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{{#Wiki_filter:RIGRITY1ACCELERATED
{{#Wiki_filter:RIG RITY 1 ACCELERATED
RIDSPROCESSING),
RIDS PROCESSING), REGULATORY
REGULATORY
INFORMATION
INFORMATION
DISTRIBUTION
DISTRIBUTION
SYSTEM(RIDS)r'ESSIONNBR9511210113
SYSTEM (RIDS)r'ESSION NBR 9511210113
DOC~DATE'5/11/15
DOC~DATE'5/11/15
NOTARIZED
NOTARIZED NO FACIL:50-335
NOFACIL:50-335
St.Lucie Plant, Unit 1, Florida Power&Light Co.50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION
St.LuciePlant,Unit1,FloridaPower&LightCo.50-389St.LuciePlant,Unit2,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION
GOLDBERG,J.H.
GOLDBERG,J.H.
FloridaPower&'ightCo.RECIP.NAME
Florida Power&'ight Co.RECIP.NAME
RECIPIENT
RECIPIENT AFFILIATION
AFFILIATION
Document Control Branch (Document Control Desk)SUBJECT: Forwards response to NRC ltr re violations
DocumentControlBranch(Document
noted in insp repts 50-335/95-15
ControlDesk)SUBJECT:ForwardsresponsetoNRCltrreviolations
notedininsprepts50-335/95-15
&50-389/95-15.Corrective
&50-389/95-15.Corrective
actions:MSIS
actions:MSIS
wasblocked&resetimmediately
was blocked&reset immediately
following
following event on 950802.I DISTRIBUTION
eventon950802.IDISTRIBUTION
CODE: IE01D COPIES RECEIVED:LTR
CODE:IE01DCOPIESRECEIVED:LTR
ENCL SIZE: TITLE: General (50 Dkt)-Insp Rept/Notice
ENCLSIZE:TITLE:General(50Dkt)-Insp
of Violation Response NOTES DOCKET N 05000335 05000389 INTERNAL: RECIPIENT ID CODE/NAME PD2-1 PD ACRS AEOD/SPD/RAB
Rept/Notice
DEDRO NRR/DISP/PIPB
ofViolation
ResponseNOTESDOCKETN0500033505000389INTERNAL:
RECIPIENT
IDCODE/NAME
PD2-1PDACRSAEOD/SPD/RAB
DEDRONRR/DISP/PIPB
NRR/DRPM/PECB
NRR/DRPM/PECB
OEDIRRGN2FILE01COPIESRECIPIENT
OE DIR RGN2 FILE 01 COPIES RECIPIENT LTTR ENCL ID CODE/NAME 1 1 NORRIS,J 2 AEOD/DEIB 1 A'E.1 FILE CENTER 1/'DRC8/H FB 1 NUDOCS-ABSTRACT
LTTRENCLIDCODE/NAME
1'GC/HDS3 1 COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 EXTERNAL: LITCO BRYCE,J H NRC PDR 1 1 1 1 NOAC 1 1 iNOTE TO ALL RIDS" RECIPIEYTS:
11NORRIS,J2AEOD/DEIB
PLEASE HELP US TO REDUCE 4VASTE!CONTACT THE DOCL'!iIEYT
1A'E.1FILECENTER1/'DRC8/HFB1NUDOCS-ABSTRACT
CO."iTROL DESK, ROOiiI Pl-37 (EXT.504-2083)TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY.
1'GC/HDS31COPIESLTTRENCL11111111111111EXTERNAL:
LISTS FOR DOCL'IiIEi'I'S
LITCOBRYCE,JHNRCPDR1111NOAC11iNOTETOALLRIDS"RECIPIEYTS:
5'OU DOi"I'L'LD!TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19
PLEASEHELPUSTOREDUCE4VASTE!CONTACTTHEDOCL'!iIEYT
4 0'  
CO."iTROL
0 Florida Power L Light Company, P.O.Box 14000, Juno Beach, FL 33408 0420 NOV 1 5$995 L-95-306 10 CFR 2.201 U.S.Nuclear Regulatory
DESK,ROOiiIPl-37(EXT.504-2083)TOELIiIINATEYOURNA!iIEFROiIDISTRIBUTIOY.
LISTSFORDOCL'IiIEi'I'S
5'OUDOi"I'L'LD!TOTALNUMBEROFCOPIESREQUIRED:
LTTR19ENCL19
40'  
0FloridaPowerLLightCompany,P.O.Box14000,JunoBeach,FL334080420NOV15$995L-95-30610CFR2.201U.S.NuclearRegulatory
Commission
Commission
Attn:DocumentControlDeskWashington,
Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15Florida Power and Light Company (FPL)has reviewed the subject inspection
D.C.20555Re:St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
report and pursuant to 10 CFR 2.201 the response to the notice of violation is attached.Very truly yours, J.H.Goldberg President-Nuclear Division JHG/DAS/EJB
InsectionReort95-15FloridaPowerandLightCompany(FPL)hasreviewedthesubjectinspection
reportandpursuantto10CFR2.201theresponsetothenoticeofviolation
isattached.
Verytrulyyours,J.H.GoldbergPresident
-NuclearDivisionJHG/DAS/EJB
Attachment
Attachment
cc:StewartD.Ebneter,RegionalAdministrator,
cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St.Lucie Plant 95ii210i13
USNRCRegionIISeniorResidentInspector,
'it5iii5 PDR ADOCK 05000335 9 PDR an FPL Group company
USNRC,St.LuciePlant95ii210i13
FPL RESPONSE TO INSPECTION
'it5iii5PDRADOCK050003359PDRanFPLGroupcompany
REPORT 95-15 SUMMARY NRC Inspection
FPLRESPONSETOINSPECTION
Report 50-335/389/95-15
REPORT95-15SUMMARYNRCInspection
Report50-335/389/95-15
considered
considered
St.LuciePlantperformance
St.Lucie Plant performance
duringthesix(6)weekperiodfromJuly30,1995throughSeptember
during the six (6)week period from July 30, 1995 through September 16, 1995.The violations
16,1995.Theviolations
below occurred during a relatively
belowoccurredduringarelatively
short period of time, as described in the inspection
shortperiodoftime,asdescribed
report, and several of the corrective
intheinspection
actions were instituted
report,andseveralofthecorrective
following an analysis of the events, collectively.
actionswereinstituted
The corrective
following
steps to avoid further violations
ananalysisoftheevents,collectively.
were in some cases determined
Thecorrective
to be generic following this analysis, and are therefore repeated in a number of the responses.
stepstoavoidfurtherviolations
The Inspection
wereinsomecasesdetermined
Report identified
tobegenericfollowing
seven (7)violations
thisanalysis,
which are listed below.Violation A: Failure to Follow Procedures
andaretherefore
and Block MSIS Actuation Violation B: Failure to Follow Procedures
repeatedinanumberoftheresponses.
During RCP Seal Restaging Violation C: Failure to Follow Procedure and Document Abnormal Valve Position in the Valve, Switch Deviation log Violation D: Failure to Follow Procedures
TheInspection
during Alignment of Shutdown Cooling System Violation E: Failure to Follow Procedure and Document a Deficiency
Reportidentified
on Containment
seven(7)violations
Spray Valve Surveillance
whicharelistedbelow.Violation
Test Procedure Violation F: Failure to Initial Maintenance
A:FailuretoFollowProcedures
Procedure Steps as Work was Completed Violation G: Failure to Follow Procedures
andBlockMSISActuation
During Venting of ECCS System Resulted in Containment
Violation
Spraydown Additionally, both Florida Power and Light (FPL)and the NRC evaluated plant events to identify common underlying
B:FailuretoFollowProcedures
themes.FPL presented a summary of events to the NRC on August 29, 1995.Weaknesses
