ML17261A969: Difference between revisions

From kanterella
Jump to navigation Jump to search
(Created page by program invented by StriderTol)
(Created page by program invented by StriderTol)
Line 17: Line 17:


=Text=
=Text=
{{#Wiki_filter:AO;ELERATEDDISHUBUTIONDEMONSHWTIONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ESSIONNBR:9003020138DOC.DATE:90/02/23NOTARIZED:NODOCKETACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterG05000244AUTH.NAME.AUTHORAFFILIATIONMECREDY,R.C.RochesterGas&ElectricCorp.RECIP.NAMERECIPIENTAFFILIATIONRUSSELL,W.T.Region1,OfcoftheDirectorSUBJECT:RespondstoviolationsnotedinInspRept50-244/89-16.DISTRIBUTIONCODEIE01DCOPIESRECEIVED:LTRENCLSIZE:TITLE:General(50Dkt)-InspRept/NoticeofVqoIationResponseNOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).E'05000244'/RECIPIENTIDCODE/NAMEPD1-3PDINTERNAL:AEODAEOD/TPADNRRSHANKMAN,SNRR/DOEADIR11NRR/DREP/PRPB11NRR/DST/DIR8E2NUDOCS-ABSTRACTOGC/HDS2RESMORISSEAU,DRNAL:LPDRNSICCOPIESLTTRENCL11111111112.2111111111111RECIPIENTIDCODE/NAMEJOHNSON,AAEOD/DEIIBDEDRONRR/DLPQ/LPEB10NRR/DREP/PEPB9DNRR/DRIS/DIRNRR/PMAS/ILRB120N,JRGN1FILE01NRCPDRCOPIESLTTRENCL11D1111,D1111S111111111111R-DANOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTETHCONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTIONLISISFORDOCUMENTSYOUDON'TNEEDlTALNUMBEROFCOPIESREQUIRED:LTTR24ENCL24D  
{{#Wiki_filter:AO;ELERATED
DISHUBUTION
DEMONSHWTION
SYSTEMREGULATORY
INFORMATION
DISTRIBUTION
SYSTEM(RIDS)ESSIONNBR:9003020138
DOC.DATE:
90/02/23NOTARIZED:
NODOCKETACIL:50-244
RobertEmmetGinnaNuclearPlant,Unit1,Rochester
G05000244AUTH.NAME.AUTHORAFFILIATION
MECREDY,R.C.
Rochester
Gas&ElectricCorp.RECIP.NAME
RECIPIENT
AFFILIATION
RUSSELL,W.T.
Region1,OfcoftheDirectorSUBJECT:Respondstoviolations
notedinInspRept50-244/89-16.
DISTRIBUTION
CODEIE01DCOPIESRECEIVED:LTR
ENCLSIZE:TITLE:General(50Dkt)-Insp
Rept/Notice
ofVqoIation
ResponseNOTES:License
Expdateinaccordance
with10CFR2,2.109(9/19/72).
E'05000244
'/RECIPIENT
IDCODE/NAME
PD1-3PDINTERNAL:
AEODAEOD/TPAD
NRRSHANKMAN,
SNRR/DOEADIR11NRR/DREP/PRPB11
NRR/DST/DIR
8E2NUDOCS-ABSTRACT
OGC/HDS2RESMORISSEAU,D
RNAL:LPDRNSICCOPIESLTTRENCL11111111112.2111111111111RECIPIENT
IDCODE/NAME
JOHNSON,A
AEOD/DEIIB
DEDRONRR/DLPQ/LPEB10
NRR/DREP/PEPB9
DNRR/DRIS/DIR
NRR/PMAS/ILRB12
0N,JRGN1FILE01NRCPDRCOPIESLTTRENCL11D1111,D1111S111111111111R-DANOTETOALL"RIDS"RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTETHCONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTION
LISISFORDOCUMENTS
YOUDON'TNEEDlTALNUMBEROFCOPIESREQUIRED:
LTTR24ENCL24D  
   
