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See also: [[followed by::IR 05000335/1995015]]


=Text=
=Text=
{{#Wiki_filter:RIG RITY 1 ACCELERATED
{{#Wiki_filter:RIG RITY ACCELERATED RIDS PROCESSING),
RIDS PROCESSING), REGULATORY
1 REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) r 'ESSION       NBR   9511210113               DOC ~ DATE'5/11/15           NOTARIZED     NO       DOCKET  N FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power                             & Light Co. 05000335 50-389 St. Lucie Plant, Unit 2, Florida Power                           & Light Co. 05000389 AUTH. NAME               AUTHOR AFFILIATION GOLDBERG,J.H.           Florida       Power     &'ight     Co.
INFORMATION
RECIP.NAME               RECIPIENT AFFILIATION Document Control Branch (Document                   Control Desk)
DISTRIBUTION
 
SYSTEM (RIDS)r'ESSION NBR 9511210113
==SUBJECT:==
DOC~DATE'5/11/15
Forwards response to NRC                 ltr re violations noted in insp repts 50-335/95-15 & 50-389/95-15.Corrective actions:MSIS was blocked & reset immediately following event on 950802.
NOTARIZED NO FACIL:50-335
I DISTRIBUTION CODE: IE01D                 COPIES RECEIVED:LTR             ENCL       SIZE:
St.Lucie Plant, Unit 1, Florida Power&Light Co.50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION
TITLE: General       (50   Dkt)-Insp Rept/Notice of Violation Response NOTES RECIPIENT                   COPIES                RECIPIENT            COPIES ID CODE/NAME                 LTTR ENCL          ID  CODE/NAME        LTTR ENCL PD2-1 PD                         1      1      NORRIS,J                  1    1 INTERNAL: ACRS                                       2      AEOD/DEIB                  1    1 AEOD/SPD/RAB                             1      A'E.                      1    1 DEDRO                                     1      FILE    CENTER            1    1 NRR/DISP/PIPB                             1            /'DRC8/H FB          1    1 NRR/DRPM/PECB                             1      NUDOCS-ABSTRACT            1    1 OE DIR                                   1  'GC/HDS3                      1    1 RGN2       FILE       01                 1 EXTERNAL: LITCO BRYCE,J H                    1      1       NOAC                      1     1 NRC PDR                          1       1 iNOTE TO ALL RIDS" RECIPIEYTS:
GOLDBERG,J.H.
PLEASE HELP US TO REDUCE 4VASTE! CONTACT THE DOCL'!iIEYTCO."iTROL DESK, ROOiiI Pl-37 (EXT. 504-2083 ) TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY. LISTS FOR DOCL'IiIEi'I'S5'OU DOi "I'L'LD!
Florida Power&'ight Co.RECIP.NAME
TOTAL NUMBER OF COPIES REQUIRED: LTTR                       19     ENCL     19
RECIPIENT AFFILIATION
 
Document Control Branch (Document Control Desk)SUBJECT: Forwards response to NRC ltr re violations
4 0'
noted in insp repts 50-335/95-15
 
&50-389/95-15.Corrective
Florida Power L Light Company, 0
actions:MSIS
P.O. Box 14000, Juno Beach, FL 33408 0420 NOV   1 5   $ 995 L-95-306 10 CFR 2.201 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Re:   St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 Florida Power and Light Company             (FPL) has reviewed the                       subject inspection report and pursuant to           10 CFR 2.201 the response                       to the notice of violation is attached.
was blocked&reset immediately
Very   truly yours, J. H. Goldberg President Nuclear Division JHG/DAS/EJB Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region                                   II Senior Resident Inspector, USNRC, St. Lucie Plant 95ii210i13 'it5iii5 PDR   ADOCK     05000335 9                     PDR an FPL Group company
following event on 950802.I DISTRIBUTION
 
CODE: IE01D COPIES RECEIVED:LTR
FPL RESPONSE TO INSPECTION REPORT 95-15
ENCL SIZE: TITLE: General (50 Dkt)-Insp Rept/Notice
 
of Violation Response NOTES DOCKET N 05000335 05000389 INTERNAL: RECIPIENT ID CODE/NAME PD2-1 PD ACRS AEOD/SPD/RAB
==SUMMARY==
DEDRO NRR/DISP/PIPB
 
NRR/DRPM/PECB
NRC   Inspection Report 50-335/389/95-15 considered St. Lucie Plant performance during the six (6) week period from July 30, 1995 through September       16, 1995. The violations below occurred during a relatively short period of time, as described in the inspection report, and several of the corrective actions were instituted following an analysis of the events, collectively.         The corrective steps to avoid further violations were in some cases determined to be generic following this analysis, and are therefore repeated in a number of the responses.       The Inspection Report identified seven (7) violations which are listed below.
OE DIR RGN2 FILE 01 COPIES RECIPIENT LTTR ENCL ID CODE/NAME 1 1 NORRIS,J 2 AEOD/DEIB 1 A'E.1 FILE CENTER 1/'DRC8/H FB 1 NUDOCS-ABSTRACT
Violation   A:   Failure to Follow Procedures and Block MSIS Actuation Violation   B:   Failure to Follow Procedures During RCP Seal Restaging Violation   C:   Failure to Follow Procedure and Document Abnormal Valve Position in the Valve, Switch Deviation log Violation   D:   Failure to Follow Procedures during Alignment of Shutdown Cooling System Violation   E:   Failure to Follow Procedure and Document a Deficiency on Containment         Spray   Valve Surveillance Test Procedure Violation   F:   Failure to Initial Maintenance Procedure Steps as Work was Completed Violation   G:   Failure to Follow Procedures During Venting of ECCS   System Resulted in Containment Spraydown Additionally, both Florida Power and Light (FPL) and the NRC evaluated plant events to identify common underlying themes.
1'GC/HDS3 1 COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 EXTERNAL: LITCO BRYCE,J H NRC PDR 1 1 1 1 NOAC 1 1 iNOTE TO ALL RIDS" RECIPIEYTS:
FPL presented a summary of events to the NRC on August 29, 1995.     Weaknesses   identified in this summary included procedure content and use, as well as management oversight of eguipment performance.
PLEASE HELP US TO REDUCE 4VASTE!CONTACT THE DOCL'!iIEYT
FPL's Plan to Improve the Operational Performance at St. Lucie was developed as a   result of the August 29, 1995, meeting and submitted to the NRC on September 15, 1995. To date, FPL has completed the activities according to the improvement plan schedule.
CO."iTROL DESK, ROOiiI Pl-37 (EXT.504-2083)TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY.
 
LISTS FOR DOCL'IiIEi'I'S
S=. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION A:
5'OU DOi"I'L'LD!TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19  
Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence.         Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.
4 0'  
OP 1-0030127, Rev 68, "Reactor Plant Cooldown Hot Standby to Cold Shutdown," required, in part, that operators block Main Steam Isolation System (MSIS) actuation when block permissive annunciations were received.           ONOP 1-0030131, Rev 60, "Plant Annunciator Summary," required that, upon valid receipt of annunciators Q-18 and Q-20, operators immediately block channels A and B,   respectively.
0 Florida Power L Light Company, P.O.Box 14000, Juno Beach, FL 33408 0420 NOV 1 5$995 L-95-306 10 CFR 2.201 U.S.Nuclear Regulatory
Contrary to the above, on August 2, 1995, during a cooldown of St.
Commission
Lucie Unit 1, valid block. permissive annunciators were received, however, operators failed to establish the required MSIS blocks, resulting in A and B channel MSIS actuations.
Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15Florida Power and Light Company (FPL)has reviewed the subject inspection
RESPONSE   A:
report and pursuant to 10 CFR 2.201 the response to the notice of violation is attached.Very truly yours, J.H.Goldberg President-Nuclear Division JHG/DAS/EJB
REASON FOR VIOLATION The root cause of   this violation was cognitive personnel error on the part of a   utility licensed   operator who failed to block the actuation   of the main   steam isolation signal (MSIS) in accordance with the requirements of the approved plant operating procedure.
Attachment
: 2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The main steam   isolation signal (MSIS) was blocked and reset immediately following the event on August 2, 1995.
cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St.Lucie Plant 95ii210i13
 
