ML20058H437

Forwards Summary of 901016 Enforcement Conference Re Events Surrounding 900819 Unit 2 Reactor Scram

ML20058H437
Person / Time
Site:	Brunswick
Issue date:	11/01/1990
From:	Reyes L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:	Eury L CAROLINA POWER & LIGHT CO.
References
NUDOCS 9011160060
Download: ML20058H437 (38)

Text

Y,J) 6 e,

NOV 011990 Docket Nos. 50-325, 50-324 License Nos. DPR-71, DPR-62 Carolina Power and Light Company ATTN:

Mr. Lynn W. Eury Executive Vice President Power Supply P. O. Box 1551 Raleigh, NC 27602 Gentlemen:

SUBJECT:

MEETING

SUMMARY

- BRUNSWICK This refers to the Enforcement Conference held at our request-on October 16, 1990.

This meeting concerned activities authorized for your Brunswick facility.

The issues discussed at this conference related to events surrounding the August 19, 1990 Unit 2 reactor scram.

A list of attendees, a summary, and a copy of your handout are enclosed.

We ar* continuing our review i

of these issues to determine the appropriate enforcement,iction.

In accordance with Section 2.790 of the NRC's " Rules of Practice " Part 2 Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.

Should you have any questions concerning this matter, please contact us.

Sincerely, (Original signed by EMerschoff/for)

Luis A. Reyes, Director Division of Reector Projects

Enclosures:

1.

List of Attendees 2.

Enforcement Conference Summary 3.

Handout cc w/encls:

(Seepage 2) l 3

s-4 (g ^* * * *Ri?.

,Yn 9011160060 901101

4 o

'., ~....

NOV 011990 Carolina Power and Light Company 2

i i

cc w/encis:

R. B. Starkey, Jr.

Vice President Brunswick Nuclear Project Box.10429 Southport, NC 28461 J. L. Harness Plant General Manager Brunswick Steam Electric Plant P. O. Box 10429 Southport, NC 28461 R. E.. Jones. General Counsel Carolina Power & Light Company

- P. 0.. Box'1551 Raleigh, NC 27602 Ms. Frankie Rabon' Board of Commissioners

. P. 0. Box 249 Bolivia, NC 28422

-Chrys Bagget.

State Clearinghouse Budget and Management--

j 116 West-Jones Street ~

Raleigh,.NC; 27603

- Dayne H. Brown, Director Division of Radiction Protection N. C. Dcpartment'of Environment, c

Health & Natural Resourcesi P'. 0.- Box 27687-

- Raleigh, NC.. 27611-7687 H. ' A. '.. Cbl e Special' Deputy Attorney General

- State of North Carolina

. P.' O. Box-629-Raleigh,,NC 127602:

a-

- Robert P. Gruber-Executive Director-

' Public Staff - NCVC P. 0. Box 29520

' Raleigh, NC. 27626-0520 e

1 J

i 1

Carolina Power and Light Company 3

NOV 01 m bec w/encls:

Document Control Desk DRP Section Chief NRC Resident inspector U.S. Nuclear Regulatory Commission Star Rte. 1. Box 208 Southport. NC 28461 y

R1:}CRP RII:D P Ril P

Ril DR MGhh n

R0'arr 1 DVerrelli s'choff ff/,( /90 10/3V90-10/y/90 10/jl/90

c i

w t

l-ENCLOSURE 1 LIST OF ATTENDEES Carolina Power and Light Company R. A. Watson, Senior VP for Nur. lear Operations K. Karr, 5)ecial Assistant to Senior VP for Nuclear Operations R. B. Star <ey, Jr., VP - Brunswick Nuclear Project J. W. Moyer, Technical Assistant to Plant General Manager K. B. Altman, Manager - Regulatory Compliance P. D. Morris, Senior Specialist, Nuclear Licensing

,+

Nuclear Regulatory Commission S. D. Ebneter, Regional Administrator, Region 11 (Rll)

J. L. Milhoan, Deputy Regional Administrator, Ril L. A. Reyes, Director, Division of Reactor Projects (DRP), RIl E

E. W.-Merschoff Deputy Director, DRP, Ri!

G. R. Jenkins, Director, Enforcement and Investigation Coordination Staff (EICS) Ril E

B. Uryc, Senior Enforcement Specialist EICS, RI!

C. A. -Julian, Chief, Engir.eering Branch, Division of Reactor Safety (DRS),RII--

D.'M. Verre111, Chief, Reactor Projects Branch 1. DRP, Ril i

G. A. Belisle, Chief Test Programs Section, DRS, RIl R. W. Borchardt, Regional Coordinator, Office of the Executive

-Director.of Operations R.- E. Carroll, Acting Chief, Reactor Projects Section 1A, DRP, R!l H. 0. Christensen, Senior Resident inspector - Grand Gulf, DRP, Ril R. L. Prevatte, Senior Resident Inspector - Brunswick, DRP, RIl W. Levis, Resident Inspector - Brunswick, DRP,~ R!l.