DuringRCPSealRestaging
Violation
C:FailuretoFollowProcedure
andDocumentAbnormalValvePositionintheValve,SwitchDeviation
logViolation
D:FailuretoFollowProcedures
duringAlignment
ofShutdownCoolingSystemViolation
E:FailuretoFollowProcedure
andDocumentaDeficiency
onContainment
SprayValveSurveillance
TestProcedure
Violation
F:FailuretoInitialMaintenance
Procedure
StepsasWorkwasCompleted
Violation
G:FailuretoFollowProcedures
DuringVentingofECCSSystemResultedinContainment
Spraydown
Additionally,
bothFloridaPowerandLight(FPL)andtheNRCevaluated
planteventstoidentifycommonunderlying
themes.FPLpresented
asummaryofeventstotheNRConAugust29,1995.Weaknesses
identified
identified
inthissummaryincludedprocedure
in this summary included procedure content and use, as well as management
contentanduse,aswellasmanagement
oversight of eguipment performance.
oversight
FPL's Plan to Improve the Operational
ofeguipment
performance.
FPL'sPlantoImprovetheOperational
Performance
Performance
atSt.Luciewasdeveloped
at St.Lucie was developed as a result of the August 29, 1995, meeting and submitted to the NRC on September 15, 1995.To date, FPL has completed the activities
asaresultoftheAugust29,1995,meetingandsubmitted
according to the improvement
totheNRConSeptember
plan schedule.  
15,1995.Todate,FPLhascompleted
S=.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION A: Technical Specification
theactivities
6.8.1.a requires that written procedures
according
be established, implemented, and maintained
totheimprovement
covering the activities
planschedule.  
S=.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
A:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
recommended
inAppendixAofRegulatory
in Appendix A of Regulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
1.dincludesadministrative
procedures
procedures
forprocedural
for procedural
adherence.
adherence.
Procedure
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
QI5-PR/PSL-1,
of Procedures," Section 5.13.2, states that all procedures
Rev.62,"Preparation,
shall be strictly adhered to.OP 1-0030127, Rev 68,"Reactor Plant Cooldown-Hot Standby to Cold Shutdown," required, in part, that operators block Main Steam Isolation System (MSIS)actuation when block permissive
Revision,
Review/Approval
ofProcedures,"
Section5.13.2,statesthatallprocedures
shallbestrictlyadheredto.OP1-0030127,
Rev68,"ReactorPlantCooldown-HotStandbytoColdShutdown,"
required,
inpart,thatoperators
blockMainSteamIsolation
System(MSIS)actuation
whenblockpermissive
annunciations
annunciations
werereceived.
were received.ONOP 1-0030131, Rev 60,"Plant Annunciator
ONOP1-0030131,
Summary," required that, upon valid receipt of annunciators
Rev60,"PlantAnnunciator
Q-18 and Q-20, operators immediately
Summary,"
block channels A and B, respectively.
requiredthat,uponvalidreceiptofannunciators
Contrary to the above, on August 2, 1995, during a cooldown of St.Lucie Unit 1, valid block.permissive
Q-18andQ-20,operators
immediately
blockchannelsAandB,respectively.
Contrarytotheabove,onAugust2,1995,duringacooldownofSt.LucieUnit1,validblock.permissive
annunciators
annunciators
werereceived,
were received, however, operators failed to establish the required MSIS blocks, resulting in A and B channel MSIS actuations.
however,operators
RESPONSE A: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to block the actuation of the main steam isolation signal (MSIS)in accordance
failedtoestablish
with the requirements
therequiredMSISblocks,resulting
of the approved plant operating procedure.
inAandBchannelMSISactuations.
RESPONSEA:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofautilitylicensedoperatorwhofailedtoblocktheactuation
ofthemainsteamisolation
signal(MSIS)inaccordance
withtherequirements
oftheapprovedplantoperating
procedure.
2.CORRECTIVE
2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.Themainsteamisolation
STEPS TAKEN AND THE RESULTS ACHIEVED A.The main steam isolation signal (MSIS)was blocked and reset immediately
signal(MSIS)wasblockedandresetimmediately
following the event on August 2, 1995.  
following
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTXVE
theeventonAugust2,1995.  
STEPS TO AVOXD FURTHER VXOLATXONS
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
A.The licensed operator who was involved in the event was counseled on the need to follow procedures
InsectionReort95-153.CORRECTXVE
and received discipline
STEPSTOAVOXDFURTHERVXOLATXONS
in accordance
A.Thelicensedoperatorwhowasinvolvedintheeventwascounseled
with plant'policy.
ontheneedtofollowprocedures
B.All Operations
andreceiveddiscipline
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
inaccordance
to this event to reiterate FPL's goal for error free performance.
withplant'policy.
C.This event will be incorporated
B.AllOperations
into licensed operator requalification
NuclearPlantSupervisors
training to emphasize procedural
(NPS)heldmeetingswiththeircrewssubsequent
compliance, proper communication
tothiseventtoreiterate
among the Control Room'team, and the importance
FPL'sgoalforerrorfreeperformance.
of supervision-in the control room maintaining
C.Thiseventwillbeincorporated
an overall awareness, of activities.
intolicensedoperatorrequalification
This action will be complete by January 1, 1996.D.St.Lucie Plant adopted verbatim compliance
trainingtoemphasize
as the only acceptable
procedural
means of procedure compliance.
compliance,
This requirement
propercommunication
has been incorporated
amongtheControlRoom'team,andtheimportance
into plant Quality Instruction
ofsupervision
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
-inthecontrolroommaintaining
of Procedures'~
anoverallawareness,
" 4.Full compliance
ofactivities.
was achieved on August 2, 1995 with the completion
ThisactionwillbecompletebyJanuary1,1996.D.St.LuciePlantadoptedverbatimcompliance
of item 2 above.  
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures'~
"4.Fullcompliance
wasachievedonAugust2,1995withthecompletion
ofitem2above.  
   
