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                                                                  UNITED STATES
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                                                NUCLEAR REOULATORY COMMISSION
. - _ _ . _ _
                              E                                     REGION 111
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!      U                     E                               801 WARRENVILLE ROAD
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                            ,#,                              USLE. ILUNOIS 60532-4351
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UNITED STATES
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NUCLEAR REOULATORY COMMISSION
E
REGION 111
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801 WARRENVILLE ROAD
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              .....
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                                                                June 9, 1997
USLE. ILUNOIS 60532-4351
.....
June 9, 1997
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L               [As 96-412, 97-001. 97-002, and 97-060
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l               Mr. John G. Cook
[As 96-412, 97-001. 97-002, and 97-060
!               Senior Vice President
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!             Illinois Power Company
Mr. John G. Cook
l               503 S. 27th Street
!
                Decatur. IL 62525
Senior Vice President
                SUEJECT:             NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES -
!
Illinois Power Company
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503 S. 27th Street
Decatur. IL 62525
SUEJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES -
i
i
                                    $450.000 (NRC Routine Inspection Report 50-461/96009(DRP). Special
$450.000 (NRC Routine Inspection Report 50-461/96009(DRP). Special
                                    Inspection Report 50-461/96010(DRP), Operational Safety Team
Inspection Report 50-461/96010(DRP), Operational Safety Team
                                  . Inspection Re) ort 50-461/96011(DRS). Inspection Report
. Inspection Re) ort 50-461/96011(DRS). Inspection Report
                                    50-461/96012()RS). Special Inspection Report 50-461/96014(DRP).
50-461/96012()RS). Special Inspection Report 50-461/96014(DRP).
                                    and Office of Investigations Report 3-96-047)
and Office of Investigations Report 3-96-047)
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                Dear Mr. Cook:
Dear Mr. Cook:
                This refers to five inspections conducted from July 30. 1996, through
This refers to five inspections conducted from July 30. 1996, through
                January 23, 1997. at the Clinton Power Station (CPS). The inspections
January 23, 1997. at the Clinton Power Station (CPS).
                included evaluations and assessments of the 1) September 5.1996. reactor
The inspections
                recirculation pt np seal failure. 2) operations and engineering activities
included evaluations and assessments of the 1) September 5.1996. reactor
!               supporting operations 3) Division III emergency diesel generator
recirculation pt np seal failure. 2) operations and engineering activities
                inoperability. 4) feedwater containment isolation check valves * inoperability,
!
                and 6) radiation protection program. A management meeting was held on
supporting operations 3) Division III emergency diesel generator
                September 23, 1996, to discuss Illinois Power Company's assessment of the
inoperability. 4) feedwater containment isolation check valves * inoperability,
                September 5,1996, reactor recirculation pump seal failure event, and a public
and 6) radiation protection program.
                exit neeting was held on October 4. 1996, to present the NRC's ins]ection
A management meeting was held on
                findir;gs. Exits for the other inspections were conducted on Novem)er 21.
September 23, 1996, to discuss Illinois Power Company's assessment of the
                1996.iDecember 12. 1996, and January 23, 1997.                           In addition, the NRC Office of
September 5,1996, reactor recirculation pump seal failure event, and a public
                Investigations conducted an investigation of the circumstances of the
exit neeting was held on October 4. 1996, to present the NRC's ins]ection
              September 5. 1996. event. Because of the seriousness of the issues emanating
findir;gs.
                from the insaections, predecisional enforcement conferences were conducted on                                     l
Exits for the other inspections were conducted on Novem)er 21.
                February 4. March 4. and March 20. 1997.
1996.iDecember 12. 1996, and January 23, 1997.
                Based on;the information developed during the inspections and the information                                     ;
In addition, the NRC Office of
,              CPS provided during the predecisional enforcement conferences, the NRC has                                         !
Investigations conducted an investigation of the circumstances of the
                determined that a number of significant violations of NRC requirements                                             j
September 5. 1996. event.
                occurred from September 5. 1996, through January 23, 1997. The violations                                         i
Because of the seriousness of the issues emanating
                demonstrate a lack of conservative decision-making. pervasive procedural                                         1
from the insaections, predecisional enforcement conferences were conducted on
    ,          adherence problems. inappropriate procedures, and a lack of rigor in
l
February 4. March 4. and March 20. 1997.
Based on;the information developed during the inspections and the information
;
CPS provided during the predecisional enforcement conferences, the NRC has
!
,
determined that a number of significant violations of NRC requirements
j
occurred from September 5. 1996, through January 23, 1997. The violations
i
demonstrate a lack of conservative decision-making. pervasive procedural
1
adherence problems. inappropriate procedures, and a lack of rigor in
,
.
conducting routine plant activities.
These violations have occurred
l
throughout various site organizations.
Enclosure 1 contains a Notice of
l
Violation and Proposed Imposition of Civil Penalties (Notice), that describes
the violations.
b
,
9706110241 970609
?
PDR
ADOCK 05000461
o
O
PDR
L
.
.
                conducting routine plant activities. These violations have occurred
,
l              throughout various site organizations. Enclosure 1 contains a Notice of
-
l              Violation and Proposed Imposition of Civil Penalties (Notice), that describes
                the violations.
                                                                                                                                  i
                                                                      b        ,
          9706110241 970609                    ?
          PDR      ADOCK 05000461              o
          O                            PDR    L
                                                .              ,  -


