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{{#Wiki_filter:RIG RITY 1 ACCELERATED RIDS PROCESSING), REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)r'ESSION NBR 9511210113 DOC~DATE'5/11/15 NOTARIZED NO FACIL:50-335 St.Lucie Plant, Unit 1, Florida Power&Light Co.50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION GOLDBERG,J.H.
{{#Wiki_filter:RIG RITY ACCELERATED RIDS PROCESSING),
Florida Power&'ight Co.RECIP.NAME RECIPIENT AFFILIATION Document Control Branch (Document Control Desk)
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:==
==SUBJECT:==
Forwards response to NRC ltr re violations noted in insp repts 50-335/95-15
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.
&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 DOCKET N 05000335 05000389 INTERNAL: RECIPIENT ID CODE/NAME PD2-1 PD ACRS AEOD/SPD/RAB DEDRO NRR/DISP/PIPB NRR/DRPM/PECB 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 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:
I DISTRIBUTION CODE: IE01D                 COPIES RECEIVED:LTR             ENCL       SIZE:
PLEASE HELP US TO REDUCE 4VASTE!CONTACT THE DOCL'!iIEYT CO."iTROL DESK, ROOiiI Pl-37 (EXT.504-2083)TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY.
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:
LISTS FOR DOCL'IiIEi'I'S 5'OU DOi"I'L'LD!TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19 4 0' 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 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 95-15Florida 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
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!
'it5iii5 PDR ADOCK 05000335 9 PDR an FPL Group company FPL RESPONSE TO INSPECTION REPORT 95-15  
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==
==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 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 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.
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.
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 if RCS temperature 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 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.
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.
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.
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.
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.
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.
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.
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:
E.St.Lucie Plant adopted verbatim compliance as the only acceptable means of procedure compliance.
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.
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.
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.
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.
Contrary to the above, on August 2, 1995, during a cooldown of St.
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.
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 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.
RESPONSE  A:
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.
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.
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.
: 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.
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.
St. Lucie Units    1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15
I Plant administrative procedures have been revised to provide for increased reviews by plant staff of the logs controlling valve repositioning.
: 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.
Full compliance was achieved on August 10, 1995, with the completion of item 2 above.  
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.
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. 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
                              ~
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 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.
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.
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.
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.
B.The system was realigned in accordance with the approved procedure and the LPSI pump was restarted.
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.
Subsequent operation of the LPSI pump was satisfactory.
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.
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.
G. This event   will be   incorporated into licensed operator requalification training.     This action will be complete by January 1, 1996.
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.
: 4. Full compliance   was achieved on August 18, 1995 with the completion of items 2A, 2C and 2D above.
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.
16}}
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

~

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.

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