'it5iii5 PDR ADOCK 05000335 9 PDR an FPL Group company  
St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
FPL RESPONSE TO INSPECTION
: 3. CORRECTXVE STEPS TO AVOXD FURTHER VXOLATXONS A. The licensed operator who was involved in the event was counseled on the need to follow procedures and received discipline in accordance with plant'policy.
REPORT 95-15 SUMMARY NRC Inspection
B. All   Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.
Report 50-335/389/95-15
C. This event   will be incorporated into licensed operator requalification     training   to emphasize     procedural compliance, proper communication among the Control Room
considered
          'team, and the importance of supervision -in the control room maintaining an overall awareness, of activities.
St.Lucie Plant performance
This action will be complete by January 1, 1996.
during the six (6)week period from July 30, 1995 through September 16, 1995.The violations
D. St. Lucie Plant adopted verbatim compliance as the only acceptable             of procedure compliance.
below occurred during a relatively
means Procedures'                        This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, " "Preparation, Revision, Review/Approval of
short period of time, as described in the inspection
: 4. Full compliance     was achieved   on August 2,   1995 with the completion of item   2 above.
report, and several of the corrective
 
actions were instituted
St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION B:
following an analysis of the events, collectively.
Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1..d includes administrative procedures for procedural adherence.         Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.
The corrective
Contrary to the above, procedures were not adhered to strictly in the following examples:
steps to avoid further violations
OP 1-0120020, Rev. 72, "Filling and Venting the RCS,"
were in some cases determined
precaution 4.2, required that Reactor Coolant System (RCS) venting, described in the procedure, not be attempted temperature was above 200'F.
to be generic following this analysis, and are therefore repeated in a number of the responses.
if RCS On August 2, 1995, Reactor Coolant Pump (RCP) seal venting, performed in an attempt to correct seal package leakage in the 1A2 RCP in accordance       with Appendix E of the subject procedure,     was   performed while RCS temperature         was approximately 370'F. As a result, design temperatures of RCP seal components were approached or exceeded.
The Inspection
: 2. OP 1-0120020, Rev. 72, "Filling and Venting the RCS," Appendix E, "Restaging Reactor Coolant Pump Seals," required the use of RCP seal injection while restaging     was attempted.
Report identified
On August 2, 1995, restaging of the 1A2 RCP seal package was attempted without seal injection aligned to the seal package.
seven (7)violations
As a result, design temperatures of RCP seal components were approached   or exceeded.
which are listed below.Violation A: Failure to Follow Procedures
RESPONSE B:
and Block MSIS Actuation Violation B: Failure to Follow Procedures
REASON FOR VIOLATION The root cause of this   violation was cognitive personnel error on the part of a       utility licensed   operator who failed to follow an approved       plant procedure while performing a restaging evolution on a Reactor Coolant 'Pump (RCP) seal package. The operator did not strictly adhere         to the conditions contained in the procedure which required that RCS temperature be no greater than 200'F, and that seal injection be in service.
During RCP Seal Restaging Violation C: Failure to Follow Procedure and Document Abnormal Valve Position in the Valve, Switch Deviation log Violation D: Failure to Follow Procedures
 
during Alignment of Shutdown Cooling System Violation E: Failure to Follow Procedure and Document a Deficiency
0 St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply'o Notice of Violation Ins ection Re ort 95-15
on Containment
: 2. CORRECTXVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The   RCP 'estaging       evolution was discontinued, and Operations cooled and depressurized       the Reactor Coolant System (RCS)     in accordance with approved plant procedure to lower RCP     seal temperatures to within the acceptable range. The 1A2       RCP was secured.
Spray Valve Surveillance
B. The damaged   1A2 RCP   seal package was   replaced prior to returning Unit     1 to operation.
Test Procedure Violation F: Failure to Initial Maintenance
: 3. CORRECTIVE STEPS TO AVOID FURTHER VXOLATXONS A. The   licensed operator involved in this event was disciplined in accordance with plant policy.
Procedure Steps as Work was Completed Violation G: Failure to Follow Procedures
B. The procedure appendix which was used for performing the restaging of the RCPs was deleted and is no longer available for use.
During Venting of ECCS System Resulted in Containment
C. Plant management performed an assessment of the decision making process that led to the restaging of the RCP seal under the existing plant conditions.             Based on this assessment, Plant policy 105, "Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures which are being implemented for the first time or for which plant conditions are different from those described in the procedures D. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.
Spraydown Additionally, both Florida Power and Light (FPL)and the NRC evaluated plant events to identify common underlying
E. St. Lucie Plant adopted verbatim compliance as the only acceptable     means     of procedure compliance.         This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, "Preparation, Revision, Review/Approval of Procedures."
themes.FPL presented a summary of events to the NRC on August 29, 1995.Weaknesses
: 4. Full compliance     was achieved     on August   2, 1995 with the completion of item 2A, above.
identified
 
in this summary included procedure content and use, as well as management
St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION C:
oversight of eguipment performance.
Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence.         Procedure QI 5-PR/PSL-1, Rev. 62, 5.13 ',
FPL's Plan to Improve the Operational
"Preparation, Revision, Review/Approval of Procedures," Section states that all procedures shall be strictly adhered to.
Performance
AP 1-0010123,   Rev 99, "Administrative Controls of Valves, Locks, and   Switches," step 8.1.6, required, in part, that all valve position deviations be documented in the Valve Switch Deviation Log.
at St.Lucie was developed as a result of the August 29, 1995, meeting and submitted to the NRC on September 15, 1995.To date, FPL has completed the activities
Contrary to the above, on or about August 1, 1995, HCV-25-1 through 7 were repositioned and left in the closed position without the required entries being made in the Valve Switch Deviation Log. The Valves'ositions complicated a loss of RCS inventory.
according to the improvement
RESPONSE   C:
plan schedule.  
REASON FOR VIOLATION The root cause   of this violation was cognitive personnel error on the part of   utility licensed operators who did not properly document the closed status of the subject valves in the Valve Switch Deviation Log, as required by the approved plant procedure.
S=.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION A: Technical Specification
: 2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED The   Safeguards Pump Room Sump Isolation valves, HCV 25-1 through HCV 25-7, were realigned to the open position immediately following the loss of RCS inventory event on August 10, 1995, when Control Room operators discovered the closed status of the valves.
6.8.1.a requires that written procedures
 
be established, implemented, and maintained
St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
covering the activities
: 3. CORRECTXVE STEPS TO AVOXD FURTHER VXOLATXONS A. All   Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.
recommended
B. The plant   has adopted verbatim compliance as the only acceptable     means   of procedure   compliance. This requirement   has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, "Preparation, Revision, Review/Approval of Procedures."
in Appendix A of Regulatory
C. Management is conducting a daily review of Control Room chronological logs to reinforce the expectation for detail   and completeness.
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
I D. Plant administrative procedures have been revised to provide for increased reviews by plant staff of the logs controlling valve repositioning.
procedures
Full compliance   was achieved on August 10, 1995, with the completion of item   2 above.
for procedural
 