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      J. G. Cook                               -2-
J. G. Cook
                                                                                      l
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                                                                                      1
1
      The violations in the Notice are grouped in five sections as follows:
The violations in the Notice are grouped in five sections as follows:
                                                                                      ;
Section A of the Notice. " Reactor Recirculation Pump Seal Failure."
      *      Section A of the Notice. " Reactor Recirculation Pump Seal Failure."
*
            describes two significant procedure violations during an activity
describes two significant procedure violations during an activity
            undertaken on September 5.1996, to allow continued plant operaticn of
undertaken on September 5.1996, to allow continued plant operaticn of
            isolating the "B" reactor coolant loop, thereby stopping. or limi:ing.
isolating the "B" reactor coolant loop, thereby stopping. or limi:ing.
            the suspected leaking pump shaft seal package.   The procedural
the suspected leaking pump shaft seal package.
            violations directly resulted in reactor coolant leakage considera0y
The procedural
            exceeding the allowed Technical Specification Limit and requiring a
violations directly resulted in reactor coolant leakage considera0y
            plant shutdown.   CPS site supervision and management inappropriately   )
exceeding the allowed Technical Specification Limit and requiring a
            emphasized attaining a single loop configuration to allow continus:     l
plant shutdown.
            power operation. This resulted in a focus to operate the plant ra:ner   ;
CPS site supervision and management inappropriately
            than the more conservative decision to shut down the unit. The
)
            deliberate actions of members of the shift crew on September 5.196.
emphasized attaining a single loop configuration to allow continus:
            resulted in very significant violations. Based on a review of the
power operation.
            evidence obtained from the Office of Investigations. NRC inspecticts.
This resulted in a focus to operate the plant ra:ner
            and enforcement conferences. CPS's actions demonstrated careless
than the more conservative decision to shut down the unit. The
            disregard for procedural requirements.
deliberate actions of members of the shift crew on September 5.196.
      .      Section B of the Notice. " Failure to Follow Procedures." involves
resulted in very significant violations.
            seventeen violations involving operations and radiation protectior
Based on a review of the
            procedures which collectively demonstrates a breakdown in the con:-ci f
evidence obtained from the Office of Investigations. NRC inspecticts.
            activities involving the adherence to procedures. The violations
and enforcement conferences. CPS's actions demonstrated careless
            demonstrated that CPS had established an environment that condonec
disregard for procedural requirements.
            procedure compliance through accomplishment of the user's interpre:ati:-
Section B of the Notice. " Failure to Follow Procedures." involves
            of the procedures * intent without regard for the actual procedurai
.
            steps.
seventeen violations involving operations and radiation protectior
      .      Section C of the Notice. " Inoperable Emergency Diesel Generator "
procedures which collectively demonstrates a breakdown in the con:-ci f
            involves two violations associated with the Division III Emergent,
activities involving the adherence to procedures. The violations
            Diesel Generator (EDG). The licensee failed to maintain design cce:rc~
demonstrated that CPS had established an environment that condonec
            with this EDG and failed to identify and correct a condition adverse ::
procedure compliance through accomplishment of the user's interpre:ati:-
            quality. As a result the EDG was inoperable for more than a year
of the procedures * intent without regard for the actual procedurai
      .      Section D of the Notice. " Failure to Perform Safety Evaluations."
steps.
            involves seven violations for a failure to perform safety evaluat":ns
Section C of the Notice. " Inoperable Emergency Diesel Generator "
            required by 10 CFR 50.59. Safety evaluations were not perforred :
.
            justify operating the plant differently than described in the updi:ec
involves two violations associated with the Division III Emergent,
            safety analysis report (USAR): to justify the acceptability of
Diesel Generator (EDG). The licensee failed to maintain design cce:rc~
            performing tests on operable equipment; or to justify continued
with this EDG and failed to identify and correct a condition adverse ::
            operation when as-found plant conditions were different than the LA
quality. As a result the EDG was inoperable for more than a year
            description. The examples represented a significant lack of atter:ior
Section D of the Notice. " Failure to Perform Safety Evaluations."
            toward the process for performing 10 CFR 50.59 evaluations.
.
      .      Section E of the Notice. " Ineffective Corrective Actions to Resche
involves seven violations for a failure to perform safety evaluat":ns
            Inoperable Containment Penetrations." involves two violations for
required by 10 CFR 50.59.
            inoperable feedwater primary containment isolation valves caused t
Safety evaluations were not perforred :
            inadequate corrective action for a longstanding equipment problem an:: e
justify operating the plant differently than described in the updi:ec
            failure to perform adequate testing to assure Technical Specifica: en
safety analysis report (USAR): to justify the acceptability of
            surveillance requirements were met. This resulted in the serious
performing tests on operable equipment; or to justify continued
            degradation of two containment penetrations such that they ma,. no: w e
operation when as-found plant conditions were different than the LA
            been able to function when required.
description.
The examples represented a significant lack of atter:ior
toward the process for performing 10 CFR 50.59 evaluations.
Section E of the Notice. " Ineffective Corrective Actions to Resche
.
Inoperable Containment Penetrations." involves two violations for
inoperable feedwater primary containment isolation valves caused t
inadequate corrective action for a longstanding equipment problem an:: e
failure to perform adequate testing to assure Technical Specifica: en
surveillance requirements were met.
This resulted in the serious
degradation of two containment penetrations such that they ma,. no: w e
been able to function when required.