   
I!I",<Ilail!~II,".Ilf/I/gpiK;',"lROCHESTERGASANDELECTRICCORPORATION~89EASTAVENUE,P5cwp.~0\1~*KI,%0%l555A55ROCHESTER,N.Y.14649-0001February23,1990TC5.EPHONCA@CACODEVI55546-2700Mr.WilliamT.RussellRegionalAdministratorU.S.NuclearRegulatoryCommissionRegionI475AllendaleRoadKingofPrussia,PA19406Subject:ResponsetoInspectionReport50-244/89-16NoticeofViolationR.E.GinnaNuclearPowerPlantDocketNo.50-244DearMr.Russell:TheenclosedresponsetotheNoticeofViolationcontainsourresponsetoViolation89-16-01fromtheinspectionattheR.E.GinnaNuclearPowerPlantfromNovember7throughDecember11,1989.TheattachedresponseincludesHumanPerformanceEvaluationSystem(HPES)investigationinformationandourcorrectiveactions.Ourlong-termcorrectiveactionshavebeendeterminedtoaddresstherepetitivenatureoftheseconcerns,andtheneedforincreasedmanagementattention.Verytrulyyours,RobertC.MecredyDivisionManagerNuclearProductionxc:U.S.NuclearRegulatoryCommissionDocumentControlDeskWashington,DC20555GinnaNRCSeniorResidentInspector5'003020'qPDRA'i'OC.I;0.000:44C~PDC(original)~zpv(I'I  
I!I",<Ilail!~II,".Ilf
/I/gpiK;',"l
ROCHESTER
GASANDELECTRICCORPORATION
~89EASTAVENUE,P5cwp.~0\1~*KI,%0%l555A55ROCHESTER,
N.Y.14649-0001
February23,1990TC5.EPHONCA@CACODEVI55546-2700Mr.WilliamT.RussellRegionalAdministrator
U.S.NuclearRegulatory
Commission
RegionI475Allendale
RoadKingofPrussia,PA19406Subject:ResponsetoInspection
Report50-244/89-16
NoticeofViolation
R.E.GinnaNuclearPowerPlantDocketNo.50-244DearMr.Russell:TheenclosedresponsetotheNoticeofViolation
containsourresponsetoViolation
89-16-01fromtheinspection
attheR.E.GinnaNuclearPowerPlantfromNovember7throughDecember11,1989.TheattachedresponseincludesHumanPerformance
Evaluation
System(HPES)investigation
information
andourcorrective
actions.Ourlong-term
corrective
actionshavebeendetermined
toaddresstherepetitive
natureoftheseconcerns,
andtheneedforincreased
management
attention.
Verytrulyyours,RobertC.MecredyDivisionManagerNuclearProduction
xc:U.S.NuclearRegulatory
Commission
DocumentControlDeskWashington,
DC20555GinnaNRCSeniorResidentInspector
5'003020'q
PDRA'i'OC.I;
0.000:44C~PDC(original)
~zpv(I'I  
I  
I  
RESPONSETONRCINSPECTIONREPORT50-244/89-16RoutineInspectionReport50-244/89-16,AppendixA,statedinpart:"DuringaninspectionattheR.E.GinnaNuclearPowerPlantfromNovember7throughDecember11,1989,thefollowingviolationwasidentifiedinaccordancewiththeNRCEnforcementPolicy(10CFR2,AppendixC).TechnicalSpecification6.8.1requiresinpartthatwrittenproceduresshallbe'established,implemented,and-maintained.coveringactivitiesreferencedinAppendixAofRegulatoryGuide1.33,November1972.Activitiesreferenced'nAppendixAincludemaintenanceandequipmentcontrol.CalibrationProcedure(CP)-410A,Calibrationand/orMain-'tenanceofSaturationTemperatureMonitorSystem"B"Loop,requiresrestorationofthetestswitchtotheoriginalposition.Inaddition,AdministrativeProcedure(A)-1408,.IndependentVerification,andProcedureA-52.4,ControlofLimitingConditionsForOperatingEquipment,requirein-dependentverification,byobservationofproperindicationorresponse,followingalignmentandrestorationofequipmentrequiredbytechnicalspecifications.Contrarytotheabove,onNovember17,1989,followingmaintenanceonthe'B'oopsaturationtemperaturemonitorrequiredbyTS3.5.3usingCP-410A,thetestswitchwasnotrestored.totheoriginalpositionanddidnotreceiveindependentverificationofinstrumentresponseorswitchposition."RochesterGasandElectricconcurswiththeaboveviolationasdescribed.  
RESPONSETONRCINSPECTION
REPORT50-244/89-16
RoutineInspection
Report50-244/89-16,
AppendixA,statedinpart:"Duringaninspection
attheR.E.GinnaNuclearPowerPlantfromNovember7throughDecember11,1989,thefollowing
violation
wasidentified
inaccordance
withtheNRCEnforcement
Policy(10CFR2,AppendixC).Technical
Specification
6.8.1requiresinpartthatwrittenprocedures
shallbe'established,
implemented,
and-maintained
.coveringactivities
referenced
inAppendixAofRegulatory
Guide1.33,November1972.Activities
referenced'n
AppendixAincludemaintenance
andequipment
control.Calibration
Procedure
(CP)-410A,
Calibration
and/orMain-'tenanceofSaturation
Temperature
MonitorSystem"B"Loop,requiresrestoration
ofthetestswitchtotheoriginalposition.
Inaddition,
Administrative
Procedure
(A)-1408,.
Independent
Verification,
andProcedure
A-52.4,ControlofLimitingConditions
ForOperating
Equipment,
requirein-dependent
verification,
byobservation
ofproperindication
orresponse,
following
alignment
andrestoration
ofequipment
requiredbytechnical
specifications.
Contrarytotheabove,onNovember17,1989,following
maintenance
onthe'B'oopsaturation
temperature
monitorrequiredbyTS3.5.3usingCP-410A,thetestswitchwasnotrestored.totheoriginalpositionanddidnotreceiveindependent
verification
ofinstrument
responseorswitchposition."
Rochester
GasandElectricconcurswiththeaboveviolation
asdescribed.  
J  
J  
1.ReasonforViolationAHumanPerformanceEvaluationSystem(HPES)investigationwasconductedonthisevent.ACausalFactorsCharthasbeenpreparedandisattached.Theconceptofbarriersanddefensein'depthtoensuresafeoperationandmaintenanceoftheplantwaschallengedbythisevent.TheHPESinvestigationidentifiednumerousSpecificBarriersthatweremeanttoensurecorrectperformanceofCP-410A,butinvaryingdegreeswereineffectiveinpreventingthisevent..OuranalysisofthisandothersimilareventspointstothreePrimaryRootCauses.iIInadequateproceduraldirectionIneffectivestatementofstationpolicies,mmunication,andfollow-upofthesepoliciesLapse.inthe"goodworkpractices"ofindividualsco-some20CorrectiveActionsTakenandResultsAchievedA.WhileperformingMainControlRoomchannelchecks,theoperatorsdiscoveredthe1Bsubcoolingmonitorindicatorpeggedhigh.InstrumentandControlTechnicianswerecalledinfortroubleshootingandfoundthetestswitchnotintherecpxiredposition.Thetestswitchwasrepositioned,themonitor'srestorationandindicationwasverifiedandthemonitorwasreturnedtoservice.B.OperationsandMaintenancepersonnelhavereceived"A"proceduretrainingthathighlightsA-1408,"IndependentVerification"requirementsandA-503,"ProcedureAd-herence".C.Meetingswereheldwitheachoperatingshift,selecteddisciplineandAdministrativegroups.TheHPESin-vestigationwasdiscussedwitheachgroupindetail,usingtheCausalFactorChartasapresentationaid.Thesediscussionsfocusedon:*Barriersanddefenseindepth*Workgroupinterfaces*Managementcommunicationofpolicies,andfollow-upforeffectiveimplementation*ImportanceoftheindependentverificationProcessindailyplantoperation*Corrective-ActionPlanandspecificrolesforeachworkgroup  
1.ReasonforViolation
AHumanPerformance
Evaluation
System(HPES)investigation
wasconducted
onthisevent.ACausalFactorsCharthasbeenpreparedandisattached.
Theconceptofbarriersanddefensein'depthtoensuresafeoperation
andmaintenance
oftheplantwaschallenged
bythisevent.TheHPESinvestigation
identified
numerousSpecificBarriersthatweremeanttoensurecorrectperformance
ofCP-410A,butinvaryingdegreeswereineffective
inpreventing
thisevent..OuranalysisofthisandothersimilareventspointstothreePrimaryRootCauses.iIInadequate
procedural
direction
Ineffective
statement
ofstationpolicies,
mmunication,
andfollow-up
ofthesepoliciesLapse.inthe"goodworkpractices"
ofindividuals
co-some20Corrective
ActionsTakenandResultsAchievedA.Whileperforming
MainControlRoomchannelchecks,theoperators
discovered
the1Bsubcooling
monitorindicator
peggedhigh.Instrument
andControlTechnicians
werecalledinfortroubleshooting
andfoundthetestswitchnotintherecpxired
position.
Thetestswitchwasrepositioned,
themonitor's
restoration
andindication
wasverifiedandthemonitorwasreturnedtoservice.B.Operations
andMaintenance
personnel
havereceived"A"procedure
trainingthathighlights
A-1408,"Independent
Verification"
requirements
andA-503,"Procedure
Ad-herence".
C.Meetingswereheldwitheachoperating
shift,selecteddiscipline
andAdministrative
groups.TheHPESin-vestigation
wasdiscussed
witheachgroupindetail,usingtheCausalFactorChartasapresentation
aid.Thesediscussions
focusedon:*Barriersanddefenseindepth*Workgroupinterfaces
*Management
communication
ofpolicies,
andfollow-up
foreffective
implementation
*Importance
oftheindependent
verification
Processindailyplantoperation
*Corrective
-ActionPlanandspecificrolesforeachworkgroup  
   
   
ManagementconductedagroupmeetingwiththethreeOperatorsandthethreeI&CTechniciansthatwereinvolvedinthisevent.ThismeetingaddressedWhat,Why,andUnderWhatConditionseventsoccurredfromtheperspectiveofeachparticipant.Thefocuswasonunderstandingtheeventandestablishing'basisforCorrectiveActiontopreventrecurrence.AmemotoallMaintenenancepersonnel,datedFebruary06,1990,providesinstructionstoensurethatthelatestrevisionoftheimplementingprocedureisintheworkpackageandthat.theprocedurehasbeenmarkedupforindependentverificationofrestorationstepsasapplic-able.Areadandacknowledgementsheetwasincludedwiththememo,toen'surethe.memowasunderstood.Goodworkpracticeshavebeenre-emphasizedinSection,Foreman,planning,andShiftSupervisormeetings.Also,asnotedintheRGGEresponsetoInspectionReport89-15,directionshavebeenprovidedtoOperationspersonnelconcerningimprovedon-shiftattentiontodetail,improvedin-depthcommunicationsandacknowledg-ementofresponsibilitiesforreturnofequipmenttoservice.CP-410AandCP-409Ahavebeendeletedtopreventuseofthesedeficientprocedures.ThenewProcedureUpgradeProgram(PUP)proceduresforcalibrationoftheSaturationTemperatureMonitorSystemareindraftform,readyforreview,andwillbeavailablepriortonextscheduleduse.Thisupgradecorrectsmultipleactionsteps,lackofindependentverification,inadequatetechnicalcontent,lackofproperwarnings,cautions,andnotesandimprovesonoverallprocedureformatandperformance.LabelrequestswereinitiatedandcompletedfortestswitchesTS-410A-1andTS-409A-l.,Also,aDrawingChangeRequestwasinitiatedtoreviseFoxboro'sdrawingsCD-11andCD-21toclearlyidentifythetestswitches.OtherprotectivesystemrackdrawingswerereviewedfortestswitchinstallationssimilartoTS-409A-1andTS-410A-1andnonewerefound.  
Management
conducted
agroupmeetingwiththethreeOperators
andthethreeI&CTechnicians
thatwereinvolvedinthisevent.Thismeetingaddressed
What,Why,andUnderWhatConditions
eventsoccurredfromtheperspective
ofeachparticipant.
Thefocuswasonunderstanding
theeventandestablishing'
basisforCorrective
Actiontopreventrecurrence.
AmemotoallMaintenenance
personnel,
datedFebruary06,1990,providesinstructions
toensurethatthelatestrevisionoftheimplementing
procedure
isintheworkpackageandthat.theprocedure
hasbeenmarkedupforindependent
verification
ofrestoration
stepsasapplic-able.Areadandacknowledgement
sheetwasincludedwiththememo,toen'surethe.memowasunderstood.
Goodworkpractices
havebeenre-emphasized
inSection,Foreman,planning,
andShiftSupervisor
meetings.
Also,asnotedintheRGGEresponsetoInspection
Report89-15,directions
havebeenprovidedtoOperations
personnel
concerning
improvedon-shiftattention
todetail,improvedin-depthcommunications
andacknowledg-
ementofresponsibilities
forreturnofequipment
toservice.CP-410AandCP-409Ahavebeendeletedtopreventuseofthesedeficient
procedures.
ThenewProcedure
UpgradeProgram(PUP)procedures
forcalibration
oftheSaturation
Temperature
MonitorSystemareindraftform,readyforreview,andwillbeavailable
priortonextscheduled
use.Thisupgradecorrectsmultipleactionsteps,lackofindependent
verification,
inadequate
technical
content,lackofproperwarnings,
cautions,
andnotesandimprovesonoverallprocedure
formatandperformance.
Labelrequestswereinitiated
andcompleted
fortestswitchesTS-410A-1
andTS-409A-l.
,Also,aDrawingChangeRequestwasinitiated
toreviseFoxboro's
drawingsCD-11andCD-21toclearlyidentifythetestswitches.
Otherprotective
systemrackdrawingswerereviewedfortestswitchinstallations
similartoTS-409A-1
andTS-410A-1
andnonewerefound.  
   
