IR 05000333/1997003: Difference between revisions

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{{Adams
{{Adams
| number = ML20141E369
| number = ML20217Q092
| issue date = 06/23/1997
| issue date = 08/12/1997
| title = Discusses Insp Rept 50-333/97-03 on 970304-13 & Forwards Notice of Violation.Violation Re Inadvertent Control Rod Withdrawal Event Which Resulted from Human Error
| title = Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-333/97-03 on 970629
| author name = Hehl C
| author name = Rogge J
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
| addressee name = Colomb M
| addressee name = Colomb M
Line 10: Line 10:
| license number =  
| license number =  
| contact person =  
| contact person =  
| document report number = 50-333-97-03, 50-333-97-3, EA-97-118, NUDOCS 9707010042
| document report number = 50-333-97-03, 50-333-97-3, NUDOCS 9708290146
| package number = ML20141E372
| title reference date = 07-30-1997
| document type = CORRESPONDENCE-LETTERS, OUTGOING CORRESPONDENCE
| document type = CORRESPONDENCE-LETTERS, OUTGOING CORRESPONDENCE
| page count = 5
| page count = 3
}}
}}


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=Text=
=Text=
{{#Wiki_filter:___ _  _.- _ . __
{{#Wiki_filter:- -.
,
o.
s June 23, 1997 I
 
         !
        ,
I l
August 12, 1997
EA No. 97-118 Mr. Michael Site Executive Officer New York ''ower Authority     I James A. F tzPatrick Nuclear Power Plant Post Office Box 41 Lycoming. aY 13093
         '
-
        ,
SUBJECT: NOTICE OF VIOLATION REGARDING SPECIAL INSPECTION 50-333/97-03
Mr. Michael Site Executive Officer New York Power Authority James A.' FitzPatrick Nuclear Power Plant Post Office Box 41-Lycoming,.NY 13093


==Dear Mr. Colomb:==
==Dear Mr. Colomb:==
I
Subject: NRC Inspection Report No. 50 333/97 03 and Notice of Violation
-
, This letter refers to your July 30,1997 correspondence, in response to our June 29,1997 letter.


l On March 14,1996, the NRC completed a specialinspection of Ln inadvertent control rod  l withdrawal avent which was the result of human error at your FitzPatrick Power Plant.
Thank you for informing us of the corrective and preventive actions documented in your
,
letters. These actions will be examinec' during a future inspection of your licensed program.


In this event, a licensed reactor operator, as part of impromtu training of a reactor operator
Your cooperation with us is appreciated.
,
candidate, inadvertently withdrew a control rod without following established station procedures for this evolution. The reactor operator, in order to demonstrate a control recoupling check for the trainee, noted that he intended to select a rod that was full out. I H( wever, the rod selected was not full out. In addition, the control room supervisor, a licensed senior reactor operator, granted permisFion for this activity while procedures require the shift manager to grant permission for this evolution. The causes for this event included inattention to detail and failing to control the activity per established station procedures. A predecisional enforcement conference to discuss this apparent violation was conducted on May 8,1997. A copy of your presentation is attached.


- This evolution reflects an informality in the conduct of control room activities. As discussed at the enforcement conference, this event is also similar to several past events
Sincerely, Original Signed by:
; in that personnel involved failed to cc,.. sider the consequences of their actions prior to conducting an evolution, and indicated an operating environment where a questioning attitude is not consistertly a part of station practices. For example, three incorrect control rod drives were removed during the last refueling outage. In September 1996, an automatic reactor scram was initiated during improper relay chlibration. Operator errors and performance weaknesses were evident during this event as reflected by operators
John F. Rogge, Chief Projects Branch 2 Division of Reactor Projects Docket No. 50-333 cc:
  ; transferring the reactor protection system (RPS) buses to alternate power supplies that
~ C. Rappleyea, Chairman and Chief Executive Officer
  ,
'R. Schoenberger, President and Chief Operating Officer J. Knubel, Chief Nuclear Officer and Senior Vice President
were de-energized, in spite of clear indication that the buses were energized and the alternate power supply was not powered. In each of these events, personnel failed to exercise sound decision making and a questioning attitude.
.H. P. Salmon,- Jr., Vice Presider.. of Nuclear Operations W. Josiger, Vice President - Engineering and Project Management J. Kelly, Director - Regulatory Affairs and Special Projects T. Dougherty, Vice President - Nuclear Engineering  l R. Deasy, Vice President - Appraisal and Compliance Services R. Patch, Director - Quality Assurance l-l G. Goldstein, Assistant General Counsel C. Faison, Director, Nuclear Licensing lllllh!k,5 K. Peters, Licensing Manager
  ' T. Morra, Executive Chair, Four County Nuclear Safety Committee 9708290146 970812-PDR ADOCK 05000333 G  PDR OFFICIAL RECORD COPY  IE:01
  . ,-,