T. Lo, Project Ma"ager, Office of Nulear Reactor Projects o

M. M.:Glasman, Pr ject Engineer -DRP, Ril y

I

+

O l

l ENCLOSURE 2 j

i ENFORCEMENT CONFERENCE SUMMRY I

The Region II Director of Reactor Projects opened the meeting by stating the issues to be discussed stemmed from the August 19, 1990 Unit 2 reactor scram which resulted from an inadequately performed / controlled surveillance test.

l Specifically, these issues involved:

(1) the improprieties by Instrumentation l

& Control (ISC) technicians which included the inadequate performance of the related surveillance test, lack of required independent verification during the i

test, and the willful falsification of the test procedure to reflect independent verification was performed; (2) the failure of operators to properl acknowledge and respond to annunciators induced by the surveillance test; (3) y l

technicians; (4) per/ formal communications between operators and the I&Cthe failure the lack of pro J

o and (5) revealed hardware, training, and procedural deficiencies.

CP&L's Senior Vice President for Nuclear Operations expressed his concern over the subject event and indicated that the above issues had been addressed by short i

term corrective actions, with long term corrective actions being ccptured by the Brunswick Integrated Action Plan.

l The licensee then proceeded to address the issues of concern, providing related corrective actions, an overview of safety significance, and a sequence of l

events.

it was pointed out by the licensee that the scram was investigated j

promptly, the root cause was determined, the event was initially reported, immediate corrective actions were taken, the plant was always within its i

analyzed conditions, and no safety limits or radiological dose limits were l

exceeded.

They also stated that the willful procedural noncompliance was an i

isolated incident and not indicative of a programmatic problem or a breakdown

-l in management controls.

it was further indicated that in 12 years of operating t

history this was the first incident of deliberate falsification at Brunswick.

When questioned, tne licensee stated that the surveillance tests conducted by 1

the two I&C technicians were reperformed.

l f

Command, control, and communication issues in the control room and in the l

performance of maintenance / surveillance were then discussed.

The Regional

{

Administrator indicated that he was concerned with the apparent lack of a questioning attitude on the part of operations. Two annunciators which clearly 1

indicated that Channel A2 was in a trip condition and that testing was underway on Channel B2 should have alerted the operator to stop the testing.

In addition, when - the operator confronted the technician concerning the status j

of the balf-trip condition, communication between the individuals was imprecise i

and lacking formality, in response to this concern, the licensee indicated that training in the area of formalized communications was in progress; that i

new maintenance pre / post job briefing requirements were imposed; and on August 22, 1990, all work was suspended pending site - wide briefings to review I

this and other recent events.

Additionally, in order to ensure operators do not mistakenly disregard annunciator indications during future surveillance testing, the licensee stated that annunciator procedures were revised accordingly.

l

2 Relative to the lack of timely notifications, the licensee indicated that the 4

shift technical advisor initially drew the correct conclusion relative to declaration of an unusual event when the five safety relief valves (SRVs) failed to operate properly; however, the Operations Manager elected to wait for an engineering evaluation.

Stated corrective actions in response to these problems included evaluating operational characteristics of the SRVs; development of a simple policy for event declaration; and capturing this and the other notification problems by on-going training.

When questioned about the problems operators experienced with the startup level control valve (SULCV), the licensee indicated that the trim of the valve was changed in 1988 resulting in different flow characteristics for the valve.

H

- Since this change was accomplished as a direct replacemer.t, it was not reviewed by.the training organization, and therefore, the simulator was not upgraded to reflect the change.

Stated corrective actions for identified hardware, training, and procedural deficiencies included:

reviewing direct replacement modifications issued before March 1989; including the Training Department as a member-of the Site Incident investigation Team; re-evaluation of thermal setpoints for selected valves; upgrade of simulator to reflect true SULCV operation, as well as thermal overload characteristics of the reactor core j

i isolation cooling system trip and throttle valve; revision of operating procedures and operator aids as necessary; and implementation of a design basis reconstitution program, y

The Regional-Administrator closed the meeting and +"anked the licensee for

[

their presentation.