adherence.
St. Lucie Units   1 and   2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION D:
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence.         Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5 '3.2, states that all procedures shall be strictly adhered to.
of Procedures," Section 5.13.2, states that all procedures
OP 1-0410022, Rev 22, "Shutdown Cooling," step 8.3.7, required that V3652, the B Shutdown Cooling (SDC) hot leg suction isolation valve, be locked open while placing the B SDC loop in service.
shall be strictly adhered to.OP 1-0030127, Rev 68,"Reactor Plant Cooldown-Hot Standby to Cold Shutdown," required, in part, that operators block Main Steam Isolation System (MSIS)actuation when block permissive
Contrary to the above, on August 29, a control room operator failed to place V3652 in a locked open condition while placing the B SDC loop in service. As a result, the 1B Low Pressure Safety Injection Pump was operated with its suction line isolated.
annunciations
RESPONSE   D:
were received.ONOP 1-0030131, Rev 60,"Plant Annunciator
REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to properly verify the alignment of the shutdown cooling (SDC) system flowpath in accordance           with the approved plant procedure, prior to starting the 1B Low Pressure Safety Injection (LPSI) Pump. This resulted in the failure to open the 1B LPSI Pump suction isolation valve.
Summary," required that, upon valid receipt of annunciators
: 2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The   Control Room operators noted the error in valve alignment and the LPSI pump was secured approximately 5 minutes after being started.       A subsequent inspection determined that no damage had occurred during the short period of pump operation.
Q-18 and Q-20, operators immediately
B. The system was realigned in accordance with the approved procedure and the LPSI pump was restarted. Subsequent operation of the LPSI pump was satisfactory.
block channels A and B, respectively.
C. An ASME Section XI code run   was performed satisfactorily on the     1B   LPSI Pump and   a subsequent Engineering assessment   concluded that pump operability had not been adversely affected.
Contrary to the above, on August 2, 1995, during a cooldown of St.Lucie Unit 1, valid block.permissive
 
annunciators
St. Lucie Units .1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
were received, however, operators failed to establish the required MSIS blocks, resulting in A and B channel MSIS actuations.
: 3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. The   licensed operator involved in this event             was disciplined in accordance with plant policy.
RESPONSE A: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to block the actuation of the main steam isolation signal (MSIS)in accordance
B. Operations implemented procedure changes which require the use of a dedicated procedure reader to assist in the implementation of SDC related evolutions.
with the requirements
C. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.
of the approved plant operating procedure.
D. The plant   has adopted verbatim compliance     as the only acceptable     means     of procedure   compliance. This requirement   has been incorporated into plant Quality Instruction     QI 5-PR/PSL-1,     "Preparation,   Revision, Review/Approval of Procedures."
2.CORRECTIVE
E. This event     will be included into licensed operator, requalification training. This action will be completed by January 1, 1996.
STEPS TAKEN AND THE RESULTS ACHIEVED A.The main steam isolation signal (MSIS)was blocked and reset immediately
: 4. Full compliance   was   achieved on August 29, 1995 with the completion of item     2A and 2B above.
following the event on August 2, 1995.  
 
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTXVE
St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION E:
STEPS TO AVOXD FURTHER VXOLATXONS
Technical Specification 6. 8. 1. a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence.       Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.
A.The licensed operator who was involved in the event was counseled on the need to follow procedures
QI 16-PR/PSL-2, Rev. 1, "St. Lucie Action Report (STAR) Program,"
and received discipline
required that STARs be initiated for Quality Assurance audit findings and independent technical review     recommendations'ontrary to the above, a STAR was not generated when a Quality Assurance review of an inadvertent Unit 1 containment spraydown, documented in interoffice correspondence JQQ-95-143, identified the practice of prelubricating FCV-07-1A, Containment Spray header A flow control valve, when performing valve stroke time testing.
in accordance
RESPONSE E:
with plant'policy.
: 1. REASON FOR VIOLATION The root cause of   this violation was cognitive personnel error on the part of     utility Quality Assurance (QA) personnel. QA personnel were in the process of conducting an independent review focusing on the contributing factors associated with a Unit 1 containment spray down event. The practice of pre-lubricating Containment Spray header flow control valve FCV-07-lA prior to surveillance testing was identified during this.
B.All Operations
review, but was not determined to be a contributing factor to this event. Recommendations to correct this deficiency were therefore not contained in the resulting QA report, nor was a St. Lucie Action Request (STAR) generated in a timely manner.
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
2.= CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. A St. Lucie Action Request (STAR 951048) was generated on September 7, 1995 to document the deficient practice of pre-lubricating Unit 1 and Unit 2 containment spray flow control valves prior to surveillance stroke time testing.
to this event to reiterate FPL's goal for error free performance.
B. Temporary changes were issued to plant surveillance procedures on September 2, 1995 to remove the practice of
C.This event will be incorporated
          'pre-lubricating valves prior to surveillance testing.
into licensed operator requalification
10
training to emphasize procedural
 
compliance, proper communication
St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
among the Control Room'team, and the importance
: 3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. A meeting was   held on September 13, 1995 between the Vice President of Nuclear Assurance and all St. Lucie Quality Assurance and Quality Control personnel. During this meeting, clear expectations were provided regarding the threshold for identification and documentation of deficiencies by Quality personnel.                       E B. On October 25, 1995, a second meeting was held between the site Quality Manager and St. Lucie QA personnel.
of supervision-in the control room maintaining
During this meeting, the requirements of the Quality Instruction QI 16-PR/PSL-2, "St. Lucie Action Report (STAR) Program" were reviewed. The responsibility of QA personnel for timely identification and documentation of deficiencies in accordance with this procedure was reinforced.
an overall awareness, of activities.
C. Permanent   changes   will be made to plant surveillance procedures     to discontinue the practice of pre-test lubrication of the valves prior to surveillance testing.
This action will be complete by January 1, 1996.D.St.Lucie Plant adopted verbatim compliance
This action will be completed by December 1, 1995.
as the only acceptable
: 4. Full compliance was achieved on September 7, 1995 with the completion of item 2A above.
means of procedure compliance.
 
This requirement
St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION F:
has been incorporated
Technical Specification 6.8 1.a requires that written procedures be
into plant Quality Instruction
                              ~
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence.       Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.
of Procedures'~
ADM-08.02, Rev 7, "Conduct of Maintenance," Appendix 5, step 5, required that procedures be present during work and that individual steps be initialed once performed.
" 4.Full compliance
Contrary to the above, inspection of work in progress revealed that individual steps were not initialed once performed upon completion for work conducted in accordance with Plant Change/Modification 11-195.
was achieved on August 2, 1995 with the completion
RESPONSE F:
of item 2 above.  
: 1. REASON FOR VIOLATION The root cause of   this violation was cognitive personnel error on the part of an   Electrical Department journeyman who failed to properly document the completion of steps while performing work activities associated with the trip solenoids on the 1B Emergency Diesel Generator       (EDG). The steps were not initialed as they were being performed, in accordance with approved plant procedure.
: 2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The steps of the maintenance procedure being worked were signed off by the journeyman immediately following the completion of the work on August 31, 1995, and the completed procedure was reviewed by the chief electrician and Electrical supervisor.
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION B: Technical Specification
B. The EDG circuitry was subsequently     tested following completion of the work on August 31, 1995, and performed satisfactorily.
6.8.1.a requires that written procedures
12
be established, implemented, and maintained
 
covering the activities
0 St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
recommended
: 3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. Meetings were held following this event with Electrical Maintenance employees to review this incident and emphasize     management   expectations     regarding     the documentation of w'ork activities.
in Appendix A of Regulatory
B. Supervisors from each Maintenance discipline have conducted meetings with their employees to reinforce the need   for strict adherence to the administrative requirements related to procedure use.
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1..d includes administrative
C. The plant has adopted verbatim compliance     as the only acceptable     means   of procedure     compliance. This requirement   has been incorporated into plant Quality Instruction     QI 5-PR/PSL-1,   "Preparation,     Revision, Review/Approval of Procedures."
procedures
: 4. Full compliance   was achieved on August     31, 1995 with the completion of item   2A and 2B above.
for procedural
13
adherence.
 