   
CorrectiveStesWhichWillBeTakenToAvoidFutureViolationsA.TheProcedureUpgradeProgram(PUP),forcalibrationproceduresis,inprogressandonschedulefora1990completion.Theremainingmaintenanceprocedurestobeupgradedarescheduledtobecompletedin1992.Thisupgradeprogramaddressindustryrecognizedproceduregoodpracticesintermsof'content,format,andprocess.C.-ATaskForcewillbeformedtofocusonproblemsas-sociatedwithprocedureadherence,=systemalignments,independentverificaton,andtheirrepetitivenature.TheTaskForcegoalwillbetoeliminatetheseconditions.ThistaskforcewillreporttothePlantManager.ArequestforaTrainingEffectivenessEvaluationon"A"ProceduretrainingwasgeneratedbythePlantSuperinten-dents.ThisevaluationiscurrentlybeingperformedbytheTrainingEvaluationGroup,andwillbecompletedbyMarch02,1990.TheRequestfocusedonthefollowingareas:2HoweffectiveweretheStationpersonnelincommunicatingplantneedstothetraininggroups?Howeffectiveisthetrainingprocessasitwasappliedtotrainingon"A"procedures?ThisevaluationwillassisttheTaskForce'inassessingtheeffectivenessofPlantand.TrainingOrganizationinterfaces.Thiswillprovideinformationforpotentialchangesinthetrainingprocessandthetrainingprogramsthataddressprocedureadherenceandindependentverific-ation.D.ATrainingChangeRequest(TCR)wassubmittedrequestingtrainingforI&CpersonnelconcerningtheSaturationTemperatureMonitorSysteminterrelationships.E.AsnotedintheRG&EResponsetoInspectionReport89-15"AdministativeProcedureA-52.4"ControlofLimitingConditionsforOperation"hasbeenchangedtofurtherdelineateexpectedactionsofpersonnelforreturntoserviceofpreviouslyinoperableequipment.Specificexamplesareutilizedwithinthebodyoftheproceduretoreinforcetheserequirements."ThisprocedurechangeiscurrentlyawaitingPORCapprovalfollowingcommentresolution.ThisapprovalwillbecompletedbyMarch09,1990.  
Corrective
StesWhichWillBeTakenToAvoidFutureViolations
A.TheProcedure
UpgradeProgram(PUP),forcalibration
procedures
is,inprogressandonschedulefora1990completion.
Theremaining
maintenance
procedures
tobeupgradedarescheduled
tobecompleted
in1992.Thisupgradeprogramaddressindustryrecognized
procedure
goodpractices
intermsof'content,
format,andprocess.C.-ATaskForcewillbeformedtofocusonproblemsas-sociatedwithprocedure
adherence,=
systemalignments,
independent
verificaton,
andtheirrepetitive
nature.TheTaskForcegoalwillbetoeliminate
theseconditions.
ThistaskforcewillreporttothePlantManager.ArequestforaTrainingEffectiveness
Evaluation
on"A"Procedure
trainingwasgenerated
bythePlantSuperinten-
dents.Thisevaluation
iscurrently
beingperformed
bytheTrainingEvaluation
Group,andwillbecompleted
byMarch02,1990.TheRequestfocusedonthefollowing
areas:2Howeffective
weretheStationpersonnel
incommunicating
plantneedstothetraininggroups?Howeffective
isthetrainingprocessasitwasappliedtotrainingon"A"procedures?
Thisevaluation
willassisttheTaskForce'inassessing
theeffectiveness
ofPlantand.TrainingOrganization
interfaces.
Thiswillprovideinformation
forpotential
changesinthetrainingprocessandthetrainingprogramsthataddressprocedure
adherence
andindependent
verific-ation.D.ATrainingChangeRequest(TCR)wassubmitted
requesting
trainingforI&Cpersonnel
concerning
theSaturation
Temperature
MonitorSysteminterrelationships.
E.AsnotedintheRG&EResponsetoInspection
Report89-15"Administative
Procedure
A-52.4"ControlofLimitingConditions
forOperation"
hasbeenchangedtofurtherdelineate
expectedactionsofpersonnel
forreturntoserviceofpreviously
inoperable
equipment.
Specificexamplesareutilizedwithinthebodyoftheprocedure
toreinforce
theserequirements."
Thisprocedure
changeiscurrently
awaitingPORCapprovalfollowing
commentresolution.
Thisapprovalwillbecompleted
byMarch09,1990.  
'i'  
'i'  
F.UtilizetheQualityPerformanceOrganizationtoaidmanagementbyprovidingaspecialassessmentasfeedbackontheeffectivenessofprocedureadherenceandindepen-dentverificationproceduresandactivities.4.TheDateWhenFullComlianceWillBeAchievedFullcompliancewasachievedNovember17,1989,whenthetestswitchwasrepositioned,themonitor'srestorationandindicationwasverified,andthemonitorwasreturnedtoservice.RGEErecognizestheneedforincreasedmanagementattention,duetotherepetitivenatureofproblemsassociatedwithprocedureadherence,systemalignmentsandindependentverification.Ourgoalsaretoeliminateincorrectsystemalignments,andassureindependentverificationwheneverspecified.Wehavemadeprogresstowardachievingthisgoal,andarecontinuingtoreinforceourcorrectiveactionsonanurgentbasis.Anyfutureinadequaciesinprocedureadherence,systemalignments,orindependentverificationswillbedealtwithonacase-by-casebasisandwillbethoroughlyinvestigated.Anynecessaryfollowupactionsincludingprocedurecorrections,policyclarifications,orindividualcounselingwillbetaken.  
F.UtilizetheQualityPerformance
Organization
toaidmanagement
byproviding
aspecialassessment
asfeedbackontheeffectiveness
ofprocedure
adherence
andindepen-dentverification
procedures
andactivities.
4.TheDateWhenFullComlianceWillBeAchievedFullcompliance
wasachievedNovember17,1989,whenthetestswitchwasrepositioned,
themonitor's
restoration
andindication
wasverified,
andthemonitorwasreturnedtoservice.RGEErecognizes
theneedforincreased
management
attention,
duetotherepetitive
natureofproblemsassociated
withprocedure
adherence,
systemalignments
andindependent
verification.
Ourgoalsaretoeliminate
incorrect
systemalignments,
andassureindependent
verification
wheneverspecified.
Wehavemadeprogresstowardachieving
thisgoal,andarecontinuing
toreinforce
ourcorrective
actionsonanurgentbasis.Anyfutureinadequacies
inprocedure
adherence,
systemalignments,
orindependent
verifications
willbedealtwithonacase-by-case
basisandwillbethoroughly
investigated.
Anynecessary
followupactionsincluding
procedure
corrections,
policyclarifications,
orindividual
counseling
willbetaken.  
   
