IR 05000456/1996018: Difference between revisions

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{{Adams
{{Adams
| number = ML20134B418
| number = ML20134B579
| issue date = 01/22/1997
| issue date = 01/22/1997
| title = Insp Rept 50-456/96-18 on 961012-1113.Violations Noted. Major Areas Inspected:Inadvertent Opening of Pressurizer PORV During Plant Cooldown on 961012
| title = Forwards Insp Rept 50-456/96-18 on 961012-1113 & Nov. Violation of Concern Because Broad Spectrum of Circumstances That Led to Event Including Lack of Procedural Guidance
| author name =  
| author name = Caldwell J
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
| addressee name =  
| addressee name = Stanley H
| addressee affiliation =  
| addressee affiliation = COMMONWEALTH EDISON CO.
| docket = 05000456
| docket = 05000456
| license number =  
| license number =  
| contact person =  
| contact person =  
| document report number = 50-456-96-18, NUDOCS 9701300085
| document report number = NUDOCS 9701300211
| package number = ML20134B421
| package number = ML20134B421
| document type = INSPECTION REPORT, NRC-GENERATED, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| document type = CORRESPONDENCE-LETTERS, OUTGOING CORRESPONDENCE
| page count = 11
| page count = 2
}}
}}


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=Text=
=Text=
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U.S. NUCLEAR REGULATORY COMMISSION REGION Ill
  '    .
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l p @""' % e  UNITED STATES gy  hj NUCLEAR REGULATORY COMMISSION
Docket No.: 50-456 License N NPF-72 Report No.: 50-456/96018(DRP)
. - :i  3  REGION li!
    .
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Facility: Braidwood Nuclear Plant. Unit 1 Location: RR #1. Box 79 Braceville. IL 60407
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Dates: October 12 - November 13, 1996 '
j*  801 WARRENV:i.LE ROAD uSLE, ILUNCKS 60532-4351
Inspectors: T. M. Tongue. Project Engineer C. J. Philli]s. Senior Resident Inspector l D. W. Rich. Reactor Inspector !
Approved by: R. D. Lanksbury. Chief
.
Reactor Projects Branch 3 G
 
. . . -- _ _ _ . _ . . . _ . _ - _ . . _ _ ._ _
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EXECUTIVE SUMMARY
       'i January 22, 1997 iir. H. ' Site Vice President    i Braidwood Station    '
       ,
Commonwealth Edison. Company i
,
RR #1. Box 84
Braidwood Nuclear Plant. Unit 1  j NRC Inspection Report 50-456/96018 This was a special inspection of the inadvertent opening of the pressurizer 1 power operated relief valve during a plant cooldown on Braidwood Unit 1 on :
  'Braceville, IL 60407  -
October 12, 199 .
        !
Operations
  -    :
.
The Unit 1. shutdown and cooldown procedure allowed the.0)erators to raise '
PZR level higher early in the cooldown process placing t1e plant in a '
condition that contributed to the lifting of the PORV. The failure to have a procedure or guideline adecuate for bypassing ICV-121 and the
      ,
      -
associated circumstances is consicered a significant contributor to the event. A Notice of Violation was issued. (Section 03.1)
.
  '
The inspectors concluded that the desire to get through the evolution quickly and the lack of good communications contributed to the even The disjointed communications between the control room and the field personnel is considered a significant contributor to the even (Section 04.1)
.
The inspectors concluded that the training provided on the characteristics of ICV 121 did nothing to preclude this event from occurring. (Section 05.1)
.
The licensee evaluations collectively were thorough and comprehensiv (Section 07.1)
i 2    l


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1
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        '
Report Details Summarv of Event On October 12. 1996, operators were cooling down and depressurizing Braidwood Unit 1 following a reactor shutdown for mid-cycle steam generator tube eddy current testing. The pressurizer (PZR) level was allowed to be higher than normal which contributed to the inadvertent opening of the PZR Jower operated relief valve (PORV). The PORV reseated quickly. The PORV blocc valve was operable and available in the event that the PORV had failed to reseat. Other contributing factors were a nonconservative schedule driven cooldown process, inadequate or inappropriate procedures or guidelines, communications related problems, a long standing equipment problem with the charging flow control .
SUBJECT: SPECIALINSPEbi10NREPORTNO. 50-456/96018 AND NOTICE OF .ATION
valve 1CV-121. and training weaknesse This event posed no immediate threat to the plant, workers, or the publi A detailed t'imeline is enclose I. Ooerations 03 Operations Procedures and Documentation
    .
03.1 Inadeauate Shutdown /Cooldown Procedure a. Insoection Scooe (71707)
The inspectors reviewed 18wGP 100-5 " Plant Shutdown and Cooldown."
 