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    J. G. Cook                                   -3-
J. G. Cook
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Individually and collectively, the violations are serious. These violations
Individually and collectively, the violations are serious.
    included a pervasive problem regarding procedural quality and adherence which
These violations
    you acknowledged during the predecisional enforcement conference, weaknesses
included a pervasive problem regarding procedural quality and adherence which
    in the conduct of operations. and weaknesses in engineering support to
you acknowledged during the predecisional enforcement conference, weaknesses
    operations. CPS management failed to ensure that its economic expectations
in the conduct of operations. and weaknesses in engineering support to
    had been put in proper focus with safe.. conservative facility operation. In
operations.
    the aggregate, given the depth and breadth of the violations, it is evident
CPS management failed to ensure that its economic expectations
    that existing management control systems were not used effectively to ensure
had been put in proper focus with safe.. conservative facility operation.
    early detection and timely resolution of conditions adverse to safe )lant
In
    operation. For example, a number of procedures, written to ensure tlat
the aggregate, given the depth and breadth of the violations, it is evident
    systems were operated and tested consistent with the facility's design bases,
that existing management control systems were not used effectively to ensure
    were inappropriately changed or not followed. Site-wide procedures were
early detection and timely resolution of conditions adverse to safe )lant
    usually looked upon as guidance rather than as requirements to be followed.
operation.
    Tests were performed on operating systems without procedures and without
For example, a number of procedures, written to ensure tlat
    required reviews to ensure that unreviewed safety questions did not exist.
systems were operated and tested consistent with the facility's design bases,
    Beyond the operations oriented-violations, significant deficiencies existed in
were inappropriately changed or not followed.
    the engineering 3rogram with regards to safety evaluations and operability
Site-wide procedures were
    essessments. Otler inspection activities identified a significant issue
usually looked upon as guidance rather than as requirements to be followed.
    involving the Division III EDG being inoperable for almost a year due to an
Tests were performed on operating systems without procedures and without
    inadequate calibration procedure. In addition. the feedwater outboard
required reviews to ensure that unreviewed safety questions did not exist.
    containment isolation valves' ability to fully perform their intended safety
Beyond the operations oriented-violations, significant deficiencies existed in
    function was not determined over the past operating cycle due to inadequate
the engineering 3rogram with regards to safety evaluations and operability
    test configurations. Lastly, several radiation protection violations were
essessments.
    caused by procedure compliance problems which were similar to those identified
Otler inspection activities identified a significant issue
    in operations and erigineering. These violations occurred well after the
involving the Division III EDG being inoperable for almost a year due to an
    September 5.1996, reactor recirculation pump seal failure event indicating
inadequate calibration procedure.
    CPS was having difficulty implementing effective corrective actions for
In addition. the feedwater outboard
    procedure compliance problems. In that regard, it is of particular concern
containment isolation valves' ability to fully perform their intended safety
    that the corrective actions discussed at the March 20. 1997, predecisional
function was not determined over the past operating cycle due to inadequate
    radiation protection enforcement conference were narrowly focused on the
test configurations.
    individual items. Your staff failed to discuss the issues as an integrated
Lastly, several radiation protection violations were
    theme from a radiation protection perspective and as they related to the           '
caused by procedure compliance problems which were similar to those identified
    broader procedure compliance problems discussed at the two previous
in operations and erigineering.
    enforcement conferences. This indicated that CPS was not looking at the
These violations occurred well after the
    identified problems in an integrated fashion.
September 5.1996, reactor recirculation pump seal failure event indicating
    In summary, the inspection findings demonstrated 1) a lack of conservative
CPS was having difficulty implementing effective corrective actions for
    decision-making. 2) pervasive procedural adherence problems as indicated by
procedure compliance problems.
    individuals believing it was acceptable to not follow existing procedures in
In that regard, it is of particular concern
    order to accomplish work activities. and 3) poor-quality procedures.
that the corrective actions discussed at the March 20. 1997, predecisional
    Extensive NRC intervention was recuired to ensure CPS recognized and
radiation protection enforcement conference were narrowly focused on the
    understood the problems' scope anc magnitude. This included management's lack
individual items.
    of recognition of its failure to make the conservative decision to shut down
Your staff failed to discuss the issues as an integrated
    the unit on September 5.1996, and CPS's lack of understanding of the
theme from a radiation protection perspective and as they related to the
    associated procedure violations.
'
    Due to the safety significance of the violations discussed above. their
broader procedure compliance problems discussed at the two previous
    relationship to operational safety. and in accordance with the NRC Enforcement
enforcement conferences.
    policy. NUREG-1600. the violations in Section A of the Notice have been
This indicated that CPS was not looking at the
    categorized in the aggregate as a Severity Level II problem. The violations
identified problems in an integrated fashion.
    in Sections B - E have each been categorized as Severity Level III problems.
In summary, the inspection findings demonstrated 1) a lack of conservative
decision-making. 2) pervasive procedural adherence problems as indicated by
individuals believing it was acceptable to not follow existing procedures in
order to accomplish work activities. and 3) poor-quality procedures.
Extensive NRC intervention was recuired to ensure CPS recognized and
understood the problems' scope anc magnitude.
This included management's lack
of recognition of its failure to make the conservative decision to shut down
the unit on September 5.1996, and CPS's lack of understanding of the
associated procedure violations.
Due to the safety significance of the violations discussed above. their
relationship to operational safety. and in accordance with the NRC Enforcement
policy. NUREG-1600. the violations in Section A of the Notice have been
categorized in the aggregate as a Severity Level II problem.
The violations
in Sections B - E have each been categorized as Severity Level III problems.