   
TrainingonA-lantProcedureAdhcreaccRequirements"sndworkgroupdiscussionof6/29/89memoreferringtoncwrequirementondoublesignoffwasnoteffective.TrainingonA-1408"IndcpcndentVcrilication"wasnotcffectivc.(Note:12/15/80lettertoNRCcommincdRG&Etoperformvnilicationofcorrectperformance.Maasttancntcommunicationandfollow-uponA-303andA-1408didnotoccur.Maintcnanccmemoof6/29/89follow.upmcaiagswithshopsaotheld.Doublesignroffstepsshouldhavebeenidentiliedinplanning,butwercnot.HPES90-01"CP-410ATestSmiteReturned"CAR1990NRCInspectionReport60-244/89-16Violation01ProccdurcdcsigntTestswitchisnotcalledout.Iastep5.6.7,thrccactionsarcuircdi~isconncctequipment~Rcstorcmoduletooperation~Restoretestswitch5.6.7isonthebottomofapage.Turnthcpagefor5.6.8,whichmaybcoutofsequence-ornotrcquircd?Thesamefunctionpnformcdinsecond"and"of$.6.7.g.Tech1cominuesstep5.6.72.ThC2addTech2hada4.CalibratioastepscornletcdIi.JOBSTART5.TechIbeginsstep5.6.7whichcontainsthree'stepsnncctcdbytwo"ands":fT,I2,TechIandTech2tookout-52.4,"ControlofLimiti~~dIustmentsnotrequiredPL'~.Csibrationok..ccdhdioaadattproblemunderstandingstep5.6.Uncleardirectionsfortep5.6.3'fihcprocedure.toppedanddiscussed.ng't>i.m~dCT'~~roCondrtronsforOpcraungI2t~drcstoremoduletonormal':operationaadrcstorc."Rcconncctsleadstheaindcpendenilyverifytightnessof!.alltcrminah.-Disconncaallcalibrationuipmcntandrcstorc."cvicwcdlogicsndagreedtotdqgrocecdast5.6.3.'2"w"~rr'~~~'cchIdtseoaneastestulmeat.itep5.6$isrcdundartofmiddleJrtionofste5.6.7(above).i(Friday,November17,1989air~0"f>CP,adtddWTTdrdxl$wiQ9pphours>ah~a.'.=g.IQ17hours-atp~~@IIcqhtacfhaihiAfterIulleh":-*':"",~id~%$'k<R~e55'iN~hrv~M!Nw~:sfaI'<<Pare"+I0@vrIO"'P409AandCP410Aarcdoneonlyonceayear.CP410AwasoriginallyschcdulcdforTcehsA&B,buttheywerccalledawayonanotherjob.TechIandTech2tookoverthccartatapprox.09:00hrs.Forsteps5.6.0-5.66,TechIwasinRelayRoomandTech2intheControlRoom?Duringthccourseofthcday'work,Tech2splithistimebctwcentbcRelayRoomandthcControlRoom.TechIspentthcentiredayinthcRelayRoom.To"restoremodule"rcanstorcconncaleads.Takes3-Imin.Checkstightncssoftaminals.Movesontostep5.6.8-topofanewpage.5.6.8stata"Connealeadstopairterminalsfromwhichtheywercremcved.Checktightncssofallterminals."NcithcrTechInorTech2haddoneCPr4IOAbefore.g'ceh2haddoneCPr409Asspartof1989Outage.)TcchsandplannnswnctrainedonFoxboroSpec200rnodulcsbythcvendor.Thel&CPlannerwasnotinthatdsy.Abackupplannerhandledthcp!arming.ttNo"tsilgstcscssion"(discussionbctwcenpbnncrsndcrew)wssheld.a'.6.3"Holdthcvoltageconstantacrosspairterminalrrl(approx.4.5VDC)sndincrcsscthevoltageacrosspairterminal//3untilthcalarmactuates.Thcabrmisdlowdifferentialtemp.alarmsndactuateswhenthcdifferencebetwccnthc2voltagesisTd1.0volt=.Ivolt."BrokeabarrierIntactbarrierWonders:Is5.6.8pateof"rcsiorcmoduletonormalopemtion.Itispossibletorcconrc.".andtesttiahtnessofleads,sadskipihethird"and"of5.6.7.  
TrainingonA-lantProcedure
Adhcreacc
Requirements"
sndworkgroupdiscussion
of6/29/89memoreferring
toncwrequirement
ondoublesignoffwasnoteffective.
TrainingonA-1408"Indcpcndent
Vcrilication"
wasnotcffectivc.
(Note:12/15/80letter
toNRCcommincd
RG&Etoperformvnilication
ofcorrectperformance.
Maasttancnt
communication
andfollow-up
onA-303andA-1408didnotoccur.Maintcnancc
memoof6/29/89follow.up
mcaiagswithshopsaotheld.Doublesignroffstepsshouldhavebeenidentilied
inplanning,
butwercnot.HPES90-01"CP-410ATestSmiteReturned"
CAR1990NRCInspection
Report60-244/89-16
Violation
01Proccdurc
dcsigntTestswitchisnotcalledout.Iastep5.6.7,thrccactionsarcuircdi~isconncct
equipment
~Rcstorcmoduletooperation
~Restoretestswitch5.6.7isonthebottomofapage.Turnthcpagefor5.6.8,whichmaybcoutofsequence-or
notrcquircd?
Thesamefunctionpnformcdinsecond"and"of$.6.7.g.Tech1cominuesstep5.6.72.ThC2addTech2hada4.Calibratioa
stepscornletcdIi.JOBSTART5.TechIbeginsstep5.6.7whichcontainsthree'steps
nncctcdbytwo"ands":fT,I2,TechIandTech2tookout
-52.4,"ControlofLimiti~~dIustments
notrequiredPL'~.Csibrationok..ccdhdioaadat
tproblemunderstanding
step5.6.Uncleardirections
fortep5.6.3'fihcprocedure.
toppedanddiscussed.
ng't>i.m~dCT'~~ro
Condrtrons
forOpcraungI2t~drcstore
moduletonormal':operation
aadrcstorc."Rcconnccts
leadstheaindcpendenily
verifytightness
of!.alltcrminah.-
Disconnca
allcalibration
uipmcntandrcstorc."cvicwcdlogicsndagreedtotdqgrocecdast5.6.3.
'2"w"~rr'~~~
'cchIdtseoaneas
testulmeat.itep5.6$isrcdundart
ofmiddleJrtionofste5.6.7(above).i(Friday,November17,1989air~0"f>CP,adtddWTTdrdxl$wiQ9pphours>ah~a.'.=g.
IQ17hours-atp~~@IIcqhtac
fhaihiAfterIulleh":-*':"",~id~%$'k<R~e55'iN~hrv~M!Nw~:s
faI'<<Pare"+I0@vrIO"'P409AandCP410Aarcdoneonlyonceayear.CP410Awasoriginally
schcdulcd
forTcehsA&B,buttheywerccalledawayonanotherjob.TechIandTech2tookoverthccartatapprox.09:00hrs.Forsteps5.6.0-5.6
6,TechIwasinRelayRoomandTech2intheControlRoom?Duringthccourseofthcday'work,Tech2splithistimebctwcentbcRelayRoomandthcControlRoom.TechIspentthcentiredayinthcRelayRoom.To"restoremodule"rcanstorcconncaleads.Takes3-Imin.Checkstightncss
oftaminals.
Movesontostep5.6.8-topofanewpage.5.6.8stata"Connealeadstopairterminals
fromwhichtheywercremcved.Checktightncss
ofallterminals."
NcithcrTechInorTech2haddoneCPr4IOAbefore.g'ceh2haddoneCPr409Asspartof1989Outage.)TcchsandplannnswnctrainedonFoxboroSpec200rnodulcsbythcvendor.Thel&CPlannerwasnotinthatdsy.Abackupplannerhandledthcp!arming.ttNo"tsilgstcscssion"
(discussion
bctwcenpbnncrsndcrew)wssheld.a'.6.3"Holdthcvoltageconstantacrosspairterminalrrl(approx.4.5VDC)sndincrcsscthevoltageacrosspairterminal//3untilthcalarmactuates.
Thcabrmisdlowdifferential
temp.alarmsndactuateswhenthcdifference
betwccnthc2voltagesisTd1.0volt=.Ivolt."BrokeabarrierIntactbarrierWonders:Is5.6.8pateof"rcsiorcmoduletonormalopemtion.Itispossibletorcconrc.".
andtesttiahtness
ofleads,sadskipihethird"and"of5.6.7.  
I0  
I0  