Revision ll: IBw0A PRI-1, " Excessive Primary Plant Leakage." Revision 54;
      .
      '
and interviewed the operators, supervisors and the managers involved in the even '
 
b. Observations and Findings 1BwGP 100-5 gave operators the option to raise PZR level as high as 80%.
The operators chose this option of maintaining a high PZR level to help ,
cooldown the pressurizer in preparation for going to a solid plant '
condition. As the cooldown and depressurization continued, letdown flow dropped due to decreased differential pressure across the letdown orifices. ICV-121 automatically controlled charging flow to match letdown flow. At low primary plant pressures (about 370 psig) 1CV-121 had difficulty controlling flow because of the large differential pressure (dp) across the valve (about 2100 psid). When letdown flow decreased below the point where 1CV-121 could no longer reduce charging flow the PZR level began to rise due to the charging rate being greater than the letdown rat The inspectors learned through interviews that the operators knew about the erratic behavior of ICV-121 and the inability to control flow at low pressure This problem was not discussed at the pre-evolution brief or at any other time during the cooldown. When the operators could no ,
i longer control pressurizer level the decision was made to bypass ICV-121 l and control charging flow by using a manual bypass valve around ICV-12 _ . _ . _ _ _ . . . _ .
.
.
L
,
lhe inspectors could find no specific procedure, instruction or
,
guideline in 18wGP 100-5 for bypassing 1CV-121. Based on-interviews with
*  station personnel-and procedure reviews. the use of bypass valves sat Braidwood was considered " skill of the craft" for operators. On this  ;
.
-  occasion, the authorization to bypass ICV-121 was an agreement between ' '
        ;
.
operators and supervisors that it was acceptable based on guidance in another procedure, 18w0A PRI-1. " Excessive Primary Plant Leakage."
 
Revision 54. However, the inspectors verified that the procedural guidance to bypass around ICV-121 in 18w0A PRI-1 was for a different set
-        1
        "


of circumstances involving excessive primary plant leakag +
==Dear Mr. Stanley:==
s
This refers to the special safety inspection conducted on October 12 through November 13. 1996, to assess the unplanned opening of the pressurizer power
  -
  -
During the by)assing of ICV-121 the charging rate to the reactor coolant
operated relief valve during a cooldown on Braidwood Unit 1. At the  ;
-  system and PZ1 became excessive causing the PZR level to increase rapidly resulting in the PORV opening. The inspectors verified that the PORV-
conclusion of the inspection, the findings _ were discussed with Mr. T. Tulon. i plant manager and other memt,ers of your staff identified in the enclosed report.-      l
        .
      -<
        '
lifted and reset at the proper setpoints, and that cold over pressure i
.
protection limits were not exceede ;
c. Conclusions      l i
;
IBwGP 100-5 allowed the operators to raise PZR level higher early in the  '
cooldown process. This placed the plant in a condition that contributed ;
i;  to the lifting of the PORV. The failure to have a procedure or guideline adequate for bypassing ICV-121 and the associated circumstances is i  considered a violation of 10 CFR Part 50, Appendix 8. Criterion V
.
,
  " Instructions, Procedures and Drawings" (50-456/96018-01(DRP)).
j 04 Operator Knowledge and Performance
:
04.1 Contributina Factors to the Event
; a. Insoection Scope (71707)
,
t The inspectors interviewed the control room operators, field operators i  and their supervisors to determine what led to tia event.
:
; b. Observations and Findinos
;
The inspectors learned through interviews that ICV-121 had a long
.
standing history of erratic behavior during low flow conditions. This
;
was an automatically controlled, pneumatically operated valve. The
:  valve's the poor low flow control characteristic was common knowledge among operators.