  ,
,
    J. G. Cook                               -4-
J. G. Cook
    Significant civil penalties are warranted to emphasize to you and to other
-4-
    reactor licensees the importance of strong management oversight and direction
Significant civil penalties are warranted to emphasize to you and to other
    from both the site and utility in maintaining a clear focus on operational
reactor licensees the importance of strong management oversight and direction
    safety; the need for plant personnel to challenge and investigate
from both the site and utility in maintaining a clear focus on operational
    discrepancies; the need to adequately plan safety-significant activities: the
safety; the need for plant personnel to challenge and investigate
    need to take timely and effective corrective actions: and the need for a
discrepancies; the need to adequately plan safety-significant activities: the
    strong self-assessment program. Enforcement discretion is being exercised as
need to take timely and effective corrective actions: and the need for a
    provided by Section VII.A. of the Enforcement Policy to assess civil penalties l
strong self-assessment program.
    of $200.000. (the maximum statutory amount) for the violations in Section A of l
Enforcement discretion is being exercised as
    the Notice. and civil penalties of $100.000 for the violations in Section B.   i
provided by Section VII.A. of the Enforcement Policy to assess civil penalties
    In accordance with Section VI.B.2 of the Policy, civil penalties of $50.000     l
of $200.000. (the maximum statutory amount) for the violations in Section A of
    for the violations in each of Sections C - E are being assessed. The           '
the Notice. and civil penalties of $100.000 for the violations in Section B.
    assessments are more fully described in Enclosure 2.
i
    Accordingly. I have been authorized after consultation with the Director.       l
In accordance with Section VI.B.2 of the Policy, civil penalties of $50.000
    Office of Enforcement, and the Deputy Executive Director for Regulatory
for the violations in each of Sections C - E are being assessed.
    Effectiveness, to issue the enclosed Notice of Violation and Proposed           l
The
    Imposition of Civil Penalty in the amount of $450.000. But for the extended     l
'
    shutdown of CPS and the substantial corrective actions taken during this
assessments are more fully described in Enclosure 2.
    shutdown period to improve performance, a larger civil penalty would have been
Accordingly. I have been authorized after consultation with the Director.
    proposed.
Office of Enforcement, and the Deputy Executive Director for Regulatory
    You are required to respond to this letter and should follow the instructions
Effectiveness, to issue the enclosed Notice of Violation and Proposed
    specified in the enclosed Notice when preparing your response. In your
Imposition of Civil Penalty in the amount of $450.000.
    response, you should document the specific actions taken and any additional
But for the extended
    actions you plan to prevent recurrence. After reviewing your response to this
l
    Notice, including your proposed corrective actions and the results of future
shutdown of CPS and the substantial corrective actions taken during this
    inspections, the NRC will determine whether further NRC enforcement action is
shutdown period to improve performance, a larger civil penalty would have been
    necessary to ensure compliance with NRC regulatory requirements.     I further
proposed.
    note that my staff continues to review activities at CPS, and further
You are required to respond to this letter and should follow the instructions
    enforcement actions may be taken if additional violations are identified.