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
St. Lucie Units   1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION G:
of Procedures," Section 5.13.2, states that all procedures
10 CFR 50 Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that activities affecting quality shall be prescribed by documented procedures of a type appropriate to the circumstances.
shall be strictly adhered to.Contrary to the above, procedures
Contrary to the above, on August 18, 1995, venting of the Low Pressure Safety Injection (LPSI) System was conducted in accordance with a procedure which was inappropriate to the circumstances.
were not adhered to strictly in the following examples: OP 1-0120020, Rev.72,"Filling and Venting the RCS," precaution
Specifically, OP 1-0420060, Rev. 0, "Venting of the Emergency Core Cooling and Containment Spray Systems," did not require a verification that the portions of the system being vented were hydraulically isolated from adjacent systems and flowpaths. As a result of this failure to establish proper initial conditions, water driven by the 1A LPSI pump was inadvertently directed to the A Train Containment Spray header, resulting in a spraydown of the Unit 1 Reactor Containment Building.
4.2, required that Reactor Coolant System (RCS)venting, described in the procedure, not be attempted if RCS temperature
RESPONSE   G:
was above 200'F.On August 2, 1995, Reactor Coolant Pump (RCP)seal venting, performed in an attempt to correct seal package leakage in the 1A2 RCP in accordance
REASON FOR VIOLATION The root cause of this violation was procedural deficiency in that the ECCS venting procedure, OP 1-0420060, did not state the plant conditions required to successfully vent the ECCS but relied upon the RCS heatup procedure to set plant conditions. Specifically, the venting procedure did not require operators to verify that the proper containment spray header   isolation valves   were closed prior to recirculating the water in the   SDC system.
with Appendix E of the subject procedure, was performed while RCS temperature
A   contributing factor to this event was that the operations personnel performing the ECCS venting procedure did not recognize that the existing plant conditions would result in flow to the 'A'ontainment spray header when flow was aligned through the Shutdown Cooling Heat Exchanger.
was approximately
A second contributing   factor of this event was that FCV-07-1A was placed in the open   position because this valve had failed its ASME stroke time test. Plant management made the decision to defer the valve repair and position this normally closed valve to its engineered safeguards open position in lieu of repairing the valve prior to startup.
370'F.As a result, design temperatures
14
of RCP seal components
 
were approached
St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
or exceeded.2.OP 1-0120020, Rev.72,"Filling and Venting the RCS," Appendix E,"Restaging
: 2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. Operators   secured the 1A LPSI Pump and isolated, the flowpath to the containment spray header from the LPSI Pump. The Reactor Cavity sump was drained to the Waste Management   System.
Reactor Coolant Pump Seals," required the use of RCP seal injection while restaging was attempted.
B ~ Following the event,   all nonessential work at the site was placed on hold, and Unit 1 was maintained stable in Mode 3 while senior plant management conducted meetings with all available site personnel to stress the need for worker vigilance and attention to detail. The need to reduce equipment deficiencies that impact operations was also discussed.
On August 2, 1995, restaging of the 1A2 RCP seal package was attempted without seal injection aligned to the seal package.As a result, design temperatures
C. Unit 1 was cooled down and depressurized to Mode,5 and an inspection and decontamination of containment was then conducted. The event was evaluated under an Engineering evaluation, which resulted in a comprehensive inspection of components inside containment to ensure future component   reliability.
of RCP seal components
D. Operating   procedure, OP 1-0420060, "Venting of the Emergency Core Cooling an'd Containment Spray System", was revised September 1, 1995 to include the plant conditions required to be present during venting.
were approached
: 3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. Plant policy 105, "Plant Operation Beyond the Envelope of Approved Plant Operating     Procedures", was revised to require a technical review of procedures which are being implemented for the first time or for which plant conditions are different from those described in the procedure.
or exceeded.RESPONSE B: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to follow an approved plant procedure while performing
B. The Maintenance Department established a team composed of plant staff and engineering personnel, to determine the root cause for the Containment Spray header isolation valve repeat failures and determine corrective actions to eliminate this operator workaround.         FCV-07-1A was repaired prior to returning Unit 1 to service.
a restaging evolution on a Reactor Coolant'Pump (RCP)seal package.The operator did not strictly adhere to the conditions
15
contained in the procedure which required that RCS temperature
 