Switchfunctcalledouiintraining.I&CtrainingstopsatthcSpec200Icvcl.dNotrainingtoaddressthcuniqueRG&Efcaturcs,suchasthetntswitch,'orhowthcscmodilicationsaffectthc'planioperation.SwitchwasinstalledinI9S5aspattofamodificationforthcR&Tformonthlyreactoruipbreakertesting.Switchiscalleddiffcrcntnamesbydifferentplantgroups..Testswitchisnotfail-safe.d>>4JaHPES90-01:"CP-410ATestSwitchNotRetu'-conductedhercNRCInspectionReport50>>244/89-16ViolationOlSystemtrainingforI&CcoveringTSAT(temperaturedifferentialsystem)toincludefunctionofthetestswitchwasnotdone.Testswitchisnotdirealylabeled.SwitchisauniqueGinnaStationfcaturc.Testswitchislocatednearthcbottomoftherack-aotnearthcequipmentbeingscrviccdTestswitchisnoiconsidcrcdpartofthcSpec200moduleforI&Cpurposes.Ofupto20modulesinthisrack,thisisthconlyloopwithatestswitch.Thcrcareonly3switchesofthistypeinthcentireplant.Thereareapproximately200similarmodulesintheplant.THISISANEXCEPTION.Ilf~TestswitchTwotcchsarcrcquircdtosignoffthcA-52.4.ProcedureA-52;4aswrittenandaspracticedmaybcunclearandopentoimcrprmauon.Issues:~Whoisrcsponsiblc?~Whatisevcryoncrcsponsiblcfor?.,7,lastpartofstep5.6.7:;>','"andrestoretestswitchto,-g:.originalposition."jga'OTPERFORhIED!~9.Tech1:>.'-.Oeansupjobsite.~@~.'Returnstoshop..>>",>cGocstoControlRoomtoj~clearthcA-52.4"Contro8,ContinuedproccdurcthroughS~tcp5.95,alogicalstopping9:wg:po>>t.~dr~>>Tech2leavesfordoctor'ajiiatmcnt.10,TechIcallsI&CShoP.)>II.A52.4alsosignedoffby:~3~egi>.I,-jTceh3takescall.Hcgoes-,"v>"HeadControlOperatori.-'.~a.'tothcControlRoomand"-.'+ControlRoomForeman,";'+signsoffthcA-52.4.'==~4ShiftSupervisor,'.TechIsignsoffthcA-52.4.i'~NZIeclarcdopcrablcat15:00~~I';rCdd>>Cccccctccdcc.Ncwshiftdocsproccdurc0.6.13.LoopIBsubcooling&#x17d;indicationpeggedhigh.A.~>.I"GinnaStationEventReport"lilcd.lofYi+?~~;-~y"~-+";LimiYingConditionsfor"cKV>>>>~t~m~f'iM~::::-c:::->";:.".:;:.-.:."-c"(d>>cd'~L>>;:>>>>'::c':'Ad.dc>>cd.<-14:45hours~q=;-g~,'.:;yu~d~.--.-.$~:..-Nr',.,>";...;~~",-'*.v.-"c--.=.,-,~AY,.p15:00hourst;'..ig,.-.:p;Mgg,Possibleintcrruptioa-Tech2returnstoRelayRoom?ProcedureCPAIOA,step5.6.7"~ndrcstorctestswitchtooriginalposition"wasnotpcrformcd.DoublevcriTication"withadoublechecktobcperformedbyIhcperson(s)performingtheproccdurc"wasnotdone.Step5.6.7wasnotslashedin'heplanningprocessperm<<motoindicatethatdoublesigaeffisncccssary.TcchswercnotawareofthisspeciTic(doubleveriIicatioa)suuationforstep5.6.7.Tech2hadbeeninandoutofthcControlRoomduringthcday.'echIwasiathcRelayRoom.Eatircproccdmewasnotcomplctcd.Tech2wasinthcControlRoomdurino5.7.4?Notsure.Howcvcr,hcdenotcheckinstrumentationrelatingtostepsin5.6.Tech2didnotdoawalk@owninspectionorcheckthcCoauolRoominstrumentationpriortoleavingforhisdoctor'sappointment.Goodpractices,(instrumentationcheck,walkdown,noting'asfound'ad'asis'onditions)werenotfollowed.Tech2gonetodoctorandunavailablctosignofftheA-52.4.A-52.4,step3.9forverificationofoperabihty,wasnotpcrformcdcorrectly.f(Procedurestatesi"ifoperabihtyofcquipmeatisnotdcmonstratcdbyperformingaPT,anoperatorwillveriEythcvalvel>>cup,switchandbrcakcrposition.)GoodworkpracticenotEol!owed.I&Cdidnotcheckinstrumen-tationinthcControlRoom.Goodworkpracticenotfollowed.Operationsdidnot'checkinstru-mentationinthcControlRoom.Fridayafternoon3:00pm.Goingintoawcckead.Cominguponashiftchange.BrokenbarrierIIntactdbarrierI&CPlannerwascontamcdathome.Hcknewaboutihctestswitchandsurmisedthatitwastheproblem.  
Switchfunctcalledouiintraining.
I&CtrainingstopsatthcSpec200Icvcl.dNotrainingtoaddressthcuniqueRG&Efcaturcs,
suchasthetntswitch,'orhowthcscmodilications
affectthc'plani
operation.
Switchwasinstalled
inI9S5aspattofamodification
forthcR&Tformonthlyreactoruipbreakertesting.Switchiscalleddiffcrcnt
namesbydifferent
plantgroups..Testswitchisnotfail-safe.
d>>4JaHPES90-01:"CP-410ATestSwitchNotRetu'-conducted
hercNRCInspection
Report50>>244/89-16
Violation
OlSystemtrainingforI&CcoveringTSAT(temperature
differential
system)toincludefunctionofthetestswitchwasnotdone.Testswitchisnotdirealylabeled.SwitchisauniqueGinnaStationfcaturc.Testswitchislocatednearthcbottomoftherack-aotnearthcequipment
beingscrviccdTestswitchisnoiconsidcrcd
partofthcSpec200moduleforI&Cpurposes.
Ofupto20modulesinthisrack,thisisthconlyloopwithatestswitch.Thcrcareonly3switchesofthistypeinthcentireplant.Thereareapproximately
200similarmodulesintheplant.THISISANEXCEPTION.
Ilf~TestswitchTwotcchsarcrcquircdtosignoffthcA-52.4.Procedure
A-52;4aswrittenandaspracticed
maybcunclearandopentoimcrprmauon
.Issues:~Whoisrcsponsiblc?
~Whatisevcryoncrcsponsiblc
for?.,7,lastpartofstep5.6.7:;>','"andrestoretestswitchto
,-g:.originalposition."
jga'OTPERFORhIED!
~9.Tech1:>.'-.Oeans
upjobsite.~@~.'Returns
toshop..>>",>cGocs
toControlRoomtoj~clearthcA-52.4"Contro8,Continued
proccdurc
throughS~tcp5.95,alogicalstopping9:wg:po>>t.
~dr~>>Tech2leavesfordoctor'ajiiatmcnt.10,TechIcallsI&CShoP.)>II.A52.4alsosignedoffby:~3~egi>.I,-jTceh3takescall.Hcgoes-,"v>"HeadControlOperatori.-'.~a.'tothcControl
Roomand"-.'+Control
RoomForeman,";'+signsoffthcA-52.4.'==~4ShiftSupervisor
,'.TechIsignsoffthcA-52.4.i'~NZIeclarcd
opcrablcat15:00~~I';rCdd>>Cccccctccdcc.
Ncwshiftdocsproccdurc
0.6.13.LoopIBsubcooling
&#x17d;indication
peggedhigh.A.~>.I"GinnaStationEventReport"lilcd.lofYi+?~~;-~y"~-+";LimiYing
Conditions
for"cKV>>>>~t~m~f'iM~::::-c:::->";:.".:;:.-.:."-c"(
d>>cd'~L>>;:>>>>'::c':
'Ad.dc>>cd.<-14:45hours~q=;-g~,'.:;
yu~d~.--.-.$~:..-Nr',.,>";...;~~",-'*.v.-"c
--.=.,-,~AY,.
p15:00hours
t;'..ig,.-.:p;Mgg,
Possibleintcrruptioa
-Tech2returnstoRelayRoom?Procedure
CPAIOA,step5.6.7"~ndrcstorctestswitchtooriginalposition"
wasnotpcrformcd.
DoublevcriTication
"withadoublechecktobcperformed
byIhcperson(s)
performing
theproccdurc"
wasnotdone.Step5.6.7wasnotslashedin'heplanningprocessperm<<motoindicatethatdoublesigaeffisncccssary.
TcchswercnotawareofthisspeciTic(doubleveriIicatioa)
suuationforstep5.6.7.Tech2hadbeeninandoutofthcControlRoomduringthcday.'echIwasiathcRelayRoom.Eatircproccdmewasnotcomplctcd.
Tech2wasinthcControlRoomdurino5.7.4?Notsure.Howcvcr,hcdenotcheckinstrumentation
relatingtostepsin5.6.Tech2didnotdoawalk@owninspection
orcheckthcCoauolRoominstrumentation
priortoleavingforhisdoctor'sappointment.
Goodpractices,
(instrumentation
check,walkdown,
noting'asfound'ad'asis'onditions)
werenotfollowed.
Tech2gonetodoctorandunavailablc
tosignofftheA-52.4.A-52.4,step3.9forverification
ofoperabihty,
wasnotpcrformcd
correctly.
f(Procedure
statesi"ifoperabihty
ofcquipmeat
isnotdcmonstratcd
byperforming
aPT,anoperatorwillveriEythcvalvel>>cup,switchandbrcakcrposition.
)GoodworkpracticenotEol!owed.
I&Cdidnotcheckinstrumen-
tationinthcControlRoom.Goodworkpracticenotfollowed.
Operations
didnot'check
instru-mentation
inthcControlRoom.Fridayafternoon
3:00pm.Goingintoawcckead.Cominguponashiftchange.BrokenbarrierIIntactdbarrierI&CPlannerwascontamcdathome.Hcknewaboutihctestswitchandsurmisedthatitwastheproblem.  
'
'
}}
}}