;  However. there was no evidence of an action request or i
Dur inspection concluded that the actual opening of.the pressurizer power  j operated relief valve created minimal threat to the public safety, plant  l workers or to the plant and that the investigations your staff performed of i the event were prompt and thorough. However. lifting a pressurizer relief valve was a challenge to the integrity of the reactor coolant system pressure- '
other method to report the condition and have it corrected. This was a j
boundary creating the threat of a potential loss of coolant accident. We are concerned about the broad spectrum of circumstances that led to the event  '
known " operator work around" and was not placed on that list until after this event occurred.
including the lack of appropriate procedural guidance, the lack of safety  i consideration in the nonconservative cooldown evolution that appeared to be schedule driven, the operation with a degraded charging flow control valve exhibiting erratic behavior at low flow conditions for an extended period of time without any corrective action until this event and what appeared to be the lack of good communications in several instances.


.
Based on the results of this inspection, the NRC concluded that a violation of NRC. requirements occurred as cited in the enclosed Notice of Violation (Notice). You are required to respond to this violation. The circumstances surrounding the violation are described in detail in the inspection report.
3  The inspectors determined there were several instances where the lack of e
good communications contributed to the event.
:  -
A high level of awareness (HLA) briefing was conducted at the beginning of the shift. The HLA discussion covered in detail, the


  -
Because of the complexity of the issue and the potential safety consequences, a management meeting to discuss this violation and the related circumstances has been scheduled for 10:00 a.m. (CST) on January 27, 1997, at the NRC "
plans to continue the cooldown to Mode 4 and then to shift to
Region III office in Lisle. Illinois. This meeting is being held as an
. opportunity for you to provide any insights that may not be apparent in the inspection report. to discuss your corrective actions, and to provide any additional information that you deem necessary. This meeting will be open to public observation.    '
I ;
i 9701300211 970122 PDR ADOCK 05000456 PDR gCkk* ;
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H;< Stanley'  -2-In accordance with 10 CFR 2.790 of the Commission's regulations, a copy of this letter, with enclosures, and your response will be placed in the NRC Public Document Room.     '
i We will gladly discuss any questions'you have concerning this inspection. i i


  -. - . .- -.- _ - -. - . -. ._ .-.
Sincerely
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residual heat removal (RHR) cooling. There was no discussion during l  the HLA briefing on plans to bypass ICV-121.
ames L. Caldwell Director ivision of Reactor Projects ,
        ;
        :
Docket No.: 50-456    ,
l License No: NPF-72 Enclosures: ..
        '
1. Notice of Violation-     1 2. Inspection Report No. 50-456/96018:
3. Event Timeline cc w/ encl: T. J. Maiman. Senior Vice President Nuclear Operations Division D. A. Sager..Vice President.


*
Generation Su) port H. W. Keiser. C11ef Nuclear O
  *
T. perating Officer Tulon. Station Manager T. Simpkin. Regulatory Assurance Supervisor I. Johnson Acting Nuclear Regulatory Services Manager Richard Hubbard
The inspectors learned through interviews that there was a desire
:   Nathan Schloss. Economist
:
'  Office of the Attorney General  !
.
for the cooldown evolution to go quickly and smoothly to reduce outage downtime. This was stated by several operators and was
  ;
  ;
demonstrated by the use of steam generator PORVs to increase the
State Liaison Officer    i Chairman. Illinois Commerce Commission
,
,
available cooldown rate. The operators and supervisors also pointed out that shifting from the steam dumping cooldown technique to the
Document Control Desk-Licensing-i
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RHR cooling process was attempted without a break to assess the j  situation. The operators stated that this was done in an effort to
  '
  '
i conserve time in achieving cold shutdow Several individuals
t -       1 l
  '  stated that they felt a hold point prior to reaching a reactor coolant system temperature of 350'F would have been an opportunity to consider the direction of the plant and would have resulted in the problems with flow control on 1CV-121 being discussed.
 
.
  -
When the decision was made to bypass 1CV-121, the situation had Decome urgent in-that the pressurizer level was high and the erratic
,
behavior of 1CV-121 was worse than in the past. An equipment operator (EO) and field supervisor who were working on other assignments (preparation for going to RHR cooling) were reassigned
{  to bypass around 1CV-121 on short notice and without a briefin The control room operator stated that he gave specific verbal
.
instructions via radio to the E0 and the field supervisor regarding opening of the 1CV-121 bypass valve, to the effect, "not one half
.
turn open, not one quarter turn open. but just crack it open."
 