be no greater than 200'F, and that seal injection be in service.  
St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 C. Existing plant deficiencies were reviewed by senior plant management. Additional deficiencies which could impact operations were added to the work scope of the Unit 1 shutdown. These deficiencies were corrected prior to returning the unit to service.
0  
D. Administrative procedure, AP-0010147, "Assessment of Abnormal Plant Configurations or Significant Material Deficient 'Conditions on Plant Operation", was developed to enhance outage scope review and ensure that equipment deficiencies are restored in a timely manner.
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply'o Notice of Violation Ins ection Re ort 95-15 2.CORRECTXVE
E. St. Lucie management instituted a weekly review of appropriate performance indicators and work backlog status, including the age of open items and operator workarounds.
STEPS TAKEN AND THE RESULTS ACHIEVED A.The RCP'estaging evolution was discontinued, and Operations
F. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for erro'r free performance.
cooled and depressurized
G. This event   will be   incorporated into licensed operator requalification training.     This action will be complete by January 1, 1996.
the Reactor Coolant System (RCS)in accordance
: 4. Full compliance   was achieved on August 18, 1995 with the completion of items 2A, 2C and 2D above.
with approved plant procedure to lower RCP seal temperatures
16}}
to within the acceptable
range.The 1A2 RCP was secured.B.The damaged 1A2 RCP seal package was replaced prior to returning Unit 1 to operation.
3.CORRECTIVE
STEPS TO AVOID FURTHER VXOLATXONS
A.The licensed operator involved in this event was disciplined
in accordance
with plant policy.B.The procedure appendix which was used for performing
the restaging of the RCPs was deleted and is no longer available for use.C.Plant management
performed an assessment
of the decision making process that led to the restaging of the RCP seal under the existing plant conditions.
Based on this assessment, Plant policy 105,"Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures
which are being implemented
for the first time or for which plant conditions
are different from those described in the procedures
D.All Operations
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
to this event to reiterate FPL's goal for error free performance.
E.St.Lucie Plant adopted verbatim compliance
as the only acceptable
means of procedure compliance.
This requirement
has been incorporated
into plant Quality Instruction
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
of Procedures." 4.Full compliance
was achieved on August 2, 1995 with the completion
of item 2A, above.  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION C: Technical Specification
6.8.1.a requires that written procedures
be established, implemented, and maintained
covering the activities
recommended
in Appendix A of Regulatory
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
procedures
for procedural
adherence.
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
of Procedures," Section 5.13', states that all procedures
shall be strictly adhered to.AP 1-0010123, Rev 99,"Administrative
Controls of Valves, Locks, and Switches," step 8.1.6, required, in part, that all valve position deviations
be documented
in the Valve Switch Deviation Log.Contrary to the above, on or about August 1, 1995, HCV-25-1 through 7 were repositioned
and left in the closed position without the required entries being made in the Valve Switch Deviation Log.The Valves'ositions
complicated
a loss of RCS inventory.
RESPONSE C: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility licensed operators who did not properly document the closed status of the subject valves in the Valve Switch Deviation Log, as required by the approved plant procedure.
2.CORRECTIVE
STEPS TAKEN AND THE RESULTS ACHIEVED The Safeguards
Pump Room Sump Isolation valves, HCV 25-1 through HCV 25-7, were realigned to the open position immediately
following the loss of RCS inventory event on August 10, 1995, when Control Room operators discovered
the closed status of the valves.  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTXVE
STEPS TO AVOXD FURTHER VXOLATXONS
A.All Operations
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
to this event to reiterate FPL's goal for error free performance.
B.C.D.The plant has adopted verbatim compliance
as the only acceptable
means of procedure compliance.
This requirement
has been incorporated
into plant Quality Instruction
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
of Procedures." Management
is conducting
a daily review of Control Room chronological
logs to reinforce the expectation
for detail and completeness.
I Plant administrative
procedures
have been revised to provide for increased reviews by plant staff of the logs controlling
valve repositioning.
Full compliance
was achieved on August 10, 1995, with the completion
of item 2 above.  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION D: Technical Specification
6.8.1.a requires that written procedures
be established, implemented, and maintained
covering the activities
recommended
in Appendix A of Regulatory
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
procedures
for procedural
adherence.
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
of Procedures," Section 5'3.2, states that all procedures
shall be strictly adhered to.OP 1-0410022, Rev 22,"Shutdown Cooling," step 8.3.7, required that V3652, the B Shutdown Cooling (SDC)hot leg suction isolation valve, be locked open while placing the B SDC loop in service.Contrary to the above, on August 29, a control room operator failed to place V3652 in a locked open condition while placing the B SDC loop in service.As a result, the 1B Low Pressure Safety Injection Pump was operated with its suction line isolated.RESPONSE D: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to properly verify the alignment of the shutdown cooling (SDC)system flowpath in accordance
with the approved plant procedure, prior to starting the 1B Low Pressure Safety Injection (LPSI)Pump.This resulted in the failure to open the 1B LPSI Pump suction isolation valve.2.CORRECTIVE
STEPS TAKEN AND THE RESULTS ACHIEVED A.The Control Room operators noted the error in valve alignment and the LPSI pump was secured approximately
5 minutes after being started.A subsequent
inspection
determined
that no damage had occurred during the short period of pump operation.
B.The system was realigned in accordance
with the approved procedure and the LPSI pump was restarted.
Subsequent
operation of the LPSI pump was satisfactory.
C.An ASME Section XI code run was performed satisfactorily
on the 1B LPSI Pump and a subsequent
Engineering
assessment
concluded that pump operability
had not been adversely affected.  
St.Lucie Units.1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE
STEPS TO AVOID FURTHER VIOLATIONS
A.The licensed operator involved in this event was disciplined
in accordance
with plant policy.B.Operations
implemented
procedure changes which require the use of a dedicated procedure reader to assist in the implementation
of SDC related evolutions.
C.All Operations
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
to this event to reiterate FPL's goal for error free performance.
D.The plant has adopted verbatim compliance
as the only acceptable
means of procedure compliance.
This requirement
has been incorporated
into plant Quality Instruction
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
of Procedures." E.This event will be included into licensed operator, requalification
training.This action will be completed by January 1, 1996.4.Full compliance
was achieved on August 29, 1995 with the completion
of item 2A and 2B above.  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION E: Technical Specification
6.8.1.a requires that written procedures
be established, implemented, and maintained
covering the activities
recommended
in Appendix A of Regulatory
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
procedures
for procedural
adherence.
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
of Procedures," Section 5.13.2, states that all procedures
shall be strictly adhered to.QI 16-PR/PSL-2, Rev.1,"St.Lucie Action Report (STAR)Program," required that STARs be initiated for Quality Assurance audit findings and independent
technical review recommendations'ontrary
to the above, a STAR was not generated when a Quality Assurance review of an inadvertent
Unit 1 containment
spraydown, documented
in interoffice
correspondence
JQQ-95-143, identified
the practice of prelubricating
FCV-07-1A, Containment
Spray header A flow control valve, when performing
valve stroke time testing.RESPONSE E: 1.REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility Quality Assurance (QA)personnel.
QA personnel were in the process of conducting
an independent
review focusing on the contributing
factors associated
with a Unit 1 containment
spray down event.The practice of pre-lubricating
Containment
Spray header flow control valve FCV-07-lA prior to surveillance
testing was identified
during this.review, but was not determined
to be a contributing
factor to this event.Recommendations
to correct this deficiency
were therefore not contained in the resulting QA report, nor was a St.Lucie Action Request (STAR)generated in a timely manner.2.=CORRECTIVE
STEPS TAKEN AND THE RESULTS ACHIEVED A.A St.Lucie Action Request (STAR 951048)was generated on September 7, 1995 to document the deficient practice of pre-lubricating
Unit 1 and Unit 2 containment
spray flow control valves prior to surveillance
stroke time testing.B.Temporary changes were issued to plant surveillance
procedures
on September 2, 1995 to remove the practice of'pre-lubricating
valves prior to surveillance
testing.10  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE
STEPS TO AVOID FURTHER VIOLATIONS
A.B.C.A meeting was held on September 13, 1995 between the Vice President of Nuclear Assurance and all St.Lucie Quality Assurance and Quality Control personnel.
During this meeting, clear expectations
were provided regarding the threshold for identification
and documentation
of deficiencies
by Quality personnel.
E On October 25, 1995, a second meeting was held between the site Quality Manager and St.Lucie QA personnel.
During this meeting, the requirements
of the Quality Instruction
QI 16-PR/PSL-2,"St.Lucie Action Report (STAR)Program" were reviewed.The responsibility
of QA personnel for timely identification
and documentation
of deficiencies
in accordance
with this procedure was reinforced.
Permanent changes will be made to plant surveillance
procedures
to discontinue
the practice of pre-test lubrication
of the valves prior to surveillance
testing.This action will be completed by December 1, 1995.4.Full compliance
was achieved on September 7, 1995 with the completion
of item 2A above.  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION F: Technical Specification
6.8~1.a requires that written procedures
be established, implemented, and maintained
covering the activities
recommended
in Appendix A of Regulatory
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
procedures
for procedural
adherence.
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
of Procedures," Section 5.13.2, states that all procedures
shall be strictly adhered to.ADM-08.02, Rev 7,"Conduct of Maintenance," Appendix 5, step 5, required that procedures
be present during work and that individual
steps be initialed once performed.
Contrary to the above, inspection
of work in progress revealed that individual
steps were not initialed once performed upon completion
for work conducted in accordance
with Plant Change/Modification
11-195.RESPONSE F: 1.REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of an Electrical
Department
journeyman
who failed to properly document the completion
of steps while performing
work activities
associated
with the trip solenoids on the 1B Emergency Diesel Generator (EDG).The steps were not initialed as they were being performed, in accordance
with approved plant procedure.
2.CORRECTIVE
STEPS TAKEN AND THE RESULTS ACHIEVED A.The steps of the maintenance
procedure being worked were signed off by the journeyman
immediately
following the completion
of the work on August 31, 1995, and the completed procedure was reviewed by the chief electrician
and Electrical
supervisor.
B.The EDG circuitry was subsequently
tested following completion
of the work on August 31, 1995, and performed satisfactorily.
12  
0  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE
STEPS TO AVOID FURTHER VIOLATIONS
A.Meetings were held following this event with Electrical
Maintenance
employees to review this incident and emphasize management
expectations
regarding the documentation
of w'ork activities.
B.Supervisors
from each Maintenance
discipline
have conducted meetings with their employees to reinforce the need for strict adherence to the administrative
requirements
related to procedure use.C.The plant has adopted verbatim compliance
as the only acceptable
means of procedure compliance.
This requirement
has been incorporated
into plant Quality Instruction
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
of Procedures." 4.Full compliance
was achieved on August 31, 1995 with the completion
of item 2A and 2B above.13  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION G: 10 CFR 50 Appendix B, Criterion V,"Instructions, Procedures, and Drawings," requires, in part, that activities
affecting quality shall be prescribed
by documented
procedures
of a type appropriate
to the circumstances.
Contrary to the above, on August 18, 1995, venting of the Low Pressure Safety Injection (LPSI)System was conducted in accordance
with a procedure which was inappropriate
to the circumstances.
Specifically, OP 1-0420060, Rev.0,"Venting of the Emergency Core Cooling and Containment
Spray Systems," did not require a verification
that the portions of the system being vented were hydraulically
isolated from adjacent systems and flowpaths.
As a result of this failure to establish proper initial conditions, water driven by the 1A LPSI pump was inadvertently
directed to the A Train Containment
Spray header, resulting in a spraydown of the Unit 1 Reactor Containment
Building.RESPONSE G: REASON FOR VIOLATION The root cause of this violation was procedural
deficiency
in that the ECCS venting procedure, OP 1-0420060, did not state the plant conditions
required to successfully
vent the ECCS but relied upon the RCS heatup procedure to set plant conditions.
Specifically, the venting procedure did not require operators to verify that the proper containment
spray header isolation valves were closed prior to recirculating
the water in the SDC system.A contributing
factor to this event was that the operations
personnel performing
the ECCS venting procedure did not recognize that the existing plant conditions
would result in flow to the'A'ontainment
spray header when flow was aligned through the Shutdown Cooling Heat Exchanger.
A second contributing
factor of this event was that FCV-07-1A was placed in the open position because this valve had failed its ASME stroke time test.Plant management
made the decision to defer the valve repair and position this normally closed valve to its engineered
safeguards
open position in lieu of repairing the valve prior to startup.14  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 2.CORRECTIVE
STEPS TAKEN AND THE RESULTS ACHIEVED A.Operators secured the 1A LPSI Pump and isolated, the flowpath to the containment
spray header from the LPSI Pump.The Reactor Cavity sump was drained to the Waste Management
System.B~Following the event, all nonessential
work at the site was placed on hold, and Unit 1 was maintained
stable in Mode 3 while senior plant management
conducted meetings with all available site personnel to stress the need for worker vigilance and attention to detail.The need to reduce equipment deficiencies
that impact operations
was also discussed.
C.Unit 1 was cooled down and depressurized
to Mode,5 and an inspection
and decontamination
of containment
was then conducted.
The event was evaluated under an Engineering
evaluation, which resulted in a comprehensive
inspection
of components
inside containment
to ensure future component reliability.
D.Operating procedure, OP 1-0420060,"Venting of the Emergency Core Cooling an'd Containment
Spray System", was revised September 1, 1995 to include the plant conditions
required to be present during venting.3.CORRECTIVE
STEPS TO AVOID FURTHER VIOLATIONS
A.Plant policy 105,"Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures
which are being implemented
for the first time or for which plant conditions
are different from those described in the procedure.
B.The Maintenance
Department
established
a team composed of plant staff and engineering
personnel, to determine the root cause for the Containment
Spray header isolation valve repeat failures and determine corrective
actions to eliminate this operator workaround.
FCV-07-1A was repaired prior to returning Unit 1 to service.15  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 C.Existing plant deficiencies
were reviewed by senior plant management.
Additional
deficiencies
which could impact operations
were added to the work scope of the Unit 1 shutdown.These deficiencies
were corrected prior to returning the unit to service.D.Administrative
procedure, AP-0010147,"Assessment
of Abnormal Plant Configurations
or Significant
Material Deficient'Conditions
on Plant Operation", was developed to enhance outage scope review and ensure that equipment deficiencies
are restored in a timely manner.E.St.Lucie management
instituted
a weekly review of appropriate
performance
indicators
and work backlog status, including the age of open items and operator workarounds.
F.All Operations
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
to this event to reiterate FPL's goal for erro'r free performance.
G.This event will be incorporated
into licensed operator requalification
training.This action will be complete by January 1, 1996.4.Full compliance
was achieved on August 18, 1995 with the completion
of items 2A, 2C and 2D above.16
}}