He then informed CPhl that th.y would be advised at a later date as to NRC's deliberations on these matters, l

l l

1 i

l I

l 4

1

t ENCLOSURE 3 BRUNSWICK NUCLEAR PROJECT 1

i i

l

'I AUGUST 19, 1990 REACTOR TRIP ENFORCEMENT CONFERENCE L

.l I

I l

i l'

L L

OCTOBER. 16, 1990 1

i

u-ENFORCEMENT CONFERENCE OCTOBER 16, 1990 AGEND.A h

OVERVIEW RUSS STARKEY Y

DESCRIPTION OF EVENTS BRUCE ALTMAN i

FAILURE TO FOLLOW TEST RICNARD WARDEN PROCEDURES (BRUCE ALTMAN)

L l

(324/90-29-01)

INADEQUATE PROCEDURES JOHN M0YER AND COMPLIANCE H

(324/90-29-02) i i

1 I

FAILURE TO DECLARE UNUSUAL EVENT JOHN M0YER AND MAKE PROMPT NOTIFICATION l

(324/90-29-03)

FAILURE TO MAKE PROMPT JOHN M0YER NOTIFICATION OF ESF ACTUATIONS (324/90-29-04)

ENGINEERING AND TRAINING BRUCE ALTMAN 1

SUM 4ARY RUSS STARKEY t

l

1 1

ENFORCEMENT CONFERENCE l

OVERVIEW DESCRIPTION OF EVENT (AUGUST 19.

1990)-

4 0

I&C TECHNICIANS FAILED TO FOLLOW MAINTENANCE SURVEILLANCE TEST (MST) PROCEDURE AND DELIBERATELY MISLED INVESTIGATION.

0 UNPLANNED REACTOR TRIP 4

0 EQUIPMENT, PERSONNEL, AND PROCEDURAL WEAKNESSES EVIDENCED 1

k i

4 2

I 1

ENFORCEMENT CONFERENCE l

0VERVIEW CONT'D I

i SAFETY SIGNIFICANCE l

0 N0 NUCLEAR SAFETY SIGNIFICANCE BRUNSWICK PLANT i

ALWAYS WITHIN ANALYZED CONDITION 6

ENVIRONMENT PUBLIC 0

NO RADIOLOGICAL DOSE LIMITS EXCEEDED l

l 0

WILLFUL PROCEDURE NONCOMPLIANCE IS ROI A l

PROGRAMMATIC PROBLEM.

0 NOT INDICATIVE OF A BREAKDOWN IN MANAGEMENT CONTROLS 3

~

ENFORCEMENT CONFERENCE OVERVIEW (CONT'D)

CAUSAL FACTORS AND ROOT CAUSE L

0 CAUSAL FACTORS IDENTIFIED 0

ROOT CAUSES DETERMINED AND UNDERST0OD IDENTIFICATION AND REPORTING 0

SELF IDENTIFIED L

0 INITIATING EVENT PROMPTLY REPORTED 0

IMMEDIATE CORRECTIVE ACTIONS TAKEN CORRECTIVE ACTIONS TO PRECLUDE RECURRENCE 0

PROMPT 0

COMPREHENSIVE 0

SELF INITIATED 0

SITE WIDE APPLICATION 0

HEIGHTEN AWARENESS OF PLANT AND PERSONAL CONSEQUENCES 4

ENFORCEMENT CONFERENCE OVERVIEW (CONT'D)

PAST PERFORMANCE O

ISOLATED OCCURRENCE AND NO PAST VIOLATION 0

ACKNOWLEDGED PRIOR PERSONNEL, EQUIPMENT, AND PROCEDURAL CONCERNS DILIGENTLY WORKING TO CORRECT MATERIAL CONDITION IMPROVING CONTINUALLY PERFORMANCE INDICATORS (UNTIL THIS EVENT) SHOWED CONTINUING PROGRESS PRIOR NOTICE OF SIMILAR EVENTS 0

NONE SPECIFIC TO THIS COMBINATION OF EVENTS e

5

l i

1 ENFORCEMENT CONFERENCE DESCRIPTION 0F EVENT AUGUST 19. 1990 21:37 INITIATED PERFORMANCE OF 2MST-PCIS24M 4

i 21:54 CHANNEL D TEST INITIATED WITHOUT RESETTING PREVIOUS CHANNEL C TEST TRIP i

GROUP 1 ISOLATION OCCURS - MAIN STEAM i

l ISOLATION VALVES CLOSE REACTOR SCRAMS - REACTOR RECIRC. PUMPS TRIP HPCI AND RCIC AUTO START i

i 21:55 SAFETY. RELIEF VALVES (SRV) AUT0 OPEN DUE TO HIGH PRESSURE (3.4-4 SEC DURATION)

REACTOR FEED PUMPS TRIP HPCI AND RCIC SECURED 21:56 SRVs MANUALLY OPENED TO CONTROL PRESSURE 22:00 HPCI MANUALLY STARTED FOR PRESSURE CONTROL 22:14 TORUS COOLING INITIATED

~22:15 NOTIFIED SENIOR NRC RESIDENT INSPECTOR OF EVENT

]