specified in the enclosed Notice when preparing your response.
    In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice." a copy of
In your
    this letter, its enclosure (s). and your response will be placed in the NRC
response, you should document the specific actions taken and any additional
    Public Document Room (PDR).
actions you plan to prevent recurrence. After reviewing your response to this
                                            Sincerely.
Notice, including your proposed corrective actions and the results of future
                                                      uv. O
inspections, the NRC will determine whether further NRC enforcement action is
                                            /A. Bill Beach
necessary to ensure compliance with NRC regulatory requirements.
                                            Regional Administrator
I further
      c   e o.
note that my staff continues to review activities at CPS, and further
    Enclosures:     1. Notice of Violation and Proposed
enforcement actions may be taken if additional violations are identified.
                          Imposition of Civil Penalties
In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice." a copy of
                    2. Civil Penalty Assessment
this letter, its enclosure (s). and your response will be placed in the NRC
Public Document Room (PDR).
Sincerely.
uv. O
/A. Bill Beach
Regional Administrator
c
e
o.
Enclosures:
1.
Notice of Violation and Proposed
Imposition of Civil Penalties
2.
Civil Penalty Assessment
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      ,
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        J. G. Cook                                       -5
J. G. Cook
        cc w/encls: W. D. Romberg, Assittant
-5
                      Vice President
cc w/encls:
                    P. Yocum. Plant Manager
W. D. Romberg, Assittant
                      Clinton Power Station
Vice President
                    R. Phares. Manager-Nuclear Assessment
P. Yocum. Plant Manager
                    J. Sipek Director - Licensing
Clinton Power Station
                    Nathan Schloss, Economist
R. Phares. Manager-Nuclear Assessment
                      Office of the Attorney General
J. Sipek Director - Licensing
                    G. Stramback. Regulatory Licensing
Nathan Schloss, Economist
                      Services Project Manager
Office of the Attorney General
                    General Electric Company
G. Stramback. Regulatory Licensing
                    Chairnan. DeWitt County Board
Services Project Manager
                    State Liaison Officer
General Electric Company
                    Chairman. Illinois Commerce Commission
Chairnan. DeWitt County Board
                                                            :
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                                                            l
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        L. Chandler. OGC
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        J. Cn.'dberg. OGC
J. Lieberman. OE
        S. Collins. NRR
L. Chandler. OGC
        R. Zimmerman. NRR
J. Cn.'dberg. OGC
        Enforcement Coordinators
S. Collins. NRR
          RI. Ril and RIV
R. Zimmerman. NRR
        SRI-Clinton. Dresden. LaSalle,
Enforcement Coordinators
          and Quad Cities
RI. Ril and RIV
        T. Pruett. RIV
SRI-Clinton. Dresden. LaSalle,
        G. Marcus. NRR
and Quad Cities
        D. Pickett, NRR
T. Pruett. RIV
        J. Gilliland OPA
G. Marcus. NRR
        H. Bell. OIG
D. Pickett, NRR
        G. Caputo. 01
J. Gilliland OPA
        L. Tremper. OC
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        D. Ross. AE00
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Latest revision as of 18:00, 24 May 2025