   
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION B: Technical Specification
InsectionReort95-15VIOLATION
6.8.1.a requires that written procedures
B:Technical
be established, implemented, and maintained
Specification
covering the activities
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
recommended
inAppendixAofRegulatory
in Appendix A of Regulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1..d includes administrative
1..dincludesadministrative
procedures
procedures
forprocedural
for procedural
adherence.
adherence.
Procedure
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
QI5-PR/PSL-1,
of Procedures," Section 5.13.2, states that all procedures
Rev.62,"Preparation,
shall be strictly adhered to.Contrary to the above, procedures
Revision,
were not adhered to strictly in the following examples: OP 1-0120020, Rev.72,"Filling and Venting the RCS," precaution
Review/Approval
4.2, required that Reactor Coolant System (RCS)venting, described in the procedure, not be attempted if RCS temperature
ofProcedures,"
was above 200'F.On August 2, 1995, Reactor Coolant Pump (RCP)seal venting, performed in an attempt to correct seal package leakage in the 1A2 RCP in accordance
Section5.13.2,statesthatallprocedures
with Appendix E of the subject procedure, was performed while RCS temperature
shallbestrictlyadheredto.Contrarytotheabove,procedures
was approximately
werenotadheredtostrictlyinthefollowing
370'F.As a result, design temperatures
examples:
of RCP seal components
OP1-0120020,
were approached
Rev.72,"FillingandVentingtheRCS,"precaution
or exceeded.2.OP 1-0120020, Rev.72,"Filling and Venting the RCS," Appendix E,"Restaging
4.2,requiredthatReactorCoolantSystem(RCS)venting,described
Reactor Coolant Pump Seals," required the use of RCP seal injection while restaging was attempted.
intheprocedure,
On August 2, 1995, restaging of the 1A2 RCP seal package was attempted without seal injection aligned to the seal package.As a result, design temperatures
notbeattempted
of RCP seal components
ifRCStemperature
were approached
wasabove200'F.OnAugust2,1995,ReactorCoolantPump(RCP)sealventing,performed
or exceeded.RESPONSE B: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to follow an approved plant procedure while performing
inanattempttocorrectsealpackageleakageinthe1A2RCPinaccordance
a restaging evolution on a Reactor Coolant'Pump (RCP)seal package.The operator did not strictly adhere to the conditions
withAppendixEofthesubjectprocedure,
contained in the procedure which required that RCS temperature
wasperformed
be no greater than 200'F, and that seal injection be in service.  
whileRCStemperature
wasapproximately
370'F.Asaresult,designtemperatures
ofRCPsealcomponents
wereapproached
orexceeded.
2.OP1-0120020,
Rev.72,"FillingandVentingtheRCS,"AppendixE,"Restaging
ReactorCoolantPumpSeals,"requiredtheuseofRCPsealinjection
whilerestaging
wasattempted.
OnAugust2,1995,restaging
ofthe1A2RCPsealpackagewasattempted
withoutsealinjection
alignedtothesealpackage.Asaresult,designtemperatures
ofRCPsealcomponents
wereapproached
orexceeded.
RESPONSEB:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofautilitylicensedoperatorwhofailedtofollowanapprovedplantprocedure
whileperforming
arestaging
evolution
onaReactorCoolant'Pump(RCP)sealpackage.Theoperatordidnotstrictlyadheretotheconditions
contained
intheprocedure
whichrequiredthatRCStemperature
benogreaterthan200'F,andthatsealinjection
beinservice.  
0  
0  
St.LucieUnits1and2DocketNos.50-335and50-389Reply'oNoticeofViolation
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply'o Notice of Violation Ins ection Re ort 95-15 2.CORRECTXVE
InsectionReort95-152.CORRECTXVE
STEPS TAKEN AND THE RESULTS ACHIEVED A.The RCP'estaging evolution was discontinued, and Operations
STEPSTAKENANDTHERESULTSACHIEVEDA.TheRCP'estaging
cooled and depressurized
evolution
the Reactor Coolant System (RCS)in accordance
wasdiscontinued,
with approved plant procedure to lower RCP seal temperatures
andOperations
to within the acceptable
cooledanddepressurized
range.The 1A2 RCP was secured.B.The damaged 1A2 RCP seal package was replaced prior to returning Unit 1 to operation.
theReactorCoolantSystem(RCS)inaccordance
withapprovedplantprocedure
tolowerRCPsealtemperatures
towithintheacceptable
range.The1A2RCPwassecured.B.Thedamaged1A2RCPsealpackagewasreplacedpriortoreturning
Unit1tooperation.
3.CORRECTIVE
3.CORRECTIVE
STEPSTOAVOIDFURTHERVXOLATXONS
STEPS TO AVOID FURTHER VXOLATXONS
A.Thelicensedoperatorinvolvedinthiseventwasdisciplined
A.The licensed operator involved in this event was disciplined
inaccordance
in accordance
withplantpolicy.B.Theprocedure
with plant policy.B.The procedure appendix which was used for performing
appendixwhichwasusedforperforming
the restaging of the RCPs was deleted and is no longer available for use.C.Plant management
therestaging
performed an assessment
oftheRCPswasdeletedandisnolongeravailable
of the decision making process that led to the restaging of the RCP seal under the existing plant conditions.
foruse.C.Plantmanagement
Based on this assessment, Plant policy 105,"Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures
performed
which are being implemented
anassessment
for the first time or for which plant conditions
ofthedecisionmakingprocessthatledtotherestaging
are different from those described in the procedures
oftheRCPsealundertheexistingplantconditions.
D.All Operations
Basedonthisassessment,
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
Plantpolicy105,"PlantOperation
to this event to reiterate FPL's goal for error free performance.
BeyondtheEnvelopeofApprovedPlantOperating
E.St.Lucie Plant adopted verbatim compliance
Procedures",
as the only acceptable
wasrevisedtorequireatechnical
means of procedure compliance.
reviewofprocedures
This requirement
whicharebeingimplemented
has been incorporated
forthefirsttimeorforwhichplantconditions
into plant Quality Instruction
aredifferent
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
fromthosedescribed
of Procedures." 4.Full compliance
intheprocedures
was achieved on August 2, 1995 with the completion
D.AllOperations
of item 2A, above.  
NuclearPlantSupervisors
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION C: Technical Specification
(NPS)heldmeetingswiththeircrewssubsequent
6.8.1.a requires that written procedures
tothiseventtoreiterate
be established, implemented, and maintained
FPL'sgoalforerrorfreeperformance.
covering the activities
E.St.LuciePlantadoptedverbatimcompliance
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures."
4.Fullcompliance
wasachievedonAugust2,1995withthecompletion
ofitem2A,above.  
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
C:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
recommended
inAppendixAofRegulatory
in Appendix A of Regulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
1.dincludesadministrative
procedures
procedures
forprocedural
for procedural
adherence.
adherence.
Procedure
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
QI5-PR/PSL-1,
of Procedures," Section 5.13', states that all procedures
Rev.62,"Preparation,
shall be strictly adhered to.AP 1-0010123, Rev 99,"Administrative
Revision,
Controls of Valves, Locks, and Switches," step 8.1.6, required, in part, that all valve position deviations
Review/Approval
be documented
ofProcedures,"
in the Valve Switch Deviation Log.Contrary to the above, on or about August 1, 1995, HCV-25-1 through 7 were repositioned
Section5.13',statesthatallprocedures
and left in the closed position without the required entries being made in the Valve Switch Deviation Log.The Valves'ositions
shallbestrictlyadheredto.AP1-0010123,
Rev99,"Administrative
ControlsofValves,Locks,andSwitches,"
step8.1.6,required,
inpart,thatallvalvepositiondeviations
bedocumented
intheValveSwitchDeviation
Log.Contrarytotheabove,onoraboutAugust1,1995,HCV-25-1through7wererepositioned
andleftintheclosedpositionwithouttherequiredentriesbeingmadeintheValveSwitchDeviation
Log.TheValves'ositions
complicated
complicated
alossofRCSinventory.
a loss of RCS inventory.
RESPONSEC:REASONFORVIOLATION
RESPONSE C: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility licensed operators who did not properly document the closed status of the subject valves in the Valve Switch Deviation Log, as required by the approved plant procedure.
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofutilitylicensedoperators
whodidnotproperlydocumenttheclosedstatusofthesubjectvalvesintheValveSwitchDeviation
Log,asrequiredbytheapprovedplantprocedure.
2.CORRECTIVE
2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDTheSafeguards
STEPS TAKEN AND THE RESULTS ACHIEVED The Safeguards
PumpRoomSumpIsolation
Pump Room Sump Isolation valves, HCV 25-1 through HCV 25-7, were realigned to the open position immediately
valves,HCV25-1throughHCV25-7,wererealigned
following the loss of RCS inventory event on August 10, 1995, when Control Room operators discovered
totheopenpositionimmediately
the closed status of the valves.  
following
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTXVE
thelossofRCSinventory
STEPS TO AVOXD FURTHER VXOLATXONS
eventonAugust10,1995,whenControlRoomoperators
A.All Operations
discovered
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
theclosedstatusofthevalves.  
to this event to reiterate FPL's goal for error free performance.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
B.C.D.The plant has adopted verbatim compliance
InsectionReort95-153.CORRECTXVE
as the only acceptable
STEPSTOAVOXDFURTHERVXOLATXONS
means of procedure compliance.
A.AllOperations
This requirement
NuclearPlantSupervisors
has been incorporated
(NPS)heldmeetingswiththeircrewssubsequent
into plant Quality Instruction
tothiseventtoreiterate
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
FPL'sgoalforerrorfreeperformance.
of Procedures." Management
B.C.D.Theplanthasadoptedverbatimcompliance
is conducting
astheonlyacceptable
a daily review of Control Room chronological
meansofprocedure
logs to reinforce the expectation
compliance.
for detail and completeness.
Thisrequirement
I Plant administrative
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures."
Management
isconducting
adailyreviewofControlRoomchronological
logstoreinforce
theexpectation
fordetailandcompleteness.
IPlantadministrative
procedures
procedures
havebeenrevisedtoprovideforincreased
have been revised to provide for increased reviews by plant staff of the logs controlling
reviewsbyplantstaffofthelogscontrolling
valve repositioning.
valverepositioning.
Full compliance
Fullcompliance
was achieved on August 10, 1995, with the completion
wasachievedonAugust10,1995,withthecompletion
of item 2 above.  
ofitem2above.  
   