22:16 RCIC MANUALLY STARTED FOR LEVEL CONTROL i

22:26 GROUP 1 ISOLATION OCCURS-LOW CONDENSER VACUUM l

22:34 HPCI AND RCIC' SECURED 23:05/09 RCIC AND HPCI MANUALLY STARTED FOR PRESSURE CONTROL (HPCI STOP VALVE CYCLES) j i

23:17 REACTOR PROTECTION SYSTEM TRIP - LOW LEVEL 23:23 HPCI AND RCIC TRANSFERRED TO LEVEL CONTROL MSIVs OPENED l

(

i 23:27 HPCI AND RCIC SECURED 23:53 2B REACTOR FEED PUMP STARTED-SULCV PROBLEM ENCOUNTERED 6

[

1

)

ENFORCENENT CONFERENCE DESCRIPTION 0F EVENT (CONT'D) ll 2

AUGUST 20, 1990 i

~00:00 SCRAM INCIDENT INVESTIGATION TEAM MEETS ON-SITE 00:04 REACTOR PROTECTION SYSTEM TRIP-LOW LEVEL 00:05 HPCI MANUALLY STARTED FOR LEVEL CONTROL AND THEN SECURED (HPCI STOP VALVE CYCLES) 00:06 LEVEL CONTROL INITIATED BY CONTROLLING SPEED OF 28 REACTOR FEED PilMP 00:23 2B REACTOR FEED PUMP IRIPS DUE TO HIGH LEVEL 00:27 GROUP 3 ISOLATION (RWCU) DUE TO HI DIFFERENTIAL FLOW 00:31 SECURED CONDENSATE BOOSTER PUMPS DUE TO INCREASING LEVEL i

(

01:52 10CFR 50.72 FOUR HOUR RED PHONE REPORT MADE FOR SCRAM 4

02:00 RCIC TRIP AND THROTTLE VALVE TRIPS ON OVERLOAD WHILE ALIGNING SYSTEM TO STANDBY 02:00 SCRAM INCIDENT INVESTIGATION TEAM CONCLUDES SURVEILLANCE TEST PROCEDURE NOT FOLLOWED AND DETERMINES RECORDS FALSIFIED i

02:17 2A CONDENSATE B0OSTER PUMP STARTED-DISCHARGE VALVE TRIPS ON OVERLOAD 02:20 2B CONDENSATE B0OSTER PUMP STARTED FOR VESSEL LEVEL CONTROL AND SULCV PLACED IN AUTO END OF EVENT 7

y

-t y

wg----vr.r-.e,,---w---.---.-

v,,e,-e~--.-

+-*e--

-i..+v.,..w.,.

, -.-%---s-w

-=--.-w.--- -.

~,-.v-

t ENFORCEMENT CONFERENCE DESCRIPTION OF EVENT (CONT'D)

AUGUST 20. 1990 17:45 UNUSUAL EVENT DECLARED AND 7 RMINATED AUGUST 21, 1990 11:08 FOLLOWUP 10CFR50.72 REPORT COMPLETED FOR:

GROUP 1 ISOLATION-LOW VACUUM RPS TRIPS (2)-LOW LEVEL i

SEPTEMBER 7, 1990 11:05 FOLLOWUP 10CFR50.72 REPORT COMPLETED FOR GROUP 3 ISOLATION (RWCU) l^

I i

i l

i l

8 l

l

3 ENFORCEMENT CONFERENCE FAILURE TO FOLLOW TEST PROCEDURES (324/90-29-01) i l

IISI 0

MST ON PCIS 24M -LOGIC TRIP TEST F012 HIGH L

CONDENSER PRESSURE ERRORS l

0 MISSED PROCEDURE STEPS INDEPENDENT VERIFICATION i

RESETOFCHkNNELC i

0 MISCOMMUNICATION WITH CO-0 FALSIFIED SURVEILLANCE TEST RECORD 0

INITIAL DENIAL OF ERROR 1

1.

N 9

i l

l:

)

ENFORCEMENT CONFERENCE FAILURE TO FOLLOW TEST PROCEDURES (CONT'D)

N0 GENERIC IMPLICATIONS (ISOLATED OCCURRENCE) 0 HIGH MST PERFORMANCE VISIBILITY CDs, FOREMEN, MANAGERS, STAS, CJ-WORKERS, NRC, 0A 0

HIGH FREQUENCY OF MSTs a 200/ MONTH r

I 0

NRC INSPECTIONS AND OBSERVATIONS 4/ MONTH FORMAL 0

QA/QC AUDIT AND SURVEILLANCE t

ON-G0ING I

0 MAINTENANCE AUDITS WEEKLY i

i 10

.. -. -,., - -......... -. -....., _., ~... _...