Latest revision as of 22:03, 29 October 2019

Forwards Response to NRC Ltr Re Violations Noted in Insp Repts 50-335/95-15 & 50-389/95-15.Corrective Actions:Msis Was Blocked & Reset Immediately Following Event on 950802
ML17228B327
Person / Time
Site: Saint Lucie  NextEra Energy icon.png
Issue date: 11/15/1995
From: Goldberg J
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-95-306, NUDOCS 9511210113
Download: ML17228B327 (23)


Text

RIG RITY ACCELERATED RIDS PROCESSING),

1 REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) r 'ESSION NBR 9511210113 DOC ~ DATE'5/11/15 NOTARIZED NO DOCKET N FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME AUTHOR AFFILIATION GOLDBERG,J.H. Florida Power &'ight Co.

RECIP.NAME RECIPIENT AFFILIATION Document Control Branch (Document Control Desk)

SUBJECT:

Forwards response to NRC ltr re violations noted in insp repts 50-335/95-15 & 50-389/95-15.Corrective actions:MSIS was blocked & reset immediately following event on 950802.

I DISTRIBUTION CODE: IE01D COPIES RECEIVED:LTR ENCL SIZE:

TITLE: General (50 Dkt)-Insp Rept/Notice of Violation Response NOTES RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 PD 1 1 NORRIS,J 1 1 INTERNAL: ACRS 2 AEOD/DEIB 1 1 AEOD/SPD/RAB 1 A'E. 1 1 DEDRO 1 FILE CENTER 1 1 NRR/DISP/PIPB 1 /'DRC8/H FB 1 1 NRR/DRPM/PECB 1 NUDOCS-ABSTRACT 1 1 OE DIR 1 'GC/HDS3 1 1 RGN2 FILE 01 1 EXTERNAL: LITCO BRYCE,J H 1 1 NOAC 1 1 NRC PDR 1 1 iNOTE TO ALL RIDS" RECIPIEYTS:

PLEASE HELP US TO REDUCE 4VASTE! CONTACT THE DOCL'!iIEYTCO."iTROL DESK, ROOiiI Pl-37 (EXT. 504-2083 ) TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY. LISTS FOR DOCL'IiIEi'I'S5'OU DOi "I'L'LD!

TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19

4 0'

Florida Power L Light Company, 0

P.O. Box 14000, Juno Beach, FL 33408 0420 NOV 1 5 $ 995 L-95-306 10 CFR 2.201 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Re: St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 Florida Power and Light Company (FPL) has reviewed the subject inspection report and pursuant to 10 CFR 2.201 the response to the notice of violation is attached.

Very truly yours, J. H. Goldberg President Nuclear Division JHG/DAS/EJB Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St. Lucie Plant 95ii210i13 'it5iii5 PDR ADOCK 05000335 9 PDR an FPL Group company

FPL RESPONSE TO INSPECTION REPORT 95-15

SUMMARY

NRC Inspection Report 50-335/389/95-15 considered St. Lucie Plant performance during the six (6) week period from July 30, 1995 through September 16, 1995. The violations below occurred during a relatively short period of time, as described in the inspection report, and several of the corrective actions were instituted following an analysis of the events, collectively. The corrective steps to avoid further violations were in some cases determined to be generic following this analysis, and are therefore repeated in a number of the responses. The Inspection Report identified seven (7) violations which are listed below.

Violation A: Failure to Follow Procedures and Block MSIS Actuation Violation B: Failure to Follow Procedures During RCP Seal Restaging Violation C: Failure to Follow Procedure and Document Abnormal Valve Position in the Valve, Switch Deviation log Violation D: Failure to Follow Procedures during Alignment of Shutdown Cooling System Violation E: Failure to Follow Procedure and Document a Deficiency on Containment Spray Valve Surveillance Test Procedure Violation F: Failure to Initial Maintenance Procedure Steps as Work was Completed Violation G: Failure to Follow Procedures During Venting of ECCS System Resulted in Containment Spraydown Additionally, both Florida Power and Light (FPL) and the NRC evaluated plant events to identify common underlying themes.