   
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION D: Technical Specification
InsectionReort95-15VIOLATION
6.8.1.a requires that written procedures
D:Technical
be established, implemented, and maintained
Specification
covering the activities
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
recommended
inAppendixAofRegulatory
in Appendix A of Regulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
1.dincludesadministrative
procedures
procedures
forprocedural
for procedural
adherence.
adherence.
Procedure
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
QI5-PR/PSL-1,
of Procedures," Section 5'3.2, states that all procedures
Rev.62,"Preparation,
shall be strictly adhered to.OP 1-0410022, Rev 22,"Shutdown Cooling," step 8.3.7, required that V3652, the B Shutdown Cooling (SDC)hot leg suction isolation valve, be locked open while placing the B SDC loop in service.Contrary to the above, on August 29, a control room operator failed to place V3652 in a locked open condition while placing the B SDC loop in service.As a result, the 1B Low Pressure Safety Injection Pump was operated with its suction line isolated.RESPONSE D: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to properly verify the alignment of the shutdown cooling (SDC)system flowpath in accordance
Revision,
with the approved plant procedure, prior to starting the 1B Low Pressure Safety Injection (LPSI)Pump.This resulted in the failure to open the 1B LPSI Pump suction isolation valve.2.CORRECTIVE
Review/Approval
STEPS TAKEN AND THE RESULTS ACHIEVED A.The Control Room operators noted the error in valve alignment and the LPSI pump was secured approximately
ofProcedures,"
5 minutes after being started.A subsequent
Section5'3.2,statesthatallprocedures
shallbestrictlyadheredto.OP1-0410022,
Rev22,"Shutdown
Cooling,"
step8.3.7,requiredthatV3652,theBShutdownCooling(SDC)hotlegsuctionisolation
valve,belockedopenwhileplacingtheBSDCloopinservice.Contrarytotheabove,onAugust29,acontrolroomoperatorfailedtoplaceV3652inalockedopencondition
whileplacingtheBSDCloopinservice.Asaresult,the1BLowPressureSafetyInjection
Pumpwasoperatedwithitssuctionlineisolated.
RESPONSED:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofautilitylicensedoperatorwhofailedtoproperlyverifythealignment
oftheshutdowncooling(SDC)systemflowpathinaccordance
withtheapprovedplantprocedure,
priortostartingthe1BLowPressureSafetyInjection
(LPSI)Pump.Thisresultedinthefailuretoopenthe1BLPSIPumpsuctionisolation
valve.2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.TheControlRoomoperators
notedtheerrorinvalvealignment
andtheLPSIpumpwassecuredapproximately
5minutesafterbeingstarted.Asubsequent
inspection
inspection
determined
determined
thatnodamagehadoccurredduringtheshortperiodofpumpoperation.
that no damage had occurred during the short period of pump operation.
B.Thesystemwasrealigned
B.The system was realigned in accordance
inaccordance
with the approved procedure and the LPSI pump was restarted.
withtheapprovedprocedure
andtheLPSIpumpwasrestarted.
Subsequent
Subsequent
operation
operation of the LPSI pump was satisfactory.
oftheLPSIpumpwassatisfactory.
C.An ASME Section XI code run was performed satisfactorily
C.AnASMESectionXIcoderunwasperformed
on the 1B LPSI Pump and a subsequent
satisfactorily
onthe1BLPSIPumpandasubsequent
Engineering
Engineering
assessment
assessment
concluded
concluded that pump operability
thatpumpoperability
had not been adversely affected.  
hadnotbeenadversely
St.Lucie Units.1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE
affected.  
STEPS TO AVOID FURTHER VIOLATIONS
St.LucieUnits.1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
A.The licensed operator involved in this event was disciplined
InsectionReort95-153.CORRECTIVE
in accordance
STEPSTOAVOIDFURTHERVIOLATIONS
with plant policy.B.Operations
A.Thelicensedoperatorinvolvedinthiseventwasdisciplined
inaccordance
withplantpolicy.B.Operations
implemented
implemented
procedure
procedure changes which require the use of a dedicated procedure reader to assist in the implementation
changeswhichrequiretheuseofadedicated
of SDC related evolutions.
procedure
C.All Operations
readertoassistintheimplementation
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
ofSDCrelatedevolutions.
to this event to reiterate FPL's goal for error free performance.
C.AllOperations
D.The plant has adopted verbatim compliance
NuclearPlantSupervisors
as the only acceptable
(NPS)heldmeetingswiththeircrewssubsequent
means of procedure compliance.
tothiseventtoreiterate
This requirement
FPL'sgoalforerrorfreeperformance.
has been incorporated
D.Theplanthasadoptedverbatimcompliance
into plant Quality Instruction
astheonlyacceptable
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
meansofprocedure
of Procedures." E.This event will be included into licensed operator, requalification
compliance.
training.This action will be completed by January 1, 1996.4.Full compliance
Thisrequirement
was achieved on August 29, 1995 with the completion
hasbeenincorporated
of item 2A and 2B above.  
intoplantQualityInstruction
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION E: Technical Specification
QI5-PR/PSL-1,
6.8.1.a requires that written procedures
"Preparation,
be established, implemented, and maintained
Revision,
covering the activities
Review/Approval
ofProcedures."
E.Thiseventwillbeincludedintolicensedoperator,
requalification
training.
Thisactionwillbecompleted
byJanuary1,1996.4.Fullcompliance
wasachievedonAugust29,1995withthecompletion
ofitem2Aand2Babove.  
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
E:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
recommended
inAppendixAofRegulatory
in Appendix A of Regulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
1.dincludesadministrative
procedures
procedures
forprocedural
for procedural
adherence.
adherence.
Procedure
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
QI5-PR/PSL-1,
of Procedures," Section 5.13.2, states that all procedures
Rev.62,"Preparation,
shall be strictly adhered to.QI 16-PR/PSL-2, Rev.1,"St.Lucie Action Report (STAR)Program," required that STARs be initiated for Quality Assurance audit findings and independent
Revision,
technical review recommendations'ontrary
Review/Approval
to the above, a STAR was not generated when a Quality Assurance review of an inadvertent
ofProcedures,"
Unit 1 containment
Section5.13.2,statesthatallprocedures
spraydown, documented
shallbestrictlyadheredto.QI16-PR/PSL-2,
in interoffice
Rev.1,"St.LucieActionReport(STAR)Program,"
requiredthatSTARsbeinitiated
forQualityAssurance
auditfindingsandindependent
technical
reviewrecommendations'ontrary
totheabove,aSTARwasnotgenerated
whenaQualityAssurance
reviewofaninadvertent
Unit1containment
spraydown,
documented
ininteroffice
correspondence
correspondence
JQQ-95-143,
JQQ-95-143, identified
identified
the practice of prelubricating
thepracticeofprelubricating
FCV-07-1A, Containment
FCV-07-1A,
Spray header A flow control valve, when performing
valve stroke time testing.RESPONSE E: 1.REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility Quality Assurance (QA)personnel.
QA personnel were in the process of conducting
an independent
review focusing on the contributing
factors associated
with a Unit 1 containment
spray down event.The practice of pre-lubricating
Containment
Containment
SprayheaderAflowcontrolvalve,whenperforming
Spray header flow control valve FCV-07-lA prior to surveillance
valvestroketimetesting.RESPONSEE:1.REASONFORVIOLATION
testing was identified
Therootcauseofthisviolation
during this.review, but was not determined
wascognitive
to be a contributing
personnel
factor to this event.Recommendations
erroronthepartofutilityQualityAssurance
to correct this deficiency
(QA)personnel.
were therefore not contained in the resulting QA report, nor was a St.Lucie Action Request (STAR)generated in a timely manner.2.=CORRECTIVE
QApersonnel
STEPS TAKEN AND THE RESULTS ACHIEVED A.A St.Lucie Action Request (STAR 951048)was generated on September 7, 1995 to document the deficient practice of pre-lubricating
wereintheprocessofconducting
Unit 1 and Unit 2 containment
anindependent
spray flow control valves prior to surveillance
reviewfocusingonthecontributing
stroke time testing.B.Temporary changes were issued to plant surveillance
factorsassociated
withaUnit1containment
spraydownevent.Thepracticeofpre-lubricating
Containment