ENFORCEMENT CONFERENCE FAILURE TO FOLLOW TEST PROCEDURE (CONT'D)

PERSONNEL 0

TWO MAINTENANCE TECHNICIANS SIGNIFICANCE OF UNDERLYING VIOLATION I

L O

ISOLATED OCCURRENCE 0

NO PREVIOUS VIOLATION INTENT OF INDIVIDUAL EMPLOYEE 4

0 OVER CONFIDENCE LED T0. GROSS NEGLIGENCE h

0 DID NOT DELIBERATELY INTEND TO CAUSE PLANT PROBLEMS 0

N0. ECONOMIC INCENTIVE INVOLVED 11 M

-__a-_

__m_mm__._.___.m__---m-______mm

._-___mm.=m___-_.-__.__----_.--m_m-..-_-*--._

_ ____z_

m--..

-a.____mm-_._.

___.__mu__._a__._______.-_-m.-___a.:.__-m_-

ENFORCEMENT CONFERENCE I

FAILURE TO FOLLOW TEST PROCEDURE (CONT'D) l l

INTENT OF LICENSEE (CP&L)

C PROVIDED STANDARDS AND PROCEDURES TO PREVENT SUCH ACTIONS i

0 POLICY REINFORCED VIA TRAINING, MANAGEMENT EXAMPLE, AND CONDUCT OF OPERATION 0

HAD N0 PRIOR KNCWLEDGE OF INTENT OF INDIVIDUAL 0

TECHNICIAN SELECTION STANDARDS ALL'MSTTECANICIANSAREI&CTECHNICAL t

LEVEL ONE (ANS QUALIFIED)

ONLY TOP QUALITY I&C TECHNICIANS ASSIGNED TO MST CREWS MST CREWS RECEIVE PRIORITY MANNING MST CREWS EXPERIENCE LEVELS ARE:

~7 YEARS AVERAGE I&C EXPERIENCE

~4.7 YEARS AVERAGE MST EXPERIENCE 12 m

---

c-,

-.ce-.--,_-. - - + -. -. - +... --..

.wv+-*-

+-w v-w+=g--e we

=e--e++=~-w++

~~--"~-v---*--s--

l ENFORCEMENT CONFERENCE i

FAILURE TO FOLLOW TEST PROCEDURE (CONT'D)

CORRECTIVE ACTIONS O

RE-PERFORMED MSTs CONDUCTED BY THE TECHNICIANS INVOLVED, 1

0 AUGUST 20 - IMPOSED NEW MAINTENANCE PRE AND POST J0B BRIEFING REQUIREMENTS:

IDENTIFICATION OF CRITICAL TASKS CONSEQUENCES OF IMPROPER PERFORMANCE REQUIRED INTERFACES SAFETY AND ALARA CONSIDERATIONS l

O AUGUST 22 - WORK SUSPENDED PENDING SITE-WIDE I

BRIEFINGS:

WORK CONTROL BRIEFINGS TO REVIEW RECENT EVENTS PRE-JOB BRIEFINGS BY FIRST LINE SUPERVISORS REQUIRED i

0 PLANT MANAGER HAD PERSONAL MEETINGS (THE FOLLOWING WEEK) WITH ALL PLANT WORK GROUPS.

l l

13 i

....,<en,-,

n,-

---.m,v.w

,,.,,-,.,.,.,_-..,,.,,-w,-,,,,w,,,_...

,-s.

n

i 1

W ENFORCEMENT CONFERENCE 1

8 FAILURE TO FOLLOW TEST PROCEDURE (CONT'D)

CORRECTIVE ACTIONS-(CONT'D)

~

o

-0 AUGUST 127 - COMPLETED INVESTIGATION AND TERMINATED ~ EMPLOYMENT OF TECHNICIANS O

FORMALIZED COMMUNICATIONS TRAINING IN PROGRESS-IMMEDIATE - MST-I&C' CREWS TRAINED REAL TIME TRAINING - DURING.4TH QTR. 1990 R

.0 STANDARDS OF EXCELLENCE ~ ADOPTED BY MAINTENANCE i

i COMPLETED OCTOBER 13, 1990-t i

1 14 q 1

o k

STANDARDS OF: EXCELLENCE.

IN MAINTENANCE TO MEZT

.J2 CHALLENGES AND RESPONSIBILITIES 0F THE NUCLEAR INDUSTRY WE, AS BRUNSWICK i

NUCLEAR PROJECT MAINTENANCE, HEREBY ADOPT THE I

FOLLOWING PROFESSIONAL STANDARDS:

l WE WILL ENSURE THAT'THE SAFETY OF THE PUBLIC, PLANT PERSONNEL AND PLANT EQUIPMENT IS GIVEN HIGHEST PRIORITY IN ALL ASPECTS OF MAINTENANCE.

PERFORM-QUALITY MAINTENANCE TO THE HIGHEST-PROFESSIONAL

~ STANDARDS; INCLUDING COMPLIANCE TO ESTABLISHED

- PROCEDURES.