I 9<07010042 970623      i PDR ADOCK 05000333      I
  - _ _ _
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Michael cc w/ copy of Licensee's Response Letter:
    ,
Supervisor, Town of Scriba_
t t 0FFICIAL RECORD COPY Tc: 0;
C. Donaldsoni Esquire, Assistant Attorney General, New York Department of Law P. Eddy, Director, Electric Division, Department of Public Service, State of New York G. T. Goering, Consultant, New York Power Authority J. E. Gagliardo, Consultant, New York Power Authority E. S. Beckjord, Consultant, New York Power Authority F. William Valentino, President, New York State Energy Research and Development Authority J. Spath, Program Director, New York State Energy Research and Development Authority    s
        ,
..
  -
  . . .


... . - . _ _ _ _. _ __ -
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_ . _ _ _ _ - _ _ _ _ _ . _ _
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Michael Distribution w/ copy of Licensee's Response Letter:
Michael The NRC recognizes that the automatic systems functioned to limit the rod withdrawal,
RI EDO Coordinator A. Dromerick, NRR K. Cotton, NRR D. Hood, NRR M. Campion, RI R. Correia, NRR F. Talbot, NRR Nuclear Safety Information Center (NSIC)
;
PUBLIC NRC Resident inspector Region l Docket Room (with concurrences)
and the reactor operator reicted appropriately when a rod block monitor alarm alerted the operator to the error. Nc.ietheless, this event demonstrates the importance of formality i and oversight during the conduct of control room operations. Based on this event, a
Inspection Program Branch, NRR (IPAS)
:
J. Rogge, DRP R. Barkley, DRP R. Junod, DRP DOCDESK
' violation is being cited. The violation is described in the endorsed Notice of Violation and is classified at Severity Level IV in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.
 
DOCUMENT NAME: A:\RL9703.FTZ
- To receive a copy of this document, Indicate in the box: "C" = Copy without attachment / enclosure "E" =
Copy with attachment / enclosure '"N" = No copy l OFFICE Hl/DRP  Rl/DRP lNAME- GHunegs JRogge /J d    ,
lDATE 08/gl97-- 08/tg9T OFFICIAL RECORD COPY
    ._.
 
.
*
, ,
        *j J:mes A. Fit: Patrick
  , . Nucteer Power Ptent
**  K4 Lcks Motd Po Bos 41 Lycomeg, New York 13093 315 342 3640
#> NewWrkPower    Ze'd!da";!
4# Authority
 
July 30, 1997 l
JAFP-97-0268  -
U.S. Nuclear Regulatory Commission Attention: Document Control Desk Mail Station P1 137 Washington, DC 20555
        !
SUBJECT:  James A. FitzPatrick Nuclear Power Plant Docket No. 50 333 Reply to Notice of Violation 14RC SoecialInsoection Reoort 50 333/97 03 Gentlemen:
In accordance with the provisions of 10 CFR 2.201, Notice of Violation, the Authority submits a response to the notice transmitted by your letter dated June 23,1997. Your letter refers to the results of the special safety inspection cor. ducted by Messrs. G. Hunegs, L. Briggs, and R. Fernandes from March 4,1997 to March 13,1997, at the James A. FitzPatrick Nuclear Power Plant.
 
The Authority believes the corrective actions taken have been effective in improving our human performance. There have been no significant errors since the March 3,1997 ovent and there is indication that the number of personnel errors has decreased through the last quarter (April- June,1997). A heightened awareness of human performance has been achieved. Daily and weekly manager observations in the field have noted personnel exercising sound decision making and a questioning attitude. When discrepancies are identified, corrections are made and the appropriate feedback is provided to the plant staff via standdowns, tailgates, or briefs. Senior Plant Management continues to reinforce that reactor safety a a site and individual culture that must be personalized in our day-to day activities. Emphasis and monitoring of human performance results will continue to ensure an improving trend.
 
Attachment 1 provides the description of the violation, reason for the violation, the corrective actions that.have been taken and the results achieved, corrective actions to be taken to avoid'further violations, and the date of full compliance.
 
