term 'dequacy corrective actions.

Perform a review of policies issued QC-ADMIN 05/01/91 (or procedures changed) as a result of this event, to ensure they are consistent with previously existing policies and/or procedures.

Incorporate the policies for long MAINT 05/01/91 term improvements in the Maintenance Work Order process into formal administrative controls.

Ensure formal guidance is OPER 07/01/91 incorporated into administrative procedures.

Ensure appropriate training is TRN-GINNA 09/01/91 conducted on the formal guidance incorporated into procedures.

Page No.

ATTACHMENT 3 LIST OF LONG TERM CORRECTIVE ACTIONS (THOSE ACTIONS SCHEDULED TO BE COMPLETED AFTER 1990, AND NOT YET COMPLETED)

DESCRIPTION OF THE ACTION GROUP SCHEDULED ASSIGNED COMPLETION DATE Implement training to all TRN-GINNA 12/01/91 applicable portions of the nuclear organization.

Implement training to all TRN-MAINT 12/01/91 applicable portions of the nuclear organization.

Develop a policy for, the use or OPER 09/01/91 reference to procedures to respond to Annunciator alarms.

Conduct follow up evaluations on PM-MGMT 06/30/91 the effectiveness of the short term corrective actions.

Conduct effectiveness reviews of OAC 12/01/91 the long term corrective actions.

Determine the need for added PM-MGMT 01/01/92 reinforcement of the short term corrective actions.

NSARB to review the preliminary GMNP-MGMT 06/15/91 results of effectiveness reviews.

NSARB to review the final results GMNP-MGMT 01/01/92 of effectiveness reviews.

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