Revision as of 13:20, 29 June 2018

Responds to Violations Noted in Insp Rept 50-244/89-16. Corrective Actions:Operations & Maint Personnel Received a Procedure Training That Highlights A-1408, Independent Verification, Requirements
ML17261A969
Person / Time
Site: Ginna Constellation icon.png
Issue date: 02/23/1990
From: MECREDY R C
ROCHESTER GAS & ELECTRIC CORP.
To: RUSSELL W T
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
References
NUDOCS 9003020138
Download: ML17261A969 (18)


See also: IR 05000244/1989016

Text

AO;ELERATED

DISHUBUTION

DEMONSHWTION

SYSTEMREGULATORY

INFORMATION

DISTRIBUTION

SYSTEM(RIDS)ESSIONNBR:9003020138

DOC.DATE:

90/02/23NOTARIZED:

NODOCKETACIL:50-244

RobertEmmetGinnaNuclearPlant,Unit1,Rochester

G05000244AUTH.NAME.AUTHORAFFILIATION

MECREDY,R.C.

Rochester

Gas&ElectricCorp.RECIP.NAME

RECIPIENT

AFFILIATION

RUSSELL,W.T.

Region1,OfcoftheDirectorSUBJECT:Respondstoviolations

notedinInspRept50-244/89-16.

DISTRIBUTION

CODEIE01DCOPIESRECEIVED:LTR

ENCLSIZE:TITLE:General(50Dkt)-Insp

Rept/Notice

ofVqoIation

ResponseNOTES:License

Expdateinaccordance

with10CFR2,2.109(9/19/72).

E'05000244

'/RECIPIENT

IDCODE/NAME

PD1-3PDINTERNAL:

AEODAEOD/TPAD

NRRSHANKMAN,

SNRR/DOEADIR11NRR/DREP/PRPB11

NRR/DST/DIR

8E2NUDOCS-ABSTRACT

OGC/HDS2RESMORISSEAU,D

RNAL:LPDRNSICCOPIESLTTRENCL11111111112.2111111111111RECIPIENT

IDCODE/NAME

JOHNSON,A

AEOD/DEIIB

DEDRONRR/DLPQ/LPEB10

NRR/DREP/PEPB9

DNRR/DRIS/DIR

NRR/PMAS/ILRB12

0N,JRGN1FILE01NRCPDRCOPIESLTTRENCL11D1111,D1111S111111111111R-DANOTETOALL"RIDS"RECIPIENTS:

PLEASEHELPUSTOREDUCEWASTETHCONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTION

LISISFORDOCUMENTS

YOUDON'TNEEDlTALNUMBEROFCOPIESREQUIRED:

LTTR24ENCL24D

I!I",<Ilail!~II,".Ilf

/I/gpiK;',"l

ROCHESTER

GASANDELECTRICCORPORATION

~89EASTAVENUE,P5cwp.~0\1~*KI,%0%l555A55ROCHESTER,

N.Y.14649-0001

February23,1990TC5.EPHONCA@CACODEVI55546-2700Mr.WilliamT.RussellRegionalAdministrator

U.S.NuclearRegulatory

Commission

RegionI475Allendale

RoadKingofPrussia,PA19406Subject:ResponsetoInspection

Report50-244/89-16

NoticeofViolation

R.E.GinnaNuclearPowerPlantDocketNo.50-244DearMr.Russell:TheenclosedresponsetotheNoticeofViolation

containsourresponsetoViolation

89-16-01fromtheinspection

attheR.E.GinnaNuclearPowerPlantfromNovember7throughDecember11,1989.TheattachedresponseincludesHumanPerformance

Evaluation

System(HPES)investigation

information

andourcorrective

actions.Ourlong-term

corrective

actionshavebeendetermined

toaddresstherepetitive

natureoftheseconcerns,

andtheneedforincreased

management

attention.

Verytrulyyours,RobertC.MecredyDivisionManagerNuclearProduction

xc:U.S.NuclearRegulatory

Commission

DocumentControlDeskWashington,

DC20555GinnaNRCSeniorResidentInspector

5'003020'q

PDRA'i'OC.I;

0.000:44C~PDC(original)

~zpv(I'I

I

RESPONSETONRCINSPECTION

REPORT50-244/89-16

RoutineInspection

Report50-244/89-16,

AppendixA,statedinpart:"Duringaninspection

attheR.E.GinnaNuclearPowerPlantfromNovember7throughDecember11,1989,thefollowing

violation

wasidentified

inaccordance

withtheNRCEnforcement

Policy(10CFR2,AppendixC).Technical Specification 6.8.1requiresinpartthatwrittenprocedures

shallbe'established,

implemented,

and-maintained

.coveringactivities

referenced

inAppendixAofRegulatory

Guide1.33,November1972.Activities

referenced'n

AppendixAincludemaintenance

andequipment

control.Calibration

Procedure

(CP)-410A,

Calibration

and/orMain-'tenanceofSaturation

Temperature

MonitorSystem"B"Loop,requiresrestoration

ofthetestswitchtotheoriginalposition.

Inaddition,

Administrative

Procedure

(A)-1408,.

Independent

Verification,

andProcedure

A-52.4,ControlofLimitingConditions

ForOperating

Equipment,

requirein-dependent

verification,

byobservation

ofproperindication

orresponse,

following

alignment

andrestoration

ofequipment

requiredbytechnical

specifications.

Contrarytotheabove,onNovember17,1989,following

maintenance

onthe'B'oopsaturation

temperature

monitorrequiredbyTS3.5.3usingCP-410A,thetestswitchwasnotrestored.totheoriginalpositionanddidnotreceiveindependent

verification

ofinstrument

responseorswitchposition."

Rochester

GasandElectricconcurswiththeaboveviolation

asdescribed.

J

1.ReasonforViolation

AHumanPerformance

Evaluation

System(HPES)investigation

wasconducted

onthisevent.ACausalFactorsCharthasbeenpreparedandisattached.