FPL presented a summary of events to the NRC on August 29, 1995. Weaknesses identified in this summary included procedure content and use, as well as management oversight of eguipment performance.

FPL's Plan to Improve the Operational Performance at St. Lucie was developed as a result of the August 29, 1995, meeting and submitted to the NRC on September 15, 1995. To date, FPL has completed the activities according to the improvement plan schedule.

S=. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION A:

Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence. Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.

OP 1-0030127, Rev 68, "Reactor Plant Cooldown Hot Standby to Cold Shutdown," required, in part, that operators block Main Steam Isolation System (MSIS) actuation when block permissive annunciations were received. ONOP 1-0030131, Rev 60, "Plant Annunciator Summary," required that, upon valid receipt of annunciators Q-18 and Q-20, operators immediately block channels A and B, respectively.

Contrary to the above, on August 2, 1995, during a cooldown of St.

Lucie Unit 1, valid block. permissive annunciators were received, however, operators failed to establish the required MSIS blocks, resulting in A and B channel MSIS actuations.

RESPONSE A:

REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to block the actuation of the main steam isolation signal (MSIS) in accordance with the requirements of the approved plant operating procedure.

2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The main steam isolation signal (MSIS) was blocked and reset immediately following the event on August 2, 1995.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15

3. CORRECTXVE STEPS TO AVOXD FURTHER VXOLATXONS A. The licensed operator who was involved in the event was counseled on the need to follow procedures and received discipline in accordance with plant'policy.

B. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.

C. This event will be incorporated into licensed operator requalification training to emphasize procedural compliance, proper communication among the Control Room

'team, and the importance of supervision -in the control room maintaining an overall awareness, of activities.

This action will be complete by January 1, 1996.

D. St. Lucie Plant adopted verbatim compliance as the only acceptable of procedure compliance.

means Procedures' This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, " "Preparation, Revision, Review/Approval of

4. Full compliance was achieved on August 2, 1995 with the completion of item 2 above.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION B:

Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1..d includes administrative procedures for procedural adherence. Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.

Contrary to the above, procedures were not adhered to strictly in the following examples:

OP 1-0120020, Rev. 72, "Filling and Venting the RCS,"

precaution 4.2, required that Reactor Coolant System (RCS) venting, described in the procedure, not be attempted temperature was above 200'F.

if RCS On August 2, 1995, Reactor Coolant Pump (RCP) seal venting, performed in an attempt to correct seal package leakage in the 1A2 RCP in accordance with Appendix E of the subject procedure, was performed while RCS temperature was approximately 370'F. As a result, design temperatures of RCP seal components were approached or exceeded.

2. OP 1-0120020, Rev. 72, "Filling and Venting the RCS," Appendix E, "Restaging Reactor Coolant Pump Seals," required the use of RCP seal injection while restaging was attempted.

On August 2, 1995, restaging of the 1A2 RCP seal package was attempted without seal injection aligned to the seal package.

As a result, design temperatures of RCP seal components were approached or exceeded.

RESPONSE B:

REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to follow an approved plant procedure while performing a restaging evolution on a Reactor Coolant 'Pump (RCP) seal package. The operator did not strictly adhere to the conditions contained in the procedure which required that RCS temperature be no greater than 200'F, and that seal injection be in service.

0 St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply'o Notice of Violation Ins ection Re ort 95-15

2. CORRECTXVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The RCP 'estaging evolution was discontinued, and Operations cooled and depressurized the Reactor Coolant System (RCS) in accordance with approved plant procedure to lower RCP seal temperatures to within the acceptable range. The 1A2 RCP was secured.

B. The damaged 1A2 RCP seal package was replaced prior to returning Unit 1 to operation.

3. CORRECTIVE STEPS TO AVOID FURTHER VXOLATXONS A. The licensed operator involved in this event was disciplined in accordance with plant policy.

B. The procedure appendix which was used for performing the restaging of the RCPs was deleted and is no longer available for use.

C. Plant management performed an assessment of the decision making process that led to the restaging of the RCP seal under the existing plant conditions. Based on this assessment, Plant policy 105, "Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures which are being implemented for the first time or for which plant conditions are different from those described in the procedures D. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.

E. St. Lucie Plant adopted verbatim compliance as the only acceptable means of procedure compliance. This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, "Preparation, Revision, Review/Approval of Procedures."

4. Full compliance was achieved on August 2, 1995 with the completion of item 2A, above.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION C:

Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence. Procedure QI 5-PR/PSL-1, Rev. 62, 5.13 ',

"Preparation, Revision, Review/Approval of Procedures," Section states that all procedures shall be strictly adhered to.

AP 1-0010123, Rev 99, "Administrative Controls of Valves, Locks, and Switches," step 8.1.6, required, in part, that all valve position deviations be documented in the Valve Switch Deviation Log.

Contrary to the above, on or about August 1, 1995, HCV-25-1 through 7 were repositioned and left in the closed position without the required entries being made in the Valve Switch Deviation Log. The Valves'ositions complicated a loss of RCS inventory.

RESPONSE C:

REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility licensed operators who did not properly document the closed status of the subject valves in the Valve Switch Deviation Log, as required by the approved plant procedure.

2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED The Safeguards Pump Room Sump Isolation valves, HCV 25-1 through HCV 25-7, were realigned to the open position immediately following the loss of RCS inventory event on August 10, 1995, when Control Room operators discovered the closed status of the valves.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15

3. CORRECTXVE STEPS TO AVOXD FURTHER VXOLATXONS A. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.

B. The plant has adopted verbatim compliance as the only acceptable means of procedure compliance. This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, "Preparation, Revision, Review/Approval of Procedures."

C. Management is conducting a daily review of Control Room chronological logs to reinforce the expectation for detail and completeness.

I D. Plant administrative procedures have been revised to provide for increased reviews by plant staff of the logs controlling valve repositioning.

Full compliance was achieved on August 10, 1995, with the completion of item 2 above.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION D:

Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence. Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5 '3.2, states that all procedures shall be strictly adhered to.

OP 1-0410022, Rev 22, "Shutdown Cooling," step 8.3.7, required that V3652, the B Shutdown Cooling (SDC) hot leg suction isolation valve, be locked open while placing the B SDC loop in service.

Contrary to the above, on August 29, a control room operator failed to place V3652 in a locked open condition while placing the B SDC loop in service. As a result, the 1B Low Pressure Safety Injection Pump was operated with its suction line isolated.

RESPONSE D:

REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to properly verify the alignment of the shutdown cooling (SDC) system flowpath in accordance with the approved plant procedure, prior to starting the 1B Low Pressure Safety Injection (LPSI) Pump. This resulted in the failure to open the 1B LPSI Pump suction isolation valve.

2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The Control Room operators noted the error in valve alignment and the LPSI pump was secured approximately 5 minutes after being started. A subsequent inspection determined that no damage had occurred during the short period of pump operation.

B. The system was realigned in accordance with the approved procedure and the LPSI pump was restarted. Subsequent operation of the LPSI pump was satisfactory.

C. An ASME Section XI code run was performed satisfactorily on the 1B LPSI Pump and a subsequent Engineering assessment concluded that pump operability had not been adversely affected.

St. Lucie Units .1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15

3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. The licensed operator involved in this event was disciplined in accordance with plant policy.

B. Operations implemented procedure changes which require the use of a dedicated procedure reader to assist in the implementation of SDC related evolutions.

C. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for error free performance.

D. The plant has adopted verbatim compliance as the only acceptable means of procedure compliance. This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, "Preparation, Revision, Review/Approval of Procedures."

E. This event will be included into licensed operator, requalification training. This action will be completed by January 1, 1996.

4. Full compliance was achieved on August 29, 1995 with the completion of item 2A and 2B above.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION E:

Technical Specification 6. 8. 1. a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence. Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.