There are no commitments contained in this submittal, if you have any questions, please contact Mr. Arthur Zaremba at (315) 349-6365.
 
Very truly your
  ,
STATE OF NEW YORK COUNTY OF OSWEGO
  *  Subscribed and sworn to before me
    '
  /  ,
l MICHAEL J. COLOMB
    '
p<" [* this 30 day of Ldt,
      \
      ,1997.


I You are required to respond to this letter and should follow the instructions specified in the
/ - m , O b c1 s.w d
! enclosed Notice when preparing your response. The NRC will use your response, in part,
MJC: RAP:las  Netary Pdblic c: Next page    NANCY B. CZEROW Notary Pubitc. state of NewYork Quelmed in oewego County e4664611 i ?      Commleston Empiree _ h * k- U #
' b*h,(W QQ
  ~
        - _ _ _ _ _ _ _ .


..< , ,  1
.e -
*cc: Regional Administratcr U.S. Nuclear __ Regulatory Commission -
475 Allendale Road King of Prussia, PA 19406
'
'
to deteimine whether further enforcement action is necessary to ensure compliance with regulatory requirements, j in accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter
Office of the Resident inspector U.S. Nuclear Regulatory Commission P.O. Box 136 Lycoming, Nsw York 13093 Ms. K. Cotton, Acting Project Manager Project Directorate 11 Division of Reactor Projects l/II U.S. Nuclear Regulatory Commission Mail Stop 14 B2
; and its enclosures will be placed in the NRC Public Document Room.
'
    -
    '
Washington, DC 20555 Attachments:
Reply to Notice of Violation
,
n 9
, . .   , ,


__ _ _ .
=# a ,
i . , . ,
Reply tD Notico ef Viol:: tion f    Sneelal Innoaction Raoort 97-03 -
L Violation        ,
L      .
        .  ,
'
Technical Specification 6.8(A)2 requires that written procedures and administrative
;. policies shail be established, implemented and maintained that are recommended in App'endix A of Regulatory Guide 1.33, November 1972. Appendix A of Regulatory
      .
Guide 1.33 requires. operating procedures governing the controlrod drive system and administrative procedures for safe operation. Operations Survelliance Test  i
-  Procedure (ST 20C) governs testing to verify control rod drive system operability; l
paragraph 8.1.16, in particular, govems the performance of a controlrod coupling Integrity check. NYPA Administration Procedure (AP)-12.03, Administration of Operations, Revision 9, provides direction Vo plant personnel concerning general
.
.
.   
practices and philosophy for safety operations. Paragraph 7.2 requires that self.
 
l  checking shall be practiced when operating plant equipment and paragraph 8.17,
;
  . Reactivity Management, requires independent verification of correct controlrod v  selection and motion.
 
,
'  Contrary to the above, on March 3,1997, ST-20C was not followed in that a
   - control rod that was not fully withdrawn to position 48 was selected for movement
'
and the shift manager's permission was not obtained prior the performance of the evolution. In addition, self checking and independent verification of correct control
*  rod selection and motion was not accomplished during this control rod
,
manipulation, resulting in a mispositioned controlrod. The consequence of this
!. error was an unplanned, but modest reactivity addition.


Sincerely,
This is a severity LevelIV violation (Supplement I).


;  Original Signed by:
,
!
-
Charles W. Hehl, Director,
Adminnlon Or Danlal Of The Allaaed Violation i
,   Division of Reactor Projects i Docket No.: 50-333
,
.
The Authority agrees with this violation.
License No.: DPR-59


-
-
Enclosures:
          ;
, 1. Notice of Violation 2. NYPA Handout at the May 8,1997, Enforcement Conference i
Ransons for Violation i  The cause of this violation was personnel error. A team root cause analysis of this event identified the following human performance problems:
i i
Work Praceh - Self-Checkina
    -
    ...
:  - When the RO initiated control rod movement, he failed to monitor available indications that would have immediately told him enexpected rod movement-4-  was taking place. Self-checking was not applied to verify rod selection and ensure the expected response. Rod motion was terminated on the receipt of the rod block, a design feature, as opposed to being recognized and
.  . terminated by the RO. In addition, a second ' qualified' individual was not __
present to assist in monitoring indications to detect rod motion (were it to occur) contrary to the expectations of AP 12.03.