SprayheaderflowcontrolvalveFCV-07-lApriortosurveillance
testingwasidentified
duringthis.review,butwasnotdetermined
tobeacontributing
factortothisevent.Recommendations
tocorrectthisdeficiency
weretherefore
notcontained
intheresulting
QAreport,norwasaSt.LucieActionRequest(STAR)generated
inatimelymanner.2.=CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.ASt.LucieActionRequest(STAR951048)wasgenerated
onSeptember
7,1995todocumentthedeficient
practiceofpre-lubricating
Unit1andUnit2containment
sprayflowcontrolvalvespriortosurveillance
stroketimetesting.B.Temporary
changeswereissuedtoplantsurveillance
procedures
procedures
onSeptember
on September 2, 1995 to remove the practice of'pre-lubricating
2,1995toremovethepracticeof'pre-lubricating
valves prior to surveillance
valvespriortosurveillance
testing.10  
testing.10  
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE
InsectionReort95-153.CORRECTIVE
STEPS TO AVOID FURTHER VIOLATIONS
STEPSTOAVOIDFURTHERVIOLATIONS
A.B.C.A meeting was held on September 13, 1995 between the Vice President of Nuclear Assurance and all St.Lucie Quality Assurance and Quality Control personnel.
A.B.C.AmeetingwasheldonSeptember
During this meeting, clear expectations
13,1995betweentheVicePresident
were provided regarding the threshold for identification
ofNuclearAssurance
and documentation
andallSt.LucieQualityAssurance
of deficiencies
andQualityControlpersonnel.
by Quality personnel.
Duringthismeeting,clearexpectations
E On October 25, 1995, a second meeting was held between the site Quality Manager and St.Lucie QA personnel.
wereprovidedregarding
During this meeting, the requirements
thethreshold
of the Quality Instruction
foridentification
QI 16-PR/PSL-2,"St.Lucie Action Report (STAR)Program" were reviewed.The responsibility
anddocumentation
of QA personnel for timely identification
ofdeficiencies
and documentation
byQualitypersonnel.
of deficiencies
EOnOctober25,1995,asecondmeetingwasheldbetweenthesiteQualityManagerandSt.LucieQApersonnel.
in accordance
Duringthismeeting,therequirements
with this procedure was reinforced.
oftheQualityInstruction
Permanent changes will be made to plant surveillance
QI16-PR/PSL-2,
"St.LucieActionReport(STAR)Program"werereviewed.
Theresponsibility
ofQApersonnel
fortimelyidentification
anddocumentation
ofdeficiencies
inaccordance
withthisprocedure
wasreinforced.
Permanent
changeswillbemadetoplantsurveillance
procedures
procedures
todiscontinue
to discontinue
thepracticeofpre-testlubrication
the practice of pre-test lubrication
ofthevalvespriortosurveillance
of the valves prior to surveillance
testing.Thisactionwillbecompleted
testing.This action will be completed by December 1, 1995.4.Full compliance
byDecember1,1995.4.Fullcompliance
was achieved on September 7, 1995 with the completion
wasachievedonSeptember
of item 2A above.  
7,1995withthecompletion
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION F: Technical Specification
ofitem2Aabove.  
6.8~1.a requires that written procedures
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
be established, implemented, and maintained
InsectionReort95-15VIOLATION
covering the activities
F:Technical
Specification
6.8~1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
recommended
inAppendixAofRegulatory
in Appendix A of Regulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative
1.dincludesadministrative
procedures
procedures
forprocedural
for procedural
adherence.
adherence.
Procedure
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval
QI5-PR/PSL-1,
of Procedures," Section 5.13.2, states that all procedures
Rev.62,"Preparation,
shall be strictly adhered to.ADM-08.02, Rev 7,"Conduct of Maintenance," Appendix 5, step 5, required that procedures
Revision,
be present during work and that individual
Review/Approval
steps be initialed once performed.
ofProcedures,"
Contrary to the above, inspection
Section5.13.2,statesthatallprocedures
of work in progress revealed that individual
shallbestrictlyadheredto.ADM-08.02,
steps were not initialed once performed upon completion
Rev7,"ConductofMaintenance,"
for work conducted in accordance
Appendix5,step5,requiredthatprocedures
with Plant Change/Modification
bepresentduringworkandthatindividual
11-195.RESPONSE F: 1.REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of an Electrical
stepsbeinitialed
onceperformed.
Contrarytotheabove,inspection
ofworkinprogressrevealedthatindividual
stepswerenotinitialed
onceperformed
uponcompletion
forworkconducted
inaccordance
withPlantChange/Modification
11-195.RESPONSEF:1.REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofanElectrical
Department
Department
journeyman
journeyman
whofailedtoproperlydocumentthecompletion
who failed to properly document the completion
ofstepswhileperforming
of steps while performing
workactivities
work activities
associated
associated
withthetripsolenoids
with the trip solenoids on the 1B Emergency Diesel Generator (EDG).The steps were not initialed as they were being performed, in accordance
onthe1BEmergency
with approved plant procedure.
DieselGenerator
(EDG).Thestepswerenotinitialed
astheywerebeingperformed,
inaccordance
withapprovedplantprocedure.
2.CORRECTIVE
2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.Thestepsofthemaintenance
STEPS TAKEN AND THE RESULTS ACHIEVED A.The steps of the maintenance
procedure
procedure being worked were signed off by the journeyman
beingworkedweresignedoffbythejourneyman
immediately
immediately
following
following the completion
thecompletion
of the work on August 31, 1995, and the completed procedure was reviewed by the chief electrician
oftheworkonAugust31,1995,andthecompleted
and Electrical
procedure
wasreviewedbythechiefelectrician
andElectrical
supervisor.
supervisor.
B.TheEDGcircuitry
B.The EDG circuitry was subsequently
wassubsequently
tested following completion
testedfollowing
of the work on August 31, 1995, and performed satisfactorily.
completion
oftheworkonAugust31,1995,andperformed
satisfactorily.
12  
12  
0  
0  
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE
InsectionReort95-153.CORRECTIVE
STEPS TO AVOID FURTHER VIOLATIONS
STEPSTOAVOIDFURTHERVIOLATIONS
A.Meetings were held following this event with Electrical
A.Meetingswereheldfollowing
thiseventwithElectrical
Maintenance
Maintenance
employees
employees to review this incident and emphasize management
toreviewthisincidentandemphasize
management
expectations
expectations
regarding
regarding the documentation
thedocumentation
of w'ork activities.
ofw'orkactivities.
B.Supervisors
B.Supervisors
fromeachMaintenance
from each Maintenance
discipline
discipline
haveconducted
have conducted meetings with their employees to reinforce the need for strict adherence to the administrative
meetingswiththeiremployees
toreinforce
theneedforstrictadherence
totheadministrative
requirements
requirements
relatedtoprocedure
related to procedure use.C.The plant has adopted verbatim compliance
use.C.Theplanthasadoptedverbatimcompliance
as the only acceptable
astheonlyacceptable
means of procedure compliance.
meansofprocedure
This requirement
compliance.
has been incorporated
Thisrequirement
into plant Quality Instruction
hasbeenincorporated
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval
intoplantQualityInstruction
of Procedures." 4.Full compliance
QI5-PR/PSL-1,
was achieved on August 31, 1995 with the completion
"Preparation,
of item 2A and 2B above.13  
Revision,
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION G: 10 CFR 50 Appendix B, Criterion V,"Instructions, Procedures, and Drawings," requires, in part, that activities
Review/Approval
affecting quality shall be prescribed
ofProcedures."
by documented
4.Fullcompliance
wasachievedonAugust31,1995withthecompletion
ofitem2Aand2Babove.13  
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
G:10CFR50AppendixB,Criterion
V,"Instructions,
Procedures,
andDrawings,"
requires,
inpart,thatactivities
affecting
qualityshallbeprescribed
bydocumented
procedures
procedures
ofatypeappropriate
of a type appropriate
tothecircumstances.
to the circumstances.
Contrarytotheabove,onAugust18,1995,ventingoftheLowPressureSafetyInjection
Contrary to the above, on August 18, 1995, venting of the Low Pressure Safety Injection (LPSI)System was conducted in accordance
(LPSI)Systemwasconducted
with a procedure which was inappropriate
inaccordance
to the circumstances.
withaprocedure
Specifically, OP 1-0420060, Rev.0,"Venting of the Emergency Core Cooling and Containment