However, neither the E0 nor the field supervisor could recall that
         !
         !
instruction but only recalled the urgency to get the bypass valve i  open. The bypass valve was opened considerably farther than the
  ..
:  reactor operator wanted and resulted in a large increase in charging flow, rapid pressurizer level increase and the lifting of the
  -
;  pressurizer POR c. Conclusions
;
l  The inspectors concluded that the desire to get through the evolution
,
  ~  quickly and the lack of good communications contributed to the even The disjointed communications between the control room and the field personnel was considered a significant contributor to the event.
 
l  05 Operator Training and Qualification 05.1 Doerator Trainina Recardina The Operation Of ICV-121 At low Flow i
a. Insoection Scope (71707)
' The inspectors interviewed several operators and supervisors regarding
:  their record training interviewed training instructors, and reviewed training
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l b. Observations and Findirns None of the operators interviewed could recall training on bypassing 1CV- l 121 on the simulator. 1here was no record of the classroom discussion on the topic of the erratic behavior of ICV-121 at low flow. In additio ;
the simulator was not modeled to represent the erratic behavior of 1CV- ;
121 at low flow conditions. Operations management did state however that the erratic behavior of 1CV-121 was discussed as a general topic during annual training on the chemical and volume control system. During the interviews the operators all appeared to have a knowledge of the problems with 1CV-121 at low flo c. Conclusions l
The inspectors concluded that the training provided on the characteristics of ICV-121 did nothing to preclude this event from occurrin Quality Assurance in Operations 07.1 Licensee Self-Assessment Activities
      ~
a. Insnection Scone (71707)
At the completion of the inspection the inspectors reviewed the licensee's investigation reports and interviewed the members of the )
      ,
investigation team l b. Observations and Findinas    ]
The licensee commenced investigations and evaluations promatly after the '
event. The licensee generated three separate reports on tais even I Although there were some variations in the licensees reports, collectively, each of the inspectors points were identified in at least one or more of the licensee reports, c. Conclusions The licensee evaluations collectively addressed all of the inspectors issue :
1 V. Manaaement Meetinas  !
      ,
X1 Exit Meeting Summary    l The team presented the inspection results to members of licensee management at the conclusion of the inspection on November 13, 199 The licensee acknowledged the findings presente j i
The inspector asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identifie . . . . - . - -  - . . - - - - - - - - - - - _ _ _ _ _ _ _ _ _ _ _ _ - _ _ -
*
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La
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i-I PARTIAL ~ LIST.0F PERSONS CONTACTED
<
  ,
Licensee            P
            .;
  *T. Tulon, Station Manager-  . .
R, Flessner. Site Quality verification Directo e
  *L. Weber. Shift Operations Supervisor
  *D. Hoots Unit 1 Operating Engineer .
:*B. Claveau. Operations Self Assessnent          .
  *D. Hieggelke, Root Cause Team Leader
  *P. Studdard.. Foot Cause Team Member
  *H. Pontious. Acting Regulatory Assurance Supervisor
  *M. Cassidy,' Regulatory Assurance NRC Coordinator
  *J. Naleuajka, Integrated Assessment Analyst NRC J. Adams, Resident Inspector
            ;
IDNS
* !
Esper, Illinois Department of Nuclear Safety Resident Engineer
* Denotes those attending the exit brief on November 13, 1996
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INSPECTION PROCEDURES USED IP 71707; Plant Operations
  '
ITEMS OPENED. CLOSED AND DISCUSSED
'
Opened 50-456/96018-01 VIO Failure to have procedural guidelines for bypassing CV-12 .
LIST OF ACRONYMS CV Charging System dp Differential Pressure ECCS Emergency Core Cooling System E0 Equipment Operator HLA High Level Awarenets   -  .
l PZR Pressurizer PORV Power Operated Relief Valve RCS Reactor Coolant System RHR Residual Heat Removal l
      ,
 
.
 