USE 500NO MA'INTENANCE PRACTICES OURING ' ALL PHASEM 0F MAINTENANCE TO ENSURE OPTIMUM EGUIPMENT CONDITION.AND WORK AREA' CLEANLINESS.

STRIVE TO ATTAIN TNE LOWEST POSSISLE RA0MATION EXPOSURE IN ALL PHASES OF MAINTENAN('d.

DOC'IMENT' WORK PERFORMED 7 4. A CLEAR, C0:4CISE, ACCURATE, AND COMPLETE MANNER.

NOTIFY APPROP?IATE PERSONNEL IF UNSAFE, INADEQUATE,

]

p OR'OEFELTIVE CONDITIONS'AREL06 SERVED.

L

CONTINUALLY IMP 8t0VE WORK' PERFORMANCE BY: ATTENDING O

~

f FORMAL TRAINING AN0' BY - LEARN!i1G Fft0M ' OUR OWN '

l ll l

EXPERIENCE,ANDTHE' EXPERIENCE OF-OTHERS.

EMPHAS!zt " TEAMWORK" AND' MAINTAIN GOOD WORKING-I RELATIONSHIPS'WITH10THER WORK: GROUPS:-GY TREATING FELLOW

^l, EMPLOYEES WITH RESPECT,-DIGNITY AND-COURTESY.

4 REPORT TO WORK PHYSICALLY FIT AND MENTALLY-ALERT.-

+1

$TRIVE.TO 00 RIGHT THINGS RIGHT THE FIRST TIME EVERYTIME.

- AN0' BY 00ZNG SO, BE RECOGNIzt0 ASAMOFS THE BEST IN OUR INDUSTRY.

1 g

V.

.J.

1 s,

, e

+

+---e

-*=er-

• ww-

^ ^ ^ ^ ^ ^ ^

h ENFORbEMENTCONFERENCE INADEQUATE PROCEDURES AND COMPLIANCE (324/90-29-02) r 0

' ANNUNCIATOR PROCEDURES DURING MSTs L'

COMMUNICATIONS L

p.

- 0 OPERATOR AIDS EQUALIZE MSIVs.

..1 HPCI OPERATION-1 e ;;

n 0

OPERATING PROCEDURES 1

1 RCIC CONTROL SWITCH' DC VALVE THERMAL CYCLES

' CONDENSATE AND FEEDWATER (SULCV) e i:

.I l'

16' m

v.-4

.-..4--..-c,

.. -... - -... ~ - - -

---

m. -

I

- j.

-e -

ENFORCEMENT CONFERENCE INADEQUATE PROCEDURES AND COMPLIANCE (CONT'D)

CORRECI1YLACJ10RS 0

ALL RTGB.0PERATOR AIDS REVIEWED AND REVISED AS NECESSARY FOR ACCURACY AND COMPLETENESS 0

A-THOROUGH-REVIEW 0F THESE. EVENTS DURING NEXT LOR CYCLELHAS BEEN SCHEDULED ~

o 4

V 0

REVISED RCIC PROCEDURE 0-REMODELED! SIMULATOR TO 5 SECOND HOLD.FOR

-RCIC TRIP"ANDLTHROTTLE VALVE CONTROL SWITCH-l n*

0:

DC MOTOR OPERATED? VALVE DUTY CYCLE

i "a

REQUIREMENTS UNDER REVIEW =

1 h

l o

]

0 REM 0 DELED SIMULATOR SULCV RESPONSE 4r L

nL 0-SIMULATOR TRAINING 0N RCIC CONTROL SWITCH AND'SULCV IS: COMPLETE.

F l

c I'

17 L

i l i

~

1

ENFORCEMENT CONFERENCE i

FAILljRE TO DECLAtE UiljSUAL EVENT a

A k D 4AKE- >ROMPT k OTI ICATIO i (324/90-29-03)

CONCLUSIONS 0

STA DREW CORRECT CONCLUSION RELATIVE TO SRV POTENTIAL FAILURE.

1 e

k L'

0 INDUSTRY WIDE TARGET ROCK'SRV ACTUATION PATTERN CAUSED UNCERTAINTY AND ' F0.TO AN-ERROR'IN JUDGEMENT.

3 y

- 0

. TRAINING-PROCESS WAS ADEQUATE AND CORRECT.

i I

l

'f-p 0

SEPTEMBER 27 SCRAM. DEMONSTRATED ABILITY TO L

MAKE: CONSERVATIVE-CALL.

o J

18 l

s

-.('

l.

g p

-a g

--w-*-

y g

a 3-aw y

,,w,

,-g,,

w-m,

. ~. _.