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Page 1 of 4


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Michael .
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cc w/encls:
.
C. D. Rappleyea, Chairman and Chief Executive Officer i R. Schoenberger, President and Chief Operating Officer j J. Knubel, Chief Nuclear Officer and Senior Vice President
Reply t*> N:ti:o cf Viol: tion t'
.
,.
H. P. Salmon, Jr., Vice President of Nuclear Operations
Snecial innosction Reoort 97 03  i Work Practican - Document Use
- The RO did not refer to the coupling check surveillance procedure and selected a control rod for the coupling check that was not fully withdrawn as
. he intended. The CRS and the RO considered a second verification of the selected control rod required by administrative procedure AP 12.03, Administration of Operations, was not required because actual rod motion was not anticipated.
 
Sunervisorv Methods
- The Control Room Supervisor (CRS) granted permission to perform an unplanned, unscheduled evolution without notifying th; Shift Manager (SM).
 
The CRS did not recognize that a control rod coupling check could result in control rod movement and associated reactivity changes. As a result of not recognizing potential adverse consequences of performing this task, the CRS direction to the Reactor Operator (RO) was informal and did not adequately communicate job performance and self checking standards.
 
. Manaaeria! Methods
- Management expectations prohibiting plant equipment manipulations solely for training was not clearly communicated. The absence of a clearly defined policy allowed this evolution to proceed without an adequate assessment of risks and consequences because it was an unscheduled, unplanned task, liabit Intrusion c
- The CRS and RO were not focused on the task, they viewed the task as
'
easy to perform. The individuals involved had actually performed or observed many coupling checks in the past during surveillance testing. The RO did not self check rod selection and focused his attention entirely on control rod drive (CRD) system hydraulic parameters and explanation of
'
system response to the trainee.
 
;
;
'
Corrective Actions That Have Been Taken o -
W. Josiger, Vice President - Engineering and Project Management J. Kelly, Director - Regulatory Affairs and Special Projects T. Dougherty, Vice President - Nuclear Engineering R. Deasy, Vice President - Appraisal and Compliance Services
- The improperly withdrawn control rod was restored to its original location (position 22).
; R. Patch, Director - Quality Assurance l G. C. Goldste.n, Assistant General Counsel C. D. Faison, Director, Nuclear Licensing, NYPA
 
- The CRS and RO were removed from licensed responsibilities and disciplined in accordance with Human Resources policies. Fitness' for Duty for cause testing was conducted on the RO with negative results. Both individuals were placed in a remedial training program. The CRS has been successfully remediated and retumed to licensed duties.
 
Page 2 of 4 l
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f..
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W
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. . R: ply to Nctiso cf VI:lation
,,
,
SpecialInsoection Rooort 97-03
  - Immediately after the event, the Operations Manager suspended reactivity manipulations for license candidates and conducted standdown briefings for all Operations personnel before their next operating shift to communicate the following:
  ..
  * A clear definition that any manipulation of the rod movement control switch is a control rod manipulation and a reactivity manipulation regardless of the circumstances.
 
* Reinforced the special nature of any reactivity manipulation as requiring the full concentration of the control room staff.
 
* Defined the condition under which control rod manipulation could be performed and by whose authority (i.e., Shift Manager).
 
* Established that plant equipment status changes for training purposes is not permitted unless planned, scheduled, and properly assessed for plant risks.
 
*
*
K. Peters, Licensing Manager T. Morra, Executive Chair, Four County Nuclear Safety Committee l Supervisor, Town of Scriba C. Donaldson, Esquire, Assistant Attorney General, New York Department of Law
Emphasized the responsibility of SRO's and RO's to question and challenge all activities, even those that appear uncomplicated and
. P. Eddy, Director, Electric Division, Department of Public Service. State of New York i G. T. Goering, Consultant, New York Power Authority i J. E. Gagliardo, Consultant, New York Power Authority
  * reinforced expectations for procedure use, self-checking, reactor safety, and communication.
; E. S. Beckjord, Consultant, New York Fower Authority F. WiPiam Valentino, President, New York State Energy Research and Development Authority i
 
J. Spath, Program Director, New York State Energy Research
- AP 12.03 has been revised to identify the critical responsibilities and authorities associated with reactivity control and plant configuration control that are to be implemented in a consistent manner shift to shift. It has also been revised to formalize the expectations for equipment manipulations performed for training.
; and Development Authority
 
- The Operations Department implemented a peer check policy to improve individual focus on contiol room panel manipulation. This type of policy has been successful at other utilities in helping prevent personnel errors.
 