QI 16-PR/PSL-2, Rev. 1, "St. Lucie Action Report (STAR) Program,"

required that STARs be initiated for Quality Assurance audit findings and independent technical review recommendations'ontrary to the above, a STAR was not generated when a Quality Assurance review of an inadvertent Unit 1 containment spraydown, documented in interoffice correspondence JQQ-95-143, identified the practice of prelubricating FCV-07-1A, Containment Spray header A flow control valve, when performing valve stroke time testing.

RESPONSE E:

1. REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility Quality Assurance (QA) personnel. QA personnel were in the process of conducting an independent review focusing on the contributing factors associated with a Unit 1 containment spray down event. The practice of pre-lubricating Containment Spray header flow control valve FCV-07-lA prior to surveillance testing was identified during this.

review, but was not determined to be a contributing factor to this event. Recommendations to correct this deficiency were therefore not contained in the resulting QA report, nor was a St. Lucie Action Request (STAR) generated in a timely manner.

2.= CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. A St. Lucie Action Request (STAR 951048) was generated on September 7, 1995 to document the deficient practice of pre-lubricating Unit 1 and Unit 2 containment spray flow control valves prior to surveillance stroke time testing.

B. Temporary changes were issued to plant surveillance procedures on September 2, 1995 to remove the practice of

'pre-lubricating valves prior to surveillance testing.

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St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15

3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. A meeting was held on September 13, 1995 between the Vice President of Nuclear Assurance and all St. Lucie Quality Assurance and Quality Control personnel. During this meeting, clear expectations were provided regarding the threshold for identification and documentation of deficiencies by Quality personnel. E B. On October 25, 1995, a second meeting was held between the site Quality Manager and St. Lucie QA personnel.

During this meeting, the requirements of the Quality Instruction QI 16-PR/PSL-2, "St. Lucie Action Report (STAR) Program" were reviewed. The responsibility of QA personnel for timely identification and documentation of deficiencies in accordance with this procedure was reinforced.

C. Permanent changes will be made to plant surveillance procedures to discontinue the practice of pre-test lubrication of the valves prior to surveillance testing.

This action will be completed by December 1, 1995.

4. Full compliance was achieved on September 7, 1995 with the completion of item 2A above.

St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION F:

Technical Specification 6.8 1.a requires that written procedures be

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established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Rev.2, February 1978. Appendix A, paragraph 1.d includes administrative procedures for procedural adherence. Procedure QI 5-PR/PSL-1, Rev. 62, "Preparation, Revision, Review/Approval of Procedures," Section 5.13.2, states that all procedures shall be strictly adhered to.

ADM-08.02, Rev 7, "Conduct of Maintenance," Appendix 5, step 5, required that procedures be present during work and that individual steps be initialed once performed.

Contrary to the above, inspection of work in progress revealed that individual steps were not initialed once performed upon completion for work conducted in accordance with Plant Change/Modification 11-195.

RESPONSE F:

1. REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of an Electrical Department journeyman who failed to properly document the completion of steps while performing work activities associated with the trip solenoids on the 1B Emergency Diesel Generator (EDG). The steps were not initialed as they were being performed, in accordance with approved plant procedure.
2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. The steps of the maintenance procedure being worked were signed off by the journeyman immediately following the completion of the work on August 31, 1995, and the completed procedure was reviewed by the chief electrician and Electrical supervisor.

B. The EDG circuitry was subsequently tested following completion of the work on August 31, 1995, and performed satisfactorily.

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0 St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15

3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. Meetings were held following this event with Electrical Maintenance employees to review this incident and emphasize management expectations regarding the documentation of w'ork activities.

B. Supervisors from each Maintenance discipline have conducted meetings with their employees to reinforce the need for strict adherence to the administrative requirements related to procedure use.

C. The plant has adopted verbatim compliance as the only acceptable means of procedure compliance. This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, "Preparation, Revision, Review/Approval of Procedures."

4. Full compliance was achieved on August 31, 1995 with the completion of item 2A and 2B above.

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St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION G:

10 CFR 50 Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that activities affecting quality shall be prescribed by documented procedures of a type appropriate to the circumstances.

Contrary to the above, on August 18, 1995, venting of the Low Pressure Safety Injection (LPSI) System was conducted in accordance with a procedure which was inappropriate to the circumstances.

Specifically, OP 1-0420060, Rev. 0, "Venting of the Emergency Core Cooling and Containment Spray Systems," did not require a verification that the portions of the system being vented were hydraulically isolated from adjacent systems and flowpaths. As a result of this failure to establish proper initial conditions, water driven by the 1A LPSI pump was inadvertently directed to the A Train Containment Spray header, resulting in a spraydown of the Unit 1 Reactor Containment Building.

RESPONSE G:

REASON FOR VIOLATION The root cause of this violation was procedural deficiency in that the ECCS venting procedure, OP 1-0420060, did not state the plant conditions required to successfully vent the ECCS but relied upon the RCS heatup procedure to set plant conditions. Specifically, the venting procedure did not require operators to verify that the proper containment spray header isolation valves were closed prior to recirculating the water in the SDC system.

A contributing factor to this event was that the operations personnel performing the ECCS venting procedure did not recognize that the existing plant conditions would result in flow to the 'A'ontainment spray header when flow was aligned through the Shutdown Cooling Heat Exchanger.

A second contributing factor of this event was that FCV-07-1A was placed in the open position because this valve had failed its ASME stroke time test. Plant management made the decision to defer the valve repair and position this normally closed valve to its engineered safeguards open position in lieu of repairing the valve prior to startup.

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St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15

2. CORRECTIVE STEPS TAKEN AND THE RESULTS ACHIEVED A. Operators secured the 1A LPSI Pump and isolated, the flowpath to the containment spray header from the LPSI Pump. The Reactor Cavity sump was drained to the Waste Management System.

B ~ Following the event, all nonessential work at the site was placed on hold, and Unit 1 was maintained stable in Mode 3 while senior plant management conducted meetings with all available site personnel to stress the need for worker vigilance and attention to detail. The need to reduce equipment deficiencies that impact operations was also discussed.

C. Unit 1 was cooled down and depressurized to Mode,5 and an inspection and decontamination of containment was then conducted. The event was evaluated under an Engineering evaluation, which resulted in a comprehensive inspection of components inside containment to ensure future component reliability.

D. Operating procedure, OP 1-0420060, "Venting of the Emergency Core Cooling an'd Containment Spray System", was revised September 1, 1995 to include the plant conditions required to be present during venting.

3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. Plant policy 105, "Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures which are being implemented for the first time or for which plant conditions are different from those described in the procedure.

B. The Maintenance Department established a team composed of plant staff and engineering personnel, to determine the root cause for the Containment Spray header isolation valve repeat failures and determine corrective actions to eliminate this operator workaround. FCV-07-1A was repaired prior to returning Unit 1 to service.

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St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 C. Existing plant deficiencies were reviewed by senior plant management. Additional deficiencies which could impact operations were added to the work scope of the Unit 1 shutdown. These deficiencies were corrected prior to returning the unit to service.

D. Administrative procedure, AP-0010147, "Assessment of Abnormal Plant Configurations or Significant Material Deficient 'Conditions on Plant Operation", was developed to enhance outage scope review and ensure that equipment deficiencies are restored in a timely manner.

E. St. Lucie management instituted a weekly review of appropriate performance indicators and work backlog status, including the age of open items and operator workarounds.

F. All Operations Nuclear Plant Supervisors (NPS) held meetings with their crews subsequent to this event to reiterate FPL's goal for erro'r free performance.

G. This event will be incorporated into licensed operator requalification training. This action will be complete by January 1, 1996.

4. Full compliance was achieved on August 18, 1995 with the completion of items 2A, 2C and 2D above.

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