ENFORCEMENT CONFERENCE FAILURE TO DECLARE UNUSUAL EVENT (CONT'D1 CORRECTIVE ACTIONS J

0 EVALUATED-SRV OPERATIONAi 1ARACTERISTICS AND sc DEVELOPED' SIMPLE POLICY h IDENTIFICATION AND DECLARATION o

l-a l-0 ON-GOING TRAINING i-k

'i '

l

.I-l' J.

i j'

i

.[I l

l L

4 I'

19

j.

L

.b l

er

.,-r e

w--w=-

=,

,y

+=+- = =

4. -::.;

~.

ENFORCEMENT CONFERENCE

FAILURE TO MAKL PRO 4P" nCl"IFICATION OF ES : ACTIJA"IOP S (324/90-29-04) u i

FOUR-EVENTS

_}

r.

ij 0

MSIV-CLOSURE-(GROUP 1 ISOLATION) o L

10 RPS TRIP '(2' EVENTS)

'l

/. ;:

t.

+

0-RWCU. ISOLATION t

.j(

if I

l t

'l

20 I

..~

ENFORCEMENT CONFERENCE FAILUR! TO MAKE PROM)T NOTIFICATION 0 : ESF ACTUATI0 tS (CONT'D) i CORRECTIVE ACTIONS 0

EVENT REVIEW SCHEDULED FOR NEXT LOR i

s t

0 ON-GOING TRAINING a

li P

-i ll:

V :' 1 y

(

i:

.c 21

'l

ENFORCEMENT CONFERENCE J324/90-29-02. 03. 04)

L i

SUMMARY

CONCLUSIONS 0

THOROUGH. EVENT REVIEW SCHEDULED FOR NEXT LOR CYCLE l

0 PRE-JOB BRIEFS ARE STILL REQUIRED 0-START /STOP TIMES OF MST LOGGED IN SF LOG 0.

COMMAND CONT.su AND COMMUNICATIONS PROJECT i

QUALITY TEAM

~

0

-AIT REPORT COMMENTS l

0 UNIT 2 SCRAM ON SEPTEMBER 27 0

CONTINUED IMPROVEMENT IN OPERATOR

.i --

PERFORMANCE i

1

'f i

22 i

ENFORCEMENT CONFERENCE ENGINEERING AND TRAINING I-CONCERNS ARE DESIGN CONSIDERATIONS OR ENr.NEERING INVOLVEMENT OF CONCERN?

~

I DOES' TRAINING INVOLVEMENTLIN RESPONSE TO PLANT EVENTS-NEEDiIMPROVEMENT?

4 i

F,;

' ~~

t i

i b's

)

i o

o 23-

'y '

~

y i

ENFORCEMENT CONFERENCE

" ^

ENGINEERING-AND TRAINING (CONT'D)

ElifilnEERING 0

ENGINEERING AN ACTIVE MEMBER OF EACH SITE INCIDENT INVESTIGATION TEAM

.r O.

FORMAL PROGRAM FOR RESOLUTION OF DESIGN-RELATEDLEQUIPMENT PROBLENS IS IN PLACE (ENGINEERING WORK REQUESTS)-

t 1

l OL-1 TOP TEN LIST J

L 1

O CONCEPTUAL. DESIGN REVIEWS-j

[

q

[: j.

1

0 FORMAL PROGRAM FOR CORRECTIVE MAINTENANCE IS-O E

'IN PLACE 1(WORK REQUESTS) 1

~

24

~

-, - -.... _ ~ _.. _. _,.. _ _.. _. _... _..

1,,.

ENFORCEMENT CONFERENCE h

ERG 1HEERIBG_AND_IRAINING - (CONT ' D)-

L L

0 ENGINEERING INITIATIVES j

1 INTEGRATED ACTION PLAN L,

6

SYSTEM ENGINEER UPGRADE b

l' r

6 INTERFACE IMPROVEMENT 3

't j:

'6 CENTRAL DESIGN ORGANIZATION-DESIGN BASIS' RECONSTITUTION

.l

.j i

l r

.0-ENGINEERING CORRECTIVE ACTIONS o

i

~

RE-EVALUATING THERMAL SETPOINTS FOR 1

SELECTED VALVES t

d

,1

- 6 COMPLETE OCTOBER 19,,1990-i m

25

,-p q

t (Il,

L-

.4

.c j

)-

L' ENFORCEMENT CONFERENCE p"

ENGINEERING AND TRAINING-(CONT'D)

TRAINING l

p L

E 0

PROCEDURES IN PLACE FOR PLANT MODIFICATION REVIEWS

' u u ',

a.

'1' SIMULATOR j

REAL TIME : TRAINING I

u L

TRAINING CONTENT o

I :.