Discusses Insp Repts 50-461/96-09,50-461/96-10,50-461/96-11, 50-461/96-12 & 50-461/96-14 on 960730-970123 & Forwards NOV & Proposed Imposition of Civil Penalty in Amount of $450,000
ML20148H819
Person / Time
Site: Clinton 
Issue date: 06/09/1997
From: Beach A
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To: Jackie Cook
ILLINOIS POWER CO.
Shared Package
ML20148H822 List:
References
50-461-96-09, 50-461-96-10, 50-461-96-11, 50-461-96-12, 50-461-96-14, 50-461-96-9, EA-96-412, EA-97-001, EA-97-002, EA-97-060, EA-97-1, EA-97-2, EA-97-60, NUDOCS 9706110241
Download: ML20148H819 (6)


See also: IR 05000461/1996009

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UNITED STATES

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NUCLEAR REOULATORY COMMISSION

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REGION 111

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801 WARRENVILLE ROAD

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USLE. ILUNOIS 60532-4351

.....

June 9, 1997

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[As96-412, 97-001.97-002, and 97-060

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Mr. John G. Cook

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Senior Vice President

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Illinois Power Company

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503 S. 27th Street

Decatur. IL 62525

SUEJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES -

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$450.000 (NRC Routine Inspection Report 50-461/96009(DRP). Special

Inspection Report 50-461/96010(DRP), Operational Safety Team

. Inspection Re) ort 50-461/96011(DRS). Inspection Report

50-461/96012()RS). Special Inspection Report 50-461/96014(DRP).

and Office of Investigations Report 3-96-047)

l

Dear Mr. Cook:

This refers to five inspections conducted from July 30. 1996, through

January 23, 1997. at the Clinton Power Station (CPS).

The inspections

included evaluations and assessments of the 1) September 5.1996. reactor

recirculation pt np seal failure. 2) operations and engineering activities

!

supporting operations 3) Division III emergency diesel generator

inoperability. 4) feedwater containment isolation check valves * inoperability,

and 6) radiation protection program.

A management meeting was held on

September 23, 1996, to discuss Illinois Power Company's assessment of the

September 5,1996, reactor recirculation pump seal failure event, and a public

exit neeting was held on October 4. 1996, to present the NRC's ins]ection

findir;gs.

Exits for the other inspections were conducted on Novem)er 21.

1996.iDecember 12. 1996, and January 23, 1997.

In addition, the NRC Office of

Investigations conducted an investigation of the circumstances of the

September 5. 1996. event.

Because of the seriousness of the issues emanating

from the insaections, predecisional enforcement conferences were conducted on

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February 4. March 4. and March 20. 1997.

Based on;the information developed during the inspections and the information

CPS provided during the predecisional enforcement conferences, the NRC has

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determined that a number of significant violations of NRC requirements

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occurred from September 5. 1996, through January 23, 1997. The violations

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demonstrate a lack of conservative decision-making. pervasive procedural

1

adherence problems. inappropriate procedures, and a lack of rigor in

,

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conducting routine plant activities.

These violations have occurred

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throughout various site organizations.

Enclosure 1 contains a Notice of

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Violation and Proposed Imposition of Civil Penalties (Notice), that describes

the violations.