whichwasinappropriate
Spray Systems," did not require a verification
tothecircumstances.
that the portions of the system being vented were hydraulically
Specifically,
isolated from adjacent systems and flowpaths.
OP1-0420060,
As a result of this failure to establish proper initial conditions, water driven by the 1A LPSI pump was inadvertently
Rev.0,"VentingoftheEmergency
directed to the A Train Containment
CoreCoolingandContainment
Spray header, resulting in a spraydown of the Unit 1 Reactor Containment
SpraySystems,"
Building.RESPONSE G: REASON FOR VIOLATION The root cause of this violation was procedural
didnotrequireaverification
thattheportionsofthesystembeingventedwerehydraulically
isolatedfromadjacentsystemsandflowpaths.
Asaresultofthisfailuretoestablish
properinitialconditions,
waterdrivenbythe1ALPSIpumpwasinadvertently
directedtotheATrainContainment
Sprayheader,resulting
inaspraydown
oftheUnit1ReactorContainment
Building.
RESPONSEG:REASONFORVIOLATION
Therootcauseofthisviolation
wasprocedural
deficiency
deficiency
inthattheECCSventingprocedure,
in that the ECCS venting procedure, OP 1-0420060, did not state the plant conditions
OP1-0420060,
required to successfully
didnotstatetheplantconditions
vent the ECCS but relied upon the RCS heatup procedure to set plant conditions.
requiredtosuccessfully
Specifically, the venting procedure did not require operators to verify that the proper containment
venttheECCSbutreliedupontheRCSheatupprocedure
spray header isolation valves were closed prior to recirculating
tosetplantconditions.
the water in the SDC system.A contributing
Specifically,
factor to this event was that the operations
theventingprocedure
personnel performing
didnotrequireoperators
the ECCS venting procedure did not recognize that the existing plant conditions
toverifythatthepropercontainment
would result in flow to the'A'ontainment
sprayheaderisolation
spray header when flow was aligned through the Shutdown Cooling Heat Exchanger.
valveswereclosedpriortorecirculating
A second contributing
thewaterintheSDCsystem.Acontributing
factor of this event was that FCV-07-1A was placed in the open position because this valve had failed its ASME stroke time test.Plant management
factortothiseventwasthattheoperations
made the decision to defer the valve repair and position this normally closed valve to its engineered
personnel
performing
theECCSventingprocedure
didnotrecognize
thattheexistingplantconditions
wouldresultinflowtothe'A'ontainment
sprayheaderwhenflowwasalignedthroughtheShutdownCoolingHeatExchanger.
Asecondcontributing
factorofthiseventwasthatFCV-07-1A
wasplacedintheopenpositionbecausethisvalvehadfaileditsASMEstroketimetest.Plantmanagement
madethedecisiontodeferthevalverepairandpositionthisnormallyclosedvalvetoitsengineered
safeguards
safeguards
openpositioninlieuofrepairing
open position in lieu of repairing the valve prior to startup.14  
thevalvepriortostartup.14  
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 2.CORRECTIVE
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
STEPS TAKEN AND THE RESULTS ACHIEVED A.Operators secured the 1A LPSI Pump and isolated, the flowpath to the containment
InsectionReort95-152.CORRECTIVE
spray header from the LPSI Pump.The Reactor Cavity sump was drained to the Waste Management
STEPSTAKENANDTHERESULTSACHIEVEDA.Operators
System.B~Following the event, all nonessential
securedthe1ALPSIPumpandisolated,
work at the site was placed on hold, and Unit 1 was maintained
theflowpathtothecontainment
stable in Mode 3 while senior plant management
sprayheaderfromtheLPSIPump.TheReactorCavitysumpwasdrainedtotheWasteManagement
conducted meetings with all available site personnel to stress the need for worker vigilance and attention to detail.The need to reduce equipment deficiencies
System.B~Following
that impact operations
theevent,allnonessential
was also discussed.
workatthesitewasplacedonhold,andUnit1wasmaintained
C.Unit 1 was cooled down and depressurized
stableinMode3whileseniorplantmanagement
to Mode,5 and an inspection
conducted
and decontamination
meetingswithallavailable
of containment
sitepersonnel
was then conducted.
tostresstheneedforworkervigilance
The event was evaluated under an Engineering
andattention
evaluation, which resulted in a comprehensive
todetail.Theneedtoreduceequipment
deficiencies
thatimpactoperations
wasalsodiscussed.
C.Unit1wascooleddownanddepressurized
toMode,5andaninspection
anddecontamination
ofcontainment
wasthenconducted.
Theeventwasevaluated
underanEngineering
evaluation,
whichresultedinacomprehensive
inspection
inspection
ofcomponents
of components
insidecontainment
inside containment
toensurefuturecomponent
to ensure future component reliability.
reliability.
D.Operating procedure, OP 1-0420060,"Venting of the Emergency Core Cooling an'd Containment
D.Operating
Spray System", was revised September 1, 1995 to include the plant conditions
procedure,
required to be present during venting.3.CORRECTIVE
OP1-0420060,
STEPS TO AVOID FURTHER VIOLATIONS
"VentingoftheEmergency
A.Plant policy 105,"Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures
CoreCoolingan'dContainment
which are being implemented
SpraySystem",wasrevisedSeptember
for the first time or for which plant conditions
1,1995toincludetheplantconditions
are different from those described in the procedure.
requiredtobepresentduringventing.3.CORRECTIVE
B.The Maintenance
STEPSTOAVOIDFURTHERVIOLATIONS
A.Plantpolicy105,"PlantOperation
BeyondtheEnvelopeofApprovedPlantOperating
Procedures",
wasrevisedtorequireatechnical
reviewofprocedures
whicharebeingimplemented
forthefirsttimeorforwhichplantconditions
aredifferent
fromthosedescribed
intheprocedure.
B.TheMaintenance
Department
Department
established
established
ateamcomposedofplantstaffandengineering
a team composed of plant staff and engineering
personnel,
personnel, to determine the root cause for the Containment
todetermine
Spray header isolation valve repeat failures and determine corrective
therootcausefortheContainment
actions to eliminate this operator workaround.
Sprayheaderisolation
FCV-07-1A was repaired prior to returning Unit 1 to service.15  
valverepeatfailuresanddetermine
St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 C.Existing plant deficiencies
corrective
were reviewed by senior plant management.
actionstoeliminate
thisoperatorworkaround.
FCV-07-1A
wasrepairedpriortoreturning
Unit1toservice.15  
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15C.Existingplantdeficiencies
werereviewedbyseniorplantmanagement.
Additional
Additional
deficiencies
deficiencies
whichcouldimpactoperations
which could impact operations
wereaddedtotheworkscopeoftheUnit1shutdown.
were added to the work scope of the Unit 1 shutdown.These deficiencies
Thesedeficiencies
were corrected prior to returning the unit to service.D.Administrative
werecorrected
procedure, AP-0010147,"Assessment
priortoreturning
of Abnormal Plant Configurations
theunittoservice.D.Administrative
or Significant
procedure,
Material Deficient'Conditions
AP-0010147,
on Plant Operation", was developed to enhance outage scope review and ensure that equipment deficiencies
"Assessment
are restored in a timely manner.E.St.Lucie management
ofAbnormalPlantConfigurations
orSignificant
MaterialDeficient
'Conditions
onPlantOperation",
wasdeveloped
toenhanceoutagescopereviewandensurethatequipment
deficiencies
arerestoredinatimelymanner.E.St.Luciemanagement
instituted
instituted
aweeklyreviewofappropriate
a weekly review of appropriate
performance
performance
indicators
indicators
andworkbacklogstatus,including
and work backlog status, including the age of open items and operator workarounds.
theageofopenitemsandoperatorworkarounds.
F.All Operations
F.AllOperations
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent
NuclearPlantSupervisors
to this event to reiterate FPL's goal for erro'r free performance.
(NPS)heldmeetingswiththeircrewssubsequent
G.This event will be incorporated
tothiseventtoreiterate
into licensed operator requalification
FPL'sgoalforerro'rfreeperformance.
training.This action will be complete by January 1, 1996.4.Full compliance
G.Thiseventwillbeincorporated
was achieved on August 18, 1995 with the completion
intolicensedoperatorrequalification
of items 2A, 2C and 2D above.16
training.
ThisactionwillbecompletebyJanuary1,1996.4.Fullcompliance
wasachievedonAugust18,1995withthecompletion
ofitems2A,2Cand2Dabove.16
}}
}}