- The Operations Manager conducted training on lessons learned from 14 industry events'that emphasized the importance of: supervisory oversight in the control room; procedure use; teamwork; operating practices; and reactivity management. All operators and operations training instructors
,
attended.
 
Page 3 of 4
      ~
 
  .. _  _  .
:.' . .
_,,
, . Reply t3 N3tico cf VI:l:ti:n Soncial Innoection Report 97-03 Results Achieved Management oversight during scheduled plant power reductions have shown that our Operations personnel are performing these evolutions in the proper manner with the proper respect and formality required for reactivity manipulations.
 
Management observations and oversight of other reactivity manipulations required for scheduled maintenance or core management have also confirmed that these manipulations are being conducted in a manner which meets management expectations. These observations have been conducted in the Control Room and plant simulator.


i
Qorrective Actions To Be Taken Plant management has implemented and promulgated expectations in the area of Control Room operations with additional emphasis on reactivity manipulations.


      . .
Management will continue to provide the oversight needed to reinforce that reactor safety is a site and individual culture that must be personalized in our day to-day activities. Operator performance continues to be monitored and coached both on shift and in training.
.
 
Michael Distribution w/encls:
Operations staff meetings are being conducted every two weeks and are normally attended by SRO's from 3 or 4 of the six operating shifts. These meetings are providing an excellent forum for discussing department operating standards. These meetings in the future will provide a continuing mechanism for reinforcing JAF operating philosophies, including the need for a questioning attitude.
W. Axelson, DRA D. Screnci, PAO
! R. Zimmerman, ADPR, NRR l J. Goldberg, OGC l J. Lieberman, OE (OEMAIL)
l D. Holody, EO, RI I Nuclear Safety Information Conter (NSIC)
PUBLIC NRC Resident inspector Region i Docket Room (with concurrences)  1 J.Rogge,DRP    <
R. Barkley, DRP    !
R. Junod, DRP I
Distribution w/encls: (VIA E-MAIL)
W. Dean, OEDO (WMD)
S. Bajwa, NRR K. Cotton, NRR D. Hood, NRR M. Campion, RI Inspection Program Branch, NRR (IPAS)    j R. Correia, NRR    j F. Talbot, NRR    I DOCDESK DOCUMENT NAME: G:\ BRANCH 2\lR97-03.VIO To receive a copy of this document, indicate irt the box: "C" = Copy without attachment / enclosure ,"f" = Copy with attachment / enclosure "N" = No copy OFFICE Rl/DRP [ [ Rl/DRP Rl/EO hQ Rl/DRP JRoggq9 7  CHe M
    '
NAME RBarkley [y 1V  DHolody
  '
DATE 06/$/97 06/f/j/97 06/g/97 06fd/97 ' j
,
OFFICIAL RECORD COPY


I
Management observations and assessments will continue to be conducted to ensure continued improvement in Control Room formality and questioning attitude.
.
.
Michael Distribution w/encis:
      '
W. Axelson, DRA D. Screnci, PAO


R. Zimmerman, ADPR, NRii
Data When Full Comollance Will Be Achieved Full compliance was achieved upon restoration of the control rod to its original location at position 22 on March 3,1997.
- J. Goldberg, OGC    !
J. Lieberman, OE (OEMAIL)
D. Holody, EO, RI Nuclear Safety Information Center (NSIC)


PUBLIC NRC Resident inspector Region I Docket Room (with concurrences)
~
J. Rogge, DRP R. Barkley. DRP R. Junod, DRP
  .
!
l l
Distribution w/encis: (VIA E-MAIL)
Page 4 of 4  )
W. Dean, OEDO (WMD)
l
'.
S. Bajwa, NRR K. Cotton, NRR D. Hood, NRR
'
M. Campicn, RI Inspection Program Branch, NRR (IPAS)
R. Correia, NRR F. Talbot, NRR DOCDESK DOCUMENT NAME: G:\ BRANCH 2\lR97-03.VIO
'See previous concurrences To receive a copy of this document, indicate in the box: "C" = Copy without l i
attachment / enclosure "E" = Copy with attachment / enclosure "N" = No copy
      )
OFFICE * Rl/DRP * Rl/DRP * J/EO
    ,
      * Rl/DRP l NAME RBarkley/RSB JRogge/JR DHolody/DH CHehl/CH DATE 06/19/97 06/19/97 06/20/97 06/23/97 OFFICIAL RECORD COPY  j i
}}
}}

Latest revision as of 00:26, 18 December 2021

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-333/97-03 on 970629
ML20217Q092
Person / Time
Site: FitzPatrick Constellation icon.png
Issue date: 08/12/1997
From: Rogge J
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To: Michael Colomb
POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
References
50-333-97-03, 50-333-97-3, NUDOCS 9708290146
Download: ML20217Q092 (3)
v • d • e


Text

- -.

o.