Theconceptofbarriersanddefensein'depthtoensuresafeoperation

andmaintenance

oftheplantwaschallenged

bythisevent.TheHPESinvestigation

identified

numerousSpecificBarriersthatweremeanttoensurecorrectperformance

ofCP-410A,butinvaryingdegreeswereineffective

inpreventing

thisevent..OuranalysisofthisandothersimilareventspointstothreePrimaryRootCauses.iIInadequate

procedural

direction

Ineffective

statement

ofstationpolicies,

mmunication,

andfollow-up

ofthesepoliciesLapse.inthe"goodworkpractices"

ofindividuals

co-some20Corrective

ActionsTakenandResultsAchievedA.Whileperforming

MainControlRoomchannelchecks,theoperators

discovered

the1Bsubcooling

monitorindicator

peggedhigh.Instrument

andControlTechnicians

werecalledinfortroubleshooting

andfoundthetestswitchnotintherecpxired

position.

Thetestswitchwasrepositioned,

themonitor's

restoration

andindication

wasverifiedandthemonitorwasreturnedtoservice.B.Operations

andMaintenance

personnel

havereceived"A"procedure

trainingthathighlights

A-1408,"Independent

Verification"

requirements

andA-503,"Procedure

Ad-herence".

C.Meetingswereheldwitheachoperating

shift,selecteddiscipline

andAdministrative

groups.TheHPESin-vestigation

wasdiscussed

witheachgroupindetail,usingtheCausalFactorChartasapresentation

aid.Thesediscussions

focusedon:*Barriersanddefenseindepth*Workgroupinterfaces

  • Management

communication

ofpolicies,

andfollow-up

foreffective

implementation

  • Importance

oftheindependent

verification

Processindailyplantoperation

  • Corrective

-ActionPlanandspecificrolesforeachworkgroup

Management

conducted

agroupmeetingwiththethreeOperators

andthethreeI&CTechnicians

thatwereinvolvedinthisevent.Thismeetingaddressed

What,Why,andUnderWhatConditions

eventsoccurredfromtheperspective

ofeachparticipant.

Thefocuswasonunderstanding

theeventandestablishing'

basisforCorrective

Actiontopreventrecurrence.

AmemotoallMaintenenance

personnel,

datedFebruary06,1990,providesinstructions

toensurethatthelatestrevisionoftheimplementing

procedure

isintheworkpackageandthat.theprocedure

hasbeenmarkedupforindependent

verification

ofrestoration

stepsasapplic-able.Areadandacknowledgement

sheetwasincludedwiththememo,toen'surethe.memowasunderstood.

Goodworkpractices

havebeenre-emphasized

inSection,Foreman,planning,

andShiftSupervisor

meetings.

Also,asnotedintheRGGEresponsetoInspection

Report89-15,directions

havebeenprovidedtoOperations

personnel

concerning

improvedon-shiftattention

todetail,improvedin-depthcommunications

andacknowledg-

ementofresponsibilities

forreturnofequipment

toservice.CP-410AandCP-409Ahavebeendeletedtopreventuseofthesedeficient

procedures.

ThenewProcedure

UpgradeProgram(PUP)procedures

forcalibration

oftheSaturation

Temperature

MonitorSystemareindraftform,readyforreview,andwillbeavailable

priortonextscheduled

use.Thisupgradecorrectsmultipleactionsteps,lackofindependent

verification,

inadequate

technical

content,lackofproperwarnings,

cautions,

andnotesandimprovesonoverallprocedure

formatandperformance.

Labelrequestswereinitiated

andcompleted

fortestswitchesTS-410A-1

andTS-409A-l.

,Also,aDrawingChangeRequestwasinitiated

toreviseFoxboro's

drawingsCD-11andCD-21toclearlyidentifythetestswitches.

Otherprotective

systemrackdrawingswerereviewedfortestswitchinstallations

similartoTS-409A-1

andTS-410A-1

andnonewerefound.

Corrective

StesWhichWillBeTakenToAvoidFutureViolations

A.TheProcedure

UpgradeProgram(PUP),forcalibration

procedures

is,inprogressandonschedulefora1990completion.

Theremaining

maintenance

procedures

tobeupgradedarescheduled

tobecompleted

in1992.Thisupgradeprogramaddressindustryrecognized

procedure

goodpractices

intermsof'content,

format,andprocess.C.-ATaskForcewillbeformedtofocusonproblemsas-sociatedwithprocedure

adherence,=

systemalignments,

independent

verificaton,

andtheirrepetitive

nature.TheTaskForcegoalwillbetoeliminate

theseconditions.

ThistaskforcewillreporttothePlantManager.ArequestforaTrainingEffectiveness

Evaluation

on"A"Procedure

trainingwasgenerated

bythePlantSuperinten-

dents.Thisevaluation

iscurrently

beingperformed

bytheTrainingEvaluation

Group,andwillbecompleted

byMarch02,1990.TheRequestfocusedonthefollowing

areas:2Howeffective

weretheStationpersonnel

incommunicating

plantneedstothetraininggroups?Howeffective

isthetrainingprocessasitwasappliedtotrainingon"A"procedures?

Thisevaluation

willassisttheTaskForce'inassessing

theeffectiveness

ofPlantand.TrainingOrganization

interfaces.

Thiswillprovideinformation

forpotential

changesinthetrainingprocessandthetrainingprogramsthataddressprocedure

adherence

andindependent

verific-ation.D.ATrainingChangeRequest(TCR)wassubmitted

requesting

trainingforI&Cpersonnel

concerning

theSaturation

Temperature

MonitorSysteminterrelationships.

E.AsnotedintheRG&EResponsetoInspection

Report89-15"Administative

Procedure

A-52.4"ControlofLimitingConditions

forOperation"

hasbeenchangedtofurtherdelineate

expectedactionsofpersonnel

forreturntoserviceofpreviously

inoperable

equipment.

Specificexamplesareutilizedwithinthebodyoftheprocedure

toreinforce

theserequirements."

Thisprocedure

changeiscurrently

awaitingPORCapprovalfollowing

commentresolution.

Thisapprovalwillbecompleted

byMarch09,1990.

'i'

F.UtilizetheQualityPerformance

Organization

toaidmanagement

byproviding

aspecialassessment

asfeedbackontheeffectiveness

ofprocedure

adherence

andindepen-dentverification

procedures

andactivities.

4.TheDateWhenFullComlianceWillBeAchievedFullcompliance

wasachievedNovember17,1989,whenthetestswitchwasrepositioned,

themonitor's

restoration

andindication

wasverified,

andthemonitorwasreturnedtoservice.RGEErecognizes

theneedforincreased

management

attention,

duetotherepetitive

natureofproblemsassociated

withprocedure

adherence,

systemalignments

andindependent

verification.

Ourgoalsaretoeliminate

incorrect

systemalignments,

andassureindependent

verification

wheneverspecified.

Wehavemadeprogresstowardachieving

thisgoal,andarecontinuing

toreinforce

ourcorrective

actionsonanurgentbasis.Anyfutureinadequacies

inprocedure

adherence,

systemalignments,

orindependent

verifications

willbedealtwithonacase-by-case

basisandwillbethoroughly

investigated.

Anynecessary

followupactionsincluding

procedure

corrections,

policyclarifications,

orindividual

counseling

willbetaken.

TrainingonA-lantProcedure

Adhcreacc

Requirements"

sndworkgroupdiscussion

of6/29/89memoreferring

toncwrequirement

ondoublesignoffwasnoteffective.

TrainingonA-1408"Indcpcndent

Vcrilication"

wasnotcffectivc.

(Note:12/15/80letter

toNRCcommincd

RG&Etoperformvnilication

ofcorrectperformance.

Maasttancnt

communication

andfollow-up

onA-303andA-1408didnotoccur.Maintcnancc

memoof6/29/89follow.up

mcaiagswithshopsaotheld.Doublesignroffstepsshouldhavebeenidentilied

inplanning,

butwercnot.HPES90-01"CP-410ATestSmiteReturned"

CAR1990NRCInspection

Report60-244/89-16

Violation

01Proccdurc

dcsigntTestswitchisnotcalledout.Iastep5.6.7,thrccactionsarcuircdi~isconncct

equipment

~Rcstorcmoduletooperation

~Restoretestswitch5.6.7isonthebottomofapage.Turnthcpagefor5.6.8,whichmaybcoutofsequence-or

notrcquircd?