I ENCLOSURE I
 
EVENT TIMELINE On October 12. 1996 Braldwood Unit 1 was in the process of proceeding to cold -
shutdown for the purpose of conducting a mid-cycle outage primarily for steam generator tube examinations. During the day shift. following the reactor shutdown, the plant was cooled down to 370 psig and 340 F. The reactor i l
cooldown was conducted by use of the steam dump valves and the main condense l and the use of the steam generator (SG) PORVs to the outside atmosphere. By about 3 _ removal (RHR) preparations cooling mode. were being made to go on to the residual heat
.
For the shutdown and the process of going to cold shutdown, procedure BwGP 100-5 " Plant Shutdown and Cooldown" was being use It gave the option of raising the pressurizer (PZR) level to 80% to assist in the cooldown of the PZR in preparation for going solid. During past cooldowns it had been held at 50-60% as a surge volume for emergency core cooling system (ECCS) testing. Since ECCS testing was not scheduled this .
      !
time. PZR level was allowed to increase to 80% early in the proces .      l BwGP 100-5. Step 25 required PZR level be maintained by manually '
adjusting ICV-121. " Charging flow control valve."
 
.
As the cooldown progressed to about 350 F reactor coolant system (RCS)
pressure decreased resulting in reduced letdown flow as expected Charging was adjusted by use of ICV-121 to compensate. Atthisiower flow condition.1CV-121 became erratic and difficult to control because of the high differential pressure (dp) across the valv :10 p.:
.
The decision was made to use the ICV-121 bypass as a better technique to control charging flow. 1CV-121 had a history of erratic behavior at low ,
i flow conditions. The operators stated that this time, it was more !
erratic than in the past. This has been a known " operator-work-around".
 
!
however, it was not placed on the work-around list for correction until this even l j
3:22 i l
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Excess letdown was commenced as an additional means of controlling PZR level and slowing the level increase. However, this was not very effectiv I 3:23 l
.      l The plant entered Mode 4 (hot shutdown and RCS temperature at s350 F).
 
Concurrently, personnel were stationed in preparation for going on RHR coolin .
~
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      :
      ,
      !
3:26 .
As stated to the inspector. an equipment operator (EO) and a field i supervisor were removed from other assignments and dispatched urgently to !
.
assist with bypassing CV-121 without a pre-job briefin .      :
Instructions from the control room to the E0 regarding opening the bypass l valve were " Don't open it a half turn, not just a quarter turn, but just !
crack it open." Later, field personnel could not recall the details but only the urgency of the instruction. The field operators also encountered difficulty in opening the bypass valve which required both ,
operators to open it. They also could not recall how far -they had opened !
it. The field supervisor was then directed to proceeded to CV-121 to '
shut the inlet to CV-121 in order to redude' the flow to the RCS. Due to the high dp. the inlet valve was very difficult to shut and took some time (10 min) to shut. At about the same time, the E0 was then instructed to shut the bypass valve which was also very difficult to shut due to the high dp. Both manual valves are located in positions that are not easily accessible and are difficult to operate. This resulted in a further delay (about 10 min.) and additional water in the RC :42 .
The large water addition to the RCS resulted in a sudden PZR level increase. PZR sprays were o)ened and heaters were deenergized. Howeve :
this was not effective enoug1 and the PZR PORV opened on PZR high level / pressur !
t
.
Concurrently, with the additional charging flow, flow to the reactor I coolant pump (RCP) seals increased to greater than 15 gpm each (ma indication) which is normally 8-10 gpm eac ,
.
In response, the running 1B charging (CV) pump was stoppe !
      :
3:45 .
As the RCP seal dp reduced to less than 200 psid, the 1A RCP was secure :46 '
.
This was followed by securing IB. 1C. and 10 RCP This resulted in no forced flow though the reactor core and depended on natural circulation cooling. Technical Specification 4.1.3 was entered due to no RCS pumps :
in operation. Natural convection cooling is acceptable and did commence i
but a concern was raised by the control room operators that since the RCS had not been degassed, gas pockets could form in the SG tubes resulting a flow blockage 3:52 .
RHR cooling was placed in service creating the necessary forced convection coolin ,
"
 
a a
 
.- ~ ,    ,-.
 