,

August 12, 1997

'

,

Mr. Michael Site Executive Officer New York Power Authority James A.' FitzPatrick Nuclear Power Plant Post Office Box 41-Lycoming,.NY 13093

Dear Mr. Colomb:

Subject: NRC Inspection Report No. 50 333/97 03 and Notice of Violation

-

, This letter refers to your July 30,1997 correspondence, in response to our June 29,1997 letter.

Thank you for informing us of the corrective and preventive actions documented in your

,

letters. These actions will be examinec' during a future inspection of your licensed program.

Your cooperation with us is appreciated.

Sincerely, Original Signed by:

John F. Rogge, Chief Projects Branch 2 Division of Reactor Projects Docket No. 50-333 cc:

~ C. Rappleyea, Chairman and Chief Executive Officer

'R. Schoenberger, President and Chief Operating Officer J. Knubel, Chief Nuclear Officer and Senior Vice President

.H. P. Salmon,- Jr., Vice Presider.. of Nuclear Operations W. Josiger, Vice President - Engineering and Project Management J. Kelly, Director - Regulatory Affairs and Special Projects T. Dougherty, Vice President - Nuclear Engineering l R. Deasy, Vice President - Appraisal and Compliance Services R. Patch, Director - Quality Assurance l-l G. Goldstein, Assistant General Counsel C. Faison, Director, Nuclear Licensing lllllh!k,5 K. Peters, Licensing Manager

' T. Morra, Executive Chair, Four County Nuclear Safety Committee 9708290146 970812-PDR ADOCK 05000333 G PDR OFFICIAL RECORD COPY IE:01

. ,-,

- _ _ _

,--

..

Michael cc w/ copy of Licensee's Response Letter:

Supervisor, Town of Scriba_

C. Donaldsoni Esquire, Assistant Attorney General, New York Department of Law P. Eddy, Director, Electric Division, Department of Public Service, State of New York G. T. Goering, Consultant, New York Power Authority J. E. Gagliardo, Consultant, New York Power Authority E. S. Beckjord, Consultant, New York Power Authority F. William Valentino, President, New York State Energy Research and Development Authority J. Spath, Program Director, New York State Energy Research and Development Authority s

..

. . .

_. .

.

..

Michael Distribution w/ copy of Licensee's Response Letter:

RI EDO Coordinator A. Dromerick, NRR K. Cotton, NRR D. Hood, NRR M. Campion, RI R. Correia, NRR F. Talbot, NRR Nuclear Safety Information Center (NSIC)

PUBLIC NRC Resident inspector Region l Docket Room (with concurrences)

Inspection Program Branch, NRR (IPAS)

J. Rogge, DRP R. Barkley, DRP R. Junod, DRP DOCDESK

DOCUMENT NAME: A:\RL9703.FTZ

- To receive a copy of this document, Indicate in the box: "C" = Copy without attachment / enclosure "E" =

Copy with attachment / enclosure '"N" = No copy l OFFICE Hl/DRP Rl/DRP lNAME- GHunegs JRogge /J d ,

lDATE 08/gl97-- 08/tg9T OFFICIAL RECORD COPY

._.

.

, ,

  • j J:mes A. Fit: Patrick

, . Nucteer Power Ptent

    • K4 Lcks Motd Po Bos 41 Lycomeg, New York 13093 315 342 3640
  1. > NewWrkPower Ze'd!da";!

4# Authority

July 30, 1997 l

JAFP-97-0268 -

U.S. Nuclear Regulatory Commission Attention: Document Control Desk Mail Station P1 137 Washington, DC 20555

!

SUBJECT: James A. FitzPatrick Nuclear Power Plant Docket No. 50 333 Reply to Notice of Violation 14RC SoecialInsoection Reoort 50 333/97 03 Gentlemen:

In accordance with the provisions of 10 CFR 2.201, Notice of Violation, the Authority submits a response to the notice transmitted by your letter dated June 23,1997. Your letter refers to the results of the special safety inspection cor. ducted by Messrs. G. Hunegs, L. Briggs, and R. Fernandes from March 4,1997 to March 13,1997, at the James A. FitzPatrick Nuclear Power Plant.