Revision as of 16:59, 7 July 2018

Forwards Response to NRC Ltr Re Violations Noted in Insp Repts 50-335/95-15 & 50-389/95-15.Corrective Actions:Msis Was Blocked & Reset Immediately Following Event on 950802
ML17228B327
Person / Time
Site: Saint Lucie  NextEra Energy icon.png
Issue date: 11/15/1995
From: GOLDBERG J H
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-95-306, NUDOCS 9511210113
Download: ML17228B327 (23)


See also: IR 05000335/1995015

Text

RIG RITY 1 ACCELERATED

RIDS PROCESSING), REGULATORY

INFORMATION

DISTRIBUTION

SYSTEM (RIDS)r'ESSION NBR 9511210113

DOC~DATE'5/11/15

NOTARIZED NO FACIL:50-335

St.Lucie Plant, Unit 1, Florida Power&Light Co.50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION

GOLDBERG,J.H.

Florida Power&'ight Co.RECIP.NAME

RECIPIENT AFFILIATION

Document Control Branch (Document Control Desk)SUBJECT: Forwards response to NRC ltr re violations

noted in insp repts 50-335/95-15

&50-389/95-15.Corrective

actions:MSIS

was blocked&reset immediately

following event on 950802.I DISTRIBUTION

CODE: IE01D COPIES RECEIVED:LTR

ENCL SIZE: TITLE: General (50 Dkt)-Insp Rept/Notice

of Violation Response NOTES DOCKET N 05000335 05000389 INTERNAL: RECIPIENT ID CODE/NAME PD2-1 PD ACRS AEOD/SPD/RAB

DEDRO NRR/DISP/PIPB

NRR/DRPM/PECB

OE DIR RGN2 FILE 01 COPIES RECIPIENT LTTR ENCL ID CODE/NAME 1 1 NORRIS,J 2 AEOD/DEIB 1 A'E.1 FILE CENTER 1/'DRC8/H FB 1 NUDOCS-ABSTRACT

1'GC/HDS3 1 COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 EXTERNAL: LITCO BRYCE,J H NRC PDR 1 1 1 1 NOAC 1 1 iNOTE TO ALL RIDS" RECIPIEYTS:

PLEASE HELP US TO REDUCE 4VASTE!CONTACT THE DOCL'!iIEYT

CO."iTROL DESK, ROOiiI Pl-37 (EXT.504-2083)TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY.

LISTS FOR DOCL'IiIEi'I'S

5'OU DOi"I'L'LD!TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19

4 0'

0 Florida Power L Light Company, P.O.Box 14000, Juno Beach, FL 33408 0420 NOV 1 5$995 L-95-306 10 CFR 2.201 U.S.Nuclear Regulatory

Commission

Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15Florida Power and Light Company (FPL)has reviewed the subject inspection

report and pursuant to 10 CFR 2.201 the response to the notice of violation is attached.Very truly yours, J.H.Goldberg President-Nuclear Division JHG/DAS/EJB

Attachment

cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St.Lucie Plant 95ii210i13

'it5iii5 PDR ADOCK 05000335 9 PDR an FPL Group company

FPL RESPONSE TO INSPECTION

REPORT 95-15 SUMMARY NRC Inspection

Report 50-335/389/95-15

considered

St.Lucie Plant performance

during the six (6)week period from July 30, 1995 through September 16, 1995.The violations

below occurred during a relatively

short period of time, as described in the inspection

report, and several of the corrective

actions were instituted

following an analysis of the events, collectively.

The corrective

steps to avoid further violations

were in some cases determined

to be generic following this analysis, and are therefore repeated in a number of the responses.

The Inspection

Report identified

seven (7)violations

which are listed below.Violation A: Failure to Follow Procedures

and Block MSIS Actuation Violation B: Failure to Follow Procedures

During RCP Seal Restaging Violation C: Failure to Follow Procedure and Document Abnormal Valve Position in the Valve, Switch Deviation log Violation D: Failure to Follow Procedures

during Alignment of Shutdown Cooling System Violation E: Failure to Follow Procedure and Document a Deficiency

on Containment

Spray Valve Surveillance

Test Procedure Violation F: Failure to Initial Maintenance

Procedure Steps as Work was Completed Violation G: Failure to Follow Procedures

During Venting of ECCS System Resulted in Containment

Spraydown Additionally, both Florida Power and Light (FPL)and the NRC evaluated plant events to identify common underlying

themes.FPL presented a summary of events to the NRC on August 29, 1995.Weaknesses

identified

in this summary included procedure content and use, as well as management

oversight of eguipment performance.