.
A 4:36 B CV pump was restarted with less flow to the RCS and creating the required RCP seal flo ~ '
6:22 .
The 1D RCP was restarted to give greater RCS flow and cooling and stabilizing of parameter .
Through out this event. steam dumps and SG PORVs remained in use for heat remova
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Latest revision as of 11:57, 2 September 2020

Forwards Insp Rept 50-456/96-18 on 961012-1113 & Nov. Violation of Concern Because Broad Spectrum of Circumstances That Led to Event Including Lack of Procedural Guidance
ML20134B579
Person / Time
Site: Braidwood Constellation icon.png
Issue date: 01/22/1997
From: Caldwell J
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To: Stanley H
COMMONWEALTH EDISON CO.
Shared Package
ML20134B421 List:
References
NUDOCS 9701300211
Download: ML20134B579 (2)


Text

b*'

' .

l p @""' % e UNITED STATES gy hj NUCLEAR REGULATORY COMMISSION

. - :i 3 REGION li!

{

  • #!; 1

....*

j* 801 WARRENV:i.LE ROAD uSLE, ILUNCKS 60532-4351

.

.l

'i January 22, 1997 iir. H. ' Site Vice President i Braidwood Station '

Commonwealth Edison. Company i

RR #1. Box 84

'Braceville, IL 60407 -

!

1

'

SUBJECT: SPECIALINSPEbi10NREPORTNO. 50-456/96018 AND NOTICE OF .ATION

Dear Mr. Stanley:

This refers to the special safety inspection conducted on October 12 through November 13. 1996, to assess the unplanned opening of the pressurizer power

-

operated relief valve during a cooldown on Braidwood Unit 1. At the  ;

conclusion of the inspection, the findings _ were discussed with Mr. T. Tulon. i plant manager and other memt,ers of your staff identified in the enclosed report.- l

-<

Dur inspection concluded that the actual opening of.the pressurizer power j operated relief valve created minimal threat to the public safety, plant l workers or to the plant and that the investigations your staff performed of i the event were prompt and thorough. However. lifting a pressurizer relief valve was a challenge to the integrity of the reactor coolant system pressure- '

boundary creating the threat of a potential loss of coolant accident. We are concerned about the broad spectrum of circumstances that led to the event '

including the lack of appropriate procedural guidance, the lack of safety i consideration in the nonconservative cooldown evolution that appeared to be schedule driven, the operation with a degraded charging flow control valve exhibiting erratic behavior at low flow conditions for an extended period of time without any corrective action until this event and what appeared to be the lack of good communications in several instances.

Based on the results of this inspection, the NRC concluded that a violation of NRC. requirements occurred as cited in the enclosed Notice of Violation (Notice). You are required to respond to this violation. The circumstances surrounding the violation are described in detail in the inspection report.

Because of the complexity of the issue and the potential safety consequences, a management meeting to discuss this violation and the related circumstances has been scheduled for 10:00 a.m. (CST) on January 27, 1997, at the NRC "

Region III office in Lisle. Illinois. This meeting is being held as an

. opportunity for you to provide any insights that may not be apparent in the inspection report. to discuss your corrective actions, and to provide any additional information that you deem necessary. This meeting will be open to public observation. '

I ;

i 9701300211 970122 PDR ADOCK 05000456 PDR gCkk* ;

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H;< Stanley' -2-In accordance with 10 CFR 2.790 of the Commission's regulations, a copy of this letter, with enclosures, and your response will be placed in the NRC Public Document Room. '

i We will gladly discuss any questions'you have concerning this inspection. i i

Sincerely

'. i

[b

ames L. Caldwell Director ivision of Reactor Projects ,

Docket No.: 50-456 ,

l License No: NPF-72 Enclosures: ..

'

1. Notice of Violation- 1 2. Inspection Report No. 50-456/96018:

3. Event Timeline cc w/ encl: T. J. Maiman. Senior Vice President Nuclear Operations Division D. A. Sager..Vice President.

Generation Su) port H. W. Keiser. C11ef Nuclear O

T. perating Officer Tulon. Station Manager T. Simpkin. Regulatory Assurance Supervisor I. Johnson Acting Nuclear Regulatory Services Manager Richard Hubbard

Nathan Schloss. Economist

' Office of the Attorney General  !

State Liaison Officer i Chairman. Illinois Commerce Commission

,

Document Control Desk-Licensing-i

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