The Authority believes the corrective actions taken have been effective in improving our human performance. There have been no significant errors since the March 3,1997 ovent and there is indication that the number of personnel errors has decreased through the last quarter (April- June,1997). A heightened awareness of human performance has been achieved. Daily and weekly manager observations in the field have noted personnel exercising sound decision making and a questioning attitude. When discrepancies are identified, corrections are made and the appropriate feedback is provided to the plant staff via standdowns, tailgates, or briefs. Senior Plant Management continues to reinforce that reactor safety a a site and individual culture that must be personalized in our day-to day activities. Emphasis and monitoring of human performance results will continue to ensure an improving trend.

Attachment 1 provides the description of the violation, reason for the violation, the corrective actions that.have been taken and the results achieved, corrective actions to be taken to avoid'further violations, and the date of full compliance.

There are no commitments contained in this submittal, if you have any questions, please contact Mr. Arthur Zaremba at (315) 349-6365.

Very truly your

,

STATE OF NEW YORK COUNTY OF OSWEGO

  • Subscribed and sworn to before me

'

/ ,

l MICHAEL J. COLOMB

'

p<" [* this 30 day of Ldt,

\

,1997.

/ - m , O b c1 s.w d

MJC: RAP:las Netary Pdblic c: Next page NANCY B. CZEROW Notary Pubitc. state of NewYork Quelmed in oewego County e4664611 i ? Commleston Empiree _ h * k- U #

' b*h,(W QQ

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  • cc: Regional Administratcr U.S. Nuclear __ Regulatory Commission -

475 Allendale Road King of Prussia, PA 19406

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Office of the Resident inspector U.S. Nuclear Regulatory Commission P.O. Box 136 Lycoming, Nsw York 13093 Ms. K. Cotton, Acting Project Manager Project Directorate 11 Division of Reactor Projects l/II U.S. Nuclear Regulatory Commission Mail Stop 14 B2

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Washington, DC 20555 Attachments:

Reply to Notice of Violation

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Reply tD Notico ef Viol:: tion f Sneelal Innoaction Raoort 97-03 -

L Violation ,

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Technical Specification 6.8(A)2 requires that written procedures and administrative

. policies shail be established, implemented and maintained that are recommended in App'endix A of Regulatory Guide 1.33, November 1972. Appendix A of Regulatory

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Guide 1.33 requires. operating procedures governing the controlrod drive system and administrative procedures for safe operation. Operations Survelliance Test i

- Procedure (ST 20C) governs testing to verify control rod drive system operability; l

paragraph 8.1.16, in particular, govems the performance of a controlrod coupling Integrity check. NYPA Administration Procedure (AP)-12.03, Administration of Operations, Revision 9, provides direction Vo plant personnel concerning general

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practices and philosophy for safety operations. Paragraph 7.2 requires that self.

l checking shall be practiced when operating plant equipment and paragraph 8.17,

. Reactivity Management, requires independent verification of correct controlrod v selection and motion.

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' Contrary to the above, on March 3,1997, ST-20C was not followed in that a

- control rod that was not fully withdrawn to position 48 was selected for movement

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and the shift manager's permission was not obtained prior the performance of the evolution. In addition, self checking and independent verification of correct control

  • rod selection and motion was not accomplished during this control rod

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manipulation, resulting in a mispositioned controlrod. The consequence of this

!. error was an unplanned, but modest reactivity addition.

This is a severity LevelIV violation (Supplement I).

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Adminnlon Or Danlal Of The Allaaed Violation i

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The Authority agrees with this violation.

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Ransons for Violation i The cause of this violation was personnel error. A team root cause analysis of this event identified the following human performance problems:

Work Praceh - Self-Checkina

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- When the RO initiated control rod movement, he failed to monitor available indications that would have immediately told him enexpected rod movement-4- was taking place. Self-checking was not applied to verify rod selection and ensure the expected response. Rod motion was terminated on the receipt of the rod block, a design feature, as opposed to being recognized and

. . terminated by the RO. In addition, a second ' qualified' individual was not __

present to assist in monitoring indications to detect rod motion (were it to occur) contrary to the expectations of AP 12.03.