Thesamefunctionpnformcdinsecond"and"of$.6.7.g.Tech1cominuesstep5.6.72.ThC2addTech2hada4.Calibratioa

stepscornletcdIi.JOBSTART5.TechIbeginsstep5.6.7whichcontainsthree'steps

nncctcdbytwo"ands":fT,I2,TechIandTech2tookout

-52.4,"ControlofLimiti~~dIustments

notrequiredPL'~.Csibrationok..ccdhdioaadat

tproblemunderstanding

step5.6.Uncleardirections

fortep5.6.3'fihcprocedure.

toppedanddiscussed.

ng't>i.m~dCT'~~ro

Condrtrons

forOpcraungI2t~drcstore

moduletonormal':operation

aadrcstorc."Rcconnccts

leadstheaindcpendenily

verifytightness

of!.alltcrminah.-

Disconnca

allcalibration

uipmcntandrcstorc."cvicwcdlogicsndagreedtotdqgrocecdast5.6.3.

'2"w"~rr'~~~

'cchIdtseoaneas

testulmeat.itep5.6$isrcdundart

ofmiddleJrtionofste5.6.7(above).i(Friday,November17,1989air~0"f>CP,adtddWTTdrdxl$wiQ9pphours>ah~a.'.=g.

IQ17hours-atp~~@IIcqhtac

fhaihiAfterIulleh":-*':"",~id~%$'k<R~e55'iN~hrv~M!Nw~:s

faI'<<Pare"+I0@vrIO"'P409AandCP410Aarcdoneonlyonceayear.CP410Awasoriginally

schcdulcd

forTcehsA&B,buttheywerccalledawayonanotherjob.TechIandTech2tookoverthccartatapprox.09:00hrs.Forsteps5.6.0-5.6

6,TechIwasinRelayRoomandTech2intheControlRoom?Duringthccourseofthcday'work,Tech2splithistimebctwcentbcRelayRoomandthcControlRoom.TechIspentthcentiredayinthcRelayRoom.To"restoremodule"rcanstorcconncaleads.Takes3-Imin.Checkstightncss

oftaminals.

Movesontostep5.6.8-topofanewpage.5.6.8stata"Connealeadstopairterminals

fromwhichtheywercremcved.Checktightncss

ofallterminals."

NcithcrTechInorTech2haddoneCPr4IOAbefore.g'ceh2haddoneCPr409Asspartof1989Outage.)TcchsandplannnswnctrainedonFoxboroSpec200rnodulcsbythcvendor.Thel&CPlannerwasnotinthatdsy.Abackupplannerhandledthcp!arming.ttNo"tsilgstcscssion"

(discussion

bctwcenpbnncrsndcrew)wssheld.a'.6.3"Holdthcvoltageconstantacrosspairterminalrrl(approx.4.5VDC)sndincrcsscthevoltageacrosspairterminal//3untilthcalarmactuates.

Thcabrmisdlowdifferential

temp.alarmsndactuateswhenthcdifference

betwccnthc2voltagesisTd1.0volt=.Ivolt."BrokeabarrierIntactbarrierWonders:Is5.6.8pateof"rcsiorcmoduletonormalopemtion.Itispossibletorcconrc.".

andtesttiahtness

ofleads,sadskipihethird"and"of5.6.7.

I0

Switchfunctcalledouiintraining.

I&CtrainingstopsatthcSpec200Icvcl.dNotrainingtoaddressthcuniqueRG&Efcaturcs,

suchasthetntswitch,'orhowthcscmodilications

affectthc'plani

operation.

Switchwasinstalled

inI9S5aspattofamodification

forthcR&Tformonthlyreactoruipbreakertesting.Switchiscalleddiffcrcnt

namesbydifferent

plantgroups..Testswitchisnotfail-safe.

d>>4JaHPES90-01:"CP-410ATestSwitchNotRetu'-conducted

hercNRCInspection

Report50>>244/89-16

Violation

OlSystemtrainingforI&CcoveringTSAT(temperature

differential

system)toincludefunctionofthetestswitchwasnotdone.Testswitchisnotdirealylabeled.SwitchisauniqueGinnaStationfcaturc.Testswitchislocatednearthcbottomoftherack-aotnearthcequipment

beingscrviccdTestswitchisnoiconsidcrcd

partofthcSpec200moduleforI&Cpurposes.

Ofupto20modulesinthisrack,thisisthconlyloopwithatestswitch.Thcrcareonly3switchesofthistypeinthcentireplant.Thereareapproximately

200similarmodulesintheplant.THISISANEXCEPTION.

Ilf~TestswitchTwotcchsarcrcquircdtosignoffthcA-52.4.Procedure

A-52;4aswrittenandaspracticed

maybcunclearandopentoimcrprmauon

.Issues:~Whoisrcsponsiblc?

~Whatisevcryoncrcsponsiblc

for?.,7,lastpartofstep5.6.7:;>','"andrestoretestswitchto

,-g:.originalposition."

jga'OTPERFORhIED!

~9.Tech1:>.'-.Oeans

upjobsite.~@~.'Returns

toshop..>>",>cGocs

toControlRoomtoj~clearthcA-52.4"Contro8,Continued

proccdurc

throughS~tcp5.95,alogicalstopping9:wg:po>>t.

~dr~>>Tech2leavesfordoctor'ajiiatmcnt.10,TechIcallsI&CShoP.)>II.A52.4alsosignedoffby:~3~egi>.I,-jTceh3takescall.Hcgoes-,"v>"HeadControlOperatori.-'.~a.'tothcControl

Roomand"-.'+Control

RoomForeman,";'+signsoffthcA-52.4.'==~4ShiftSupervisor

,'.TechIsignsoffthcA-52.4.i'~NZIeclarcd

opcrablcat15:00~~I';rCdd>>Cccccctccdcc.

Ncwshiftdocsproccdurc

0.6.13.LoopIBsubcooling

Žindication

peggedhigh.A.~>.I"GinnaStationEventReport"lilcd.lofYi+?~~;-~y"~-+";LimiYing

Conditions

for"cKV>>>>~t~m~f'iM~::::-c:::->";:.".:;:.-.:."-c"(

d>>cd'~L>>;:>>>>'::c':

'Ad.dc>>cd.<-14:45hours~q=;-g~,'.:;

yu~d~.--.-.$~:..-Nr',.,>";...;~~",-'*.v.-"c

--.=.,-,~AY,.

p15:00hours

t;'..ig,.-.:p;Mgg,

Possibleintcrruptioa

-Tech2returnstoRelayRoom?Procedure

CPAIOA,step5.6.7"~ndrcstorctestswitchtooriginalposition"

wasnotpcrformcd.

DoublevcriTication

"withadoublechecktobcperformed

byIhcperson(s)

performing

theproccdurc"

wasnotdone.Step5.6.7wasnotslashedin'heplanningprocessperm<<motoindicatethatdoublesigaeffisncccssary.

TcchswercnotawareofthisspeciTic(doubleveriIicatioa)

suuationforstep5.6.7.Tech2hadbeeninandoutofthcControlRoomduringthcday.'echIwasiathcRelayRoom.Eatircproccdmewasnotcomplctcd.

Tech2wasinthcControlRoomdurino5.7.4?Notsure.Howcvcr,hcdenotcheckinstrumentation

relatingtostepsin5.6.Tech2didnotdoawalk@owninspection

orcheckthcCoauolRoominstrumentation

priortoleavingforhisdoctor'sappointment.

Goodpractices,

(instrumentation

check,walkdown,

noting'asfound'ad'asis'onditions)

werenotfollowed.

Tech2gonetodoctorandunavailablc

tosignofftheA-52.4.A-52.4,step3.9forverification

ofoperabihty,

wasnotpcrformcd

correctly.

f(Procedure

statesi"ifoperabihty

ofcquipmeat

isnotdcmonstratcd

byperforming

aPT,anoperatorwillveriEythcvalvel>>cup,switchandbrcakcrposition.

)GoodworkpracticenotEol!owed.

I&Cdidnotcheckinstrumen-

tationinthcControlRoom.Goodworkpracticenotfollowed.

Operations

didnot'check

instru-mentation

inthcControlRoom.Fridayafternoon

3:00pm.Goingintoawcckead.Cominguponashiftchange.BrokenbarrierIIntactdbarrierI&CPlannerwascontamcdathome.Hcknewaboutihctestswitchandsurmisedthatitwastheproblem.

'