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9706110241 970609

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PDR

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J. G. Cook

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1

The violations in the Notice are grouped in five sections as follows:

Section A of the Notice. " Reactor Recirculation Pump Seal Failure."

describes two significant procedure violations during an activity

undertaken on September 5.1996, to allow continued plant operaticn of

isolating the "B" reactor coolant loop, thereby stopping. or limi:ing.

the suspected leaking pump shaft seal package.

The procedural

violations directly resulted in reactor coolant leakage considera0y

exceeding the allowed Technical Specification Limit and requiring a

plant shutdown.

CPS site supervision and management inappropriately

)

emphasized attaining a single loop configuration to allow continus:

power operation.

This resulted in a focus to operate the plant ra:ner

than the more conservative decision to shut down the unit. The

deliberate actions of members of the shift crew on September 5.196.

resulted in very significant violations.

Based on a review of the

evidence obtained from the Office of Investigations. NRC inspecticts.

and enforcement conferences. CPS's actions demonstrated careless

disregard for procedural requirements.

Section B of the Notice. " Failure to Follow Procedures." involves

.

seventeen violations involving operations and radiation protectior

procedures which collectively demonstrates a breakdown in the con:-ci f

activities involving the adherence to procedures. The violations

demonstrated that CPS had established an environment that condonec

procedure compliance through accomplishment of the user's interpre:ati:-

of the procedures * intent without regard for the actual procedurai

steps.

Section C of the Notice. " Inoperable Emergency Diesel Generator "

.

involves two violations associated with the Division III Emergent,

Diesel Generator (EDG). The licensee failed to maintain design cce:rc~

with this EDG and failed to identify and correct a condition adverse ::

quality. As a result the EDG was inoperable for more than a year

Section D of the Notice. " Failure to Perform Safety Evaluations."

.

involves seven violations for a failure to perform safety evaluat":ns

required by 10 CFR 50.59.

Safety evaluations were not perforred :

justify operating the plant differently than described in the updi:ec

safety analysis report (USAR): to justify the acceptability of

performing tests on operable equipment; or to justify continued

operation when as-found plant conditions were different than the LA

description.

The examples represented a significant lack of atter:ior

toward the process for performing 10 CFR 50.59 evaluations.

Section E of the Notice. " Ineffective Corrective Actions to Resche

.

Inoperable Containment Penetrations." involves two violations for

inoperable feedwater primary containment isolation valves caused t

inadequate corrective action for a longstanding equipment problem an:: e

failure to perform adequate testing to assure Technical Specifica: en

surveillance requirements were met.

This resulted in the serious

degradation of two containment penetrations such that they ma,. no: w e

been able to function when required.

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J. G. Cook

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Individually and collectively, the violations are serious.

These violations

included a pervasive problem regarding procedural quality and adherence which

you acknowledged during the predecisional enforcement conference, weaknesses

in the conduct of operations. and weaknesses in engineering support to

operations.

CPS management failed to ensure that its economic expectations

had been put in proper focus with safe.. conservative facility operation.

In

the aggregate, given the depth and breadth of the violations, it is evident

that existing management control systems were not used effectively to ensure

early detection and timely resolution of conditions adverse to safe )lant

operation.

For example, a number of procedures, written to ensure tlat

systems were operated and tested consistent with the facility's design bases,

were inappropriately changed or not followed.

Site-wide procedures were

usually looked upon as guidance rather than as requirements to be followed.

Tests were performed on operating systems without procedures and without

required reviews to ensure that unreviewed safety questions did not exist.

Beyond the operations oriented-violations, significant deficiencies existed in

the engineering 3rogram with regards to safety evaluations and operability

essessments.

Otler inspection activities identified a significant issue

involving the Division III EDG being inoperable for almost a year due to an

inadequate calibration procedure.

In addition. the feedwater outboard

containment isolation valves' ability to fully perform their intended safety

function was not determined over the past operating cycle due to inadequate

test configurations.

Lastly, several radiation protection violations were

caused by procedure compliance problems which were similar to those identified

in operations and erigineering.

These violations occurred well after the

September 5.1996, reactor recirculation pump seal failure event indicating

CPS was having difficulty implementing effective corrective actions for

procedure compliance problems.

In that regard, it is of particular concern

that the corrective actions discussed at the March 20. 1997, predecisional

radiation protection enforcement conference were narrowly focused on the

individual items.