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Reply t*> N:ti:o cf Viol: tion t'

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Snecial innosction Reoort 97 03 i Work Practican - Document Use

- The RO did not refer to the coupling check surveillance procedure and selected a control rod for the coupling check that was not fully withdrawn as

. he intended. The CRS and the RO considered a second verification of the selected control rod required by administrative procedure AP 12.03, Administration of Operations, was not required because actual rod motion was not anticipated.

Sunervisorv Methods

- The Control Room Supervisor (CRS) granted permission to perform an unplanned, unscheduled evolution without notifying th; Shift Manager (SM).

The CRS did not recognize that a control rod coupling check could result in control rod movement and associated reactivity changes. As a result of not recognizing potential adverse consequences of performing this task, the CRS direction to the Reactor Operator (RO) was informal and did not adequately communicate job performance and self checking standards.

. Manaaeria! Methods

- Management expectations prohibiting plant equipment manipulations solely for training was not clearly communicated. The absence of a clearly defined policy allowed this evolution to proceed without an adequate assessment of risks and consequences because it was an unscheduled, unplanned task, liabit Intrusion c

- The CRS and RO were not focused on the task, they viewed the task as

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easy to perform. The individuals involved had actually performed or observed many coupling checks in the past during surveillance testing. The RO did not self check rod selection and focused his attention entirely on control rod drive (CRD) system hydraulic parameters and explanation of

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system response to the trainee.

Corrective Actions That Have Been Taken o -

- The improperly withdrawn control rod was restored to its original location (position 22).

- The CRS and RO were removed from licensed responsibilities and disciplined in accordance with Human Resources policies. Fitness' for Duty for cause testing was conducted on the RO with negative results. Both individuals were placed in a remedial training program. The CRS has been successfully remediated and retumed to licensed duties.

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. . R: ply to Nctiso cf VI:lation

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SpecialInsoection Rooort 97-03

- Immediately after the event, the Operations Manager suspended reactivity manipulations for license candidates and conducted standdown briefings for all Operations personnel before their next operating shift to communicate the following:

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  • A clear definition that any manipulation of the rod movement control switch is a control rod manipulation and a reactivity manipulation regardless of the circumstances.
  • Reinforced the special nature of any reactivity manipulation as requiring the full concentration of the control room staff.
  • Defined the condition under which control rod manipulation could be performed and by whose authority (i.e., Shift Manager).
  • Established that plant equipment status changes for training purposes is not permitted unless planned, scheduled, and properly assessed for plant risks.

Emphasized the responsibility of SRO's and RO's to question and challenge all activities, even those that appear uncomplicated and

  • reinforced expectations for procedure use, self-checking, reactor safety, and communication.

- AP 12.03 has been revised to identify the critical responsibilities and authorities associated with reactivity control and plant configuration control that are to be implemented in a consistent manner shift to shift. It has also been revised to formalize the expectations for equipment manipulations performed for training.

- The Operations Department implemented a peer check policy to improve individual focus on contiol room panel manipulation. This type of policy has been successful at other utilities in helping prevent personnel errors.

- The Operations Manager conducted training on lessons learned from 14 industry events'that emphasized the importance of: supervisory oversight in the control room; procedure use; teamwork; operating practices; and reactivity management. All operators and operations training instructors

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attended.

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, . Reply t3 N3tico cf VI:l:ti:n Soncial Innoection Report 97-03 Results Achieved Management oversight during scheduled plant power reductions have shown that our Operations personnel are performing these evolutions in the proper manner with the proper respect and formality required for reactivity manipulations.

Management observations and oversight of other reactivity manipulations required for scheduled maintenance or core management have also confirmed that these manipulations are being conducted in a manner which meets management expectations. These observations have been conducted in the Control Room and plant simulator.

Qorrective Actions To Be Taken Plant management has implemented and promulgated expectations in the area of Control Room operations with additional emphasis on reactivity manipulations.

Management will continue to provide the oversight needed to reinforce that reactor safety is a site and individual culture that must be personalized in our day to-day activities. Operator performance continues to be monitored and coached both on shift and in training.

Operations staff meetings are being conducted every two weeks and are normally attended by SRO's from 3 or 4 of the six operating shifts. These meetings are providing an excellent forum for discussing department operating standards. These meetings in the future will provide a continuing mechanism for reinforcing JAF operating philosophies, including the need for a questioning attitude.

Management observations and assessments will continue to be conducted to ensure continued improvement in Control Room formality and questioning attitude.

Data When Full Comollance Will Be Achieved Full compliance was achieved upon restoration of the control rod to its original location at position 22 on March 3,1997.

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