L t

4:

t G

0 REVIEW 0F DIRECT. REPLACEMENT MODIFICATIONS J.

IN PLACE SINCE MARCH,1989 1

i' J

O' INCIDENT 1 REPORTS ARE REVIEWED 1

p l;t I

M

{)

0 FULL SCOPE TRAINING PROGRAM UPGRADE'

~

INTEGRATED ACTION PLAN r

26 i

s s

J

ENFORCEMENT CONFERENCC L

ENGINEERING AND' TRAINING (CONT'D)

L.

0-TRAINING CORRECTIVE ACTIONS i

[>

i q

O IMMEDIATE AND SPECIFIC ITEMS FIXED-j 6-SIMULATOR FIDELITY AND TRAINING-4 3:

CONTENT i

4

r o

RCIC TRIP AND' THROTTLE VALVE 4

o.

SULCV ay

.i l4 {

REVIEW 0F. DIRECT REPLACEMENT i

i:

MODIFICATIONS ISSUED BEFORE: MARCH, 1989 1-I 6-

COMPLETE MARCHL1991 ua I

1_!..

'NOW AN: ACTIVE MEMBER'0F EACH SITE 1

INCIDENT INVESTIGATION TEAM o

t4 t,

p

[,

27

[

'kl

ENFORCEMENT CONFERENCE ENGINEERING AND TRAINING (CONT'D)

CONCLUSIONS 1

i 0-SPECIFIC CORRECTIVE ACTIONS IMPLEMENTED y

0 UPGRADE ACTIONS ARE:

KNOWN:

WELL UNDERSTOOD

~

BEING IMPLEMENTED

.t--

(

28

.I

4 ENFORCEMENT CONFERENCE

SUMMARY

L 0

CONCURRENT EQUIPMENT AND OPERATIONAL QUESTIONS AND ISSUES:.

EXTENSIVELY EVALUATED IMMEDIATE CORRECTIVE ACTIONS TAKEN CONTINUING IMPROVEMENTS DEFINED AND SCHEDULED 0

INITIATING EVENT - 5 WHYS f

.j 1)

WHY DID THIS EVENT--0CCUR?

a ESTABLISHE

D. PROCEDURE

S NOT-FOLLOWED a-1 SURVEILLANCE TEST' RECORD FALSIFIED 1

1o

-2)

WHY WERE PROCEDURES NOT FOLLOWEDI I

1' TECHNICIAN " NEGLIGENT" l

3)

WHY WERE SURVEILLANCE TEST RECORDS FALSIFIED?

{

TECHNICIANS KNEW PROCEDURE. NONCOMPLIANCE CONSEQUENCES

+

MISPi. ACED TRUST AND PERSONAL FRIENDSHIP l-j 29-j q

i.

w.. :

[ 4. w x.

ENFORCEMENT CONFERENCE L

L

SUMMARY

(CONT'D) 4)

WHY IS.THE EVENT'NOT THE RESULT OF A PROGRAM 4ATIC PROBLEM?

EVENT COULD NOT BE PREDICTED PERSONNEL BEHAVIOR WAS NOT REPRESENTATIVE

[

EVENT WAS NOT GENERl'C f

5)

WHY D0 WE' CONSIDER RESPONSE ADEQUAJE1

-SELF IDENTIFIED NO PUBLIC OR NUCLEAR SAFETY IMPACT PROMPTLYREPORT5D CORRECTIVE ACTIONS (INCLUDING MEASURES T0 t

PREVENT RECURRENCE) 4 ARE SELF-INITIATED-6 ARE-COMPREHENSIVE 6

HAVE OR-WILL BE IMPLEMENTED IN A i

REASONABLE TIME NO PREVIOUS-INDEPENDENT VERIFICATION-RELATED

. VIOLATION E

^

3

~

{

e n.

ACRONYMS AIT l AUGMENTED INSPECTION TEAM (NRC)

ANS AMERICAN NATIONAL STANDARD CO CONTROL CPERATOR.

DC DIRECT CURRENT

'HPCI HIGH PRESSURE COOLANT INJECTION I&C INSTRUMENTATION AND CONTROL i

LOR LICENSED OPERATOR REQUALIFICATION MSIV-MAIN STEAM ISOLATION VALVE MST MAINTENANCE SURVEILLANCE TEST e

NRC-

-NUCLEAR REGULATORY COMMISSION

'l PCIS.

PRIMARY CONTAINMENT ISOLATION SYSTEM

QA QUALITY ASSURANCE j.

QC QUALITY CONTROL-l RCIC REACTOR CORE ISOLATION COOLING

.I RPS.

REACTOR PROTECTION' SYSTEM j

RTGB' REACTOR' TURBINE, GAUGE BOARD RWCU REACTOR WATER CLEAN-UP 1

~i

. SF SHIFT FOREMAN

' S RV '

. SAFETY RELIEF VALVE

'. [l.

.STA-SHIFT' TECHNICAL ADVISOR SULCV START-UP LEVEL CONTROL VALVE i

'l 31 i :-

L.

. i(

.