Your staff failed to discuss the issues as an integrated

theme from a radiation protection perspective and as they related to the

'

broader procedure compliance problems discussed at the two previous

enforcement conferences.

This indicated that CPS was not looking at the

identified problems in an integrated fashion.

In summary, the inspection findings demonstrated 1) a lack of conservative

decision-making. 2) pervasive procedural adherence problems as indicated by

individuals believing it was acceptable to not follow existing procedures in

order to accomplish work activities. and 3) poor-quality procedures.

Extensive NRC intervention was recuired to ensure CPS recognized and

understood the problems' scope anc magnitude.

This included management's lack

of recognition of its failure to make the conservative decision to shut down

the unit on September 5.1996, and CPS's lack of understanding of the

associated procedure violations.

Due to the safety significance of the violations discussed above. their

relationship to operational safety. and in accordance with the NRC Enforcement

policy. NUREG-1600. the violations in Section A of the Notice have been

categorized in the aggregate as a Severity Level II problem.

The violations

in Sections B - E have each been categorized as Severity Level III problems.

,

J. G. Cook

-4-

Significant civil penalties are warranted to emphasize to you and to other

reactor licensees the importance of strong management oversight and direction

from both the site and utility in maintaining a clear focus on operational

safety; the need for plant personnel to challenge and investigate

discrepancies; the need to adequately plan safety-significant activities: the

need to take timely and effective corrective actions: and the need for a

strong self-assessment program.

Enforcement discretion is being exercised as

provided by Section VII.A. of the Enforcement Policy to assess civil penalties

of $200.000. (the maximum statutory amount) for the violations in Section A of

the Notice. and civil penalties of $100.000 for the violations in Section B.

i

In accordance with Section VI.B.2 of the Policy, civil penalties of $50.000

for the violations in each of Sections C - E are being assessed.

The

'

assessments are more fully described in Enclosure 2.

Accordingly. I have been authorized after consultation with the Director.

Office of Enforcement, and the Deputy Executive Director for Regulatory

Effectiveness, to issue the enclosed Notice of Violation and Proposed

Imposition of Civil Penalty in the amount of $450.000.

But for the extended

l

shutdown of CPS and the substantial corrective actions taken during this

shutdown period to improve performance, a larger civil penalty would have been

proposed.

You are required to respond to this letter and should follow the instructions

specified in the enclosed Notice when preparing your response.

In your

response, you should document the specific actions taken and any additional

actions you plan to prevent recurrence. After reviewing your response to this

Notice, including your proposed corrective actions and the results of future

inspections, the NRC will determine whether further NRC enforcement action is

necessary to ensure compliance with NRC regulatory requirements.

I further

note that my staff continues to review activities at CPS, and further

enforcement actions may be taken if additional violations are identified.

In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice." a copy of

this letter, its enclosure (s). and your response will be placed in the NRC

Public Document Room (PDR).

Sincerely.

uv. O

/A. Bill Beach

Regional Administrator

c

e

o.

Enclosures:

1.

Notice of Violation and Proposed

Imposition of Civil Penalties

2.

Civil Penalty Assessment

i

i

,

.

J. G. Cook

-5

cc w/encls:

W. D. Romberg, Assittant

Vice President

P. Yocum. Plant Manager

Clinton Power Station

R. Phares. Manager-Nuclear Assessment

J. Sipek Director - Licensing

Nathan Schloss, Economist

Office of the Attorney General

G. Stramback. Regulatory Licensing

Services Project Manager

General Electric Company

Chairnan. DeWitt County Board

State Liaison Officer

Chairman. Illinois Commerce Commission

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h

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PUBLIC JE 4f

SECY

CA

L. Callan. EDO

E. Jordan. DEDO

J. Lieberman. OE

L. Chandler. OGC

J. Cn.'dberg. OGC

S. Collins. NRR

R. Zimmerman. NRR

Enforcement Coordinators

RI. Ril and RIV

SRI-Clinton. Dresden. LaSalle,

and Quad Cities

T. Pruett. RIV

G. Marcus. NRR

D. Pickett, NRR

J. Gilliland OPA

H. Bell. OIG

G. Caputo. 01

L. Tremper. OC

D. Ross. AE00

OE:ES

OE:EA (2)

G. Johnson. OC/DAF

RAO: Rill

SLO:RIII

PAO: Rill

OC/LFDCB

DRP

Docket File

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