FPL's Plan to Improve the Operational

Performance

at St.Lucie was developed as a result of the August 29, 1995, meeting and submitted to the NRC on September 15, 1995.To date, FPL has completed the activities

according to the improvement

plan schedule.

S=.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION A: Technical Specification 6.8.1.a requires that written procedures

be established, implemented, and maintained

covering the activities

recommended

in Appendix A of Regulatory

Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative

procedures

for procedural

adherence.

Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval

of Procedures," Section 5.13.2, states that all procedures

shall be strictly adhered to.OP 1-0030127, Rev 68,"Reactor Plant Cooldown-Hot Standby to Cold Shutdown," required, in part, that operators block Main Steam Isolation System (MSIS)actuation when block permissive

annunciations

were received.ONOP 1-0030131, Rev 60,"Plant Annunciator

Summary," required that, upon valid receipt of annunciators

Q-18 and Q-20, operators immediately

block channels A and B, respectively.

Contrary to the above, on August 2, 1995, during a cooldown of St.Lucie Unit 1, valid block.permissive

annunciators

were received, however, operators failed to establish the required MSIS blocks, resulting in A and B channel MSIS actuations.

RESPONSE A: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to block the actuation of the main steam isolation signal (MSIS)in accordance

with the requirements

of the approved plant operating procedure.

2.CORRECTIVE

STEPS TAKEN AND THE RESULTS ACHIEVED A.The main steam isolation signal (MSIS)was blocked and reset immediately

following the event on August 2, 1995.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTXVE

STEPS TO AVOXD FURTHER VXOLATXONS

A.The licensed operator who was involved in the event was counseled on the need to follow procedures

and received discipline

in accordance

with plant'policy.

B.All Operations

Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent

to this event to reiterate FPL's goal for error free performance.

C.This event will be incorporated

into licensed operator requalification

training to emphasize procedural

compliance, proper communication

among the Control Room'team, and the importance

of supervision-in the control room maintaining

an overall awareness, of activities.

This action will be complete by January 1, 1996.D.St.Lucie Plant adopted verbatim compliance

as the only acceptable

means of procedure compliance.

This requirement

has been incorporated

into plant Quality Instruction

QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval

of Procedures'~

" 4.Full compliance

was achieved on August 2, 1995 with the completion

of item 2 above.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION B: Technical Specification 6.8.1.a requires that written procedures

be established, implemented, and maintained

covering the activities

recommended

in Appendix A of Regulatory

Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1..d includes administrative

procedures

for procedural

adherence.

Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval

of Procedures," Section 5.13.2, states that all procedures

shall be strictly adhered to.Contrary to the above, procedures

were not adhered to strictly in the following examples: OP 1-0120020, Rev.72,"Filling and Venting the RCS," precaution

4.2, required that Reactor Coolant System (RCS)venting, described in the procedure, not be attempted if RCS temperature

was above 200'F.On August 2, 1995, Reactor Coolant Pump (RCP)seal venting, performed in an attempt to correct seal package leakage in the 1A2 RCP in accordance

with Appendix E of the subject procedure, was performed while RCS temperature

was approximately

370'F.As a result, design temperatures

of RCP seal components

were approached

or exceeded.2.OP 1-0120020, Rev.72,"Filling and Venting the RCS," Appendix E,"Restaging

Reactor Coolant Pump Seals," required the use of RCP seal injection while restaging was attempted.

On August 2, 1995, restaging of the 1A2 RCP seal package was attempted without seal injection aligned to the seal package.As a result, design temperatures

of RCP seal components

were approached

or exceeded.RESPONSE B: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to follow an approved plant procedure while performing

a restaging evolution on a Reactor Coolant'Pump (RCP)seal package.The operator did not strictly adhere to the conditions

contained in the procedure which required that RCS temperature

be no greater than 200'F, and that seal injection be in service.

0

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply'o Notice of Violation Ins ection Re ort 95-15 2.CORRECTXVE

STEPS TAKEN AND THE RESULTS ACHIEVED A.The RCP'estaging evolution was discontinued, and Operations

cooled and depressurized

the Reactor Coolant System (RCS)in accordance

with approved plant procedure to lower RCP seal temperatures

to within the acceptable

range.The 1A2 RCP was secured.B.The damaged 1A2 RCP seal package was replaced prior to returning Unit 1 to operation.

3.CORRECTIVE

STEPS TO AVOID FURTHER VXOLATXONS

A.The licensed operator involved in this event was disciplined

in accordance

with plant policy.B.The procedure appendix which was used for performing

the restaging of the RCPs was deleted and is no longer available for use.C.Plant management

performed an assessment

of the decision making process that led to the restaging of the RCP seal under the existing plant conditions.

Based on this assessment, Plant policy 105,"Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures

which are being implemented

for the first time or for which plant conditions

are different from those described in the procedures

D.All Operations

Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent

to this event to reiterate FPL's goal for error free performance.

E.St.Lucie Plant adopted verbatim compliance

as the only acceptable

means of procedure compliance.

This requirement

has been incorporated

into plant Quality Instruction

QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval

of Procedures." 4.Full compliance

was achieved on August 2, 1995 with the completion

of item 2A, above.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION C: Technical Specification 6.8.1.a requires that written procedures

be established, implemented, and maintained

covering the activities

recommended

in Appendix A of Regulatory

Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative

procedures

for procedural

adherence.

Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval

of Procedures," Section 5.13', states that all procedures

shall be strictly adhered to.AP 1-0010123, Rev 99,"Administrative

Controls of Valves, Locks, and Switches," step 8.1.6, required, in part, that all valve position deviations

be documented

in the Valve Switch Deviation Log.Contrary to the above, on or about August 1, 1995, HCV-25-1 through 7 were repositioned

and left in the closed position without the required entries being made in the Valve Switch Deviation Log.The Valves'ositions

complicated

a loss of RCS inventory.

RESPONSE C: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility licensed operators who did not properly document the closed status of the subject valves in the Valve Switch Deviation Log, as required by the approved plant procedure.

2.CORRECTIVE

STEPS TAKEN AND THE RESULTS ACHIEVED The Safeguards

Pump Room Sump Isolation valves, HCV 25-1 through HCV 25-7, were realigned to the open position immediately

following the loss of RCS inventory event on August 10, 1995, when Control Room operators discovered

the closed status of the valves.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTXVE

STEPS TO AVOXD FURTHER VXOLATXONS

A.All Operations

Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent

to this event to reiterate FPL's goal for error free performance.

B.C.D.The plant has adopted verbatim compliance

as the only acceptable

means of procedure compliance.

This requirement

has been incorporated

into plant Quality Instruction

QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval

of Procedures." Management

is conducting

a daily review of Control Room chronological

logs to reinforce the expectation

for detail and completeness.

I Plant administrative

procedures

have been revised to provide for increased reviews by plant staff of the logs controlling

valve repositioning.

Full compliance

was achieved on August 10, 1995, with the completion

of item 2 above.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION D: Technical Specification 6.8.1.a requires that written procedures

be established, implemented, and maintained

covering the activities

recommended

in Appendix A of Regulatory

Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative

procedures

for procedural

adherence.

Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval

of Procedures," Section 5'3.2, states that all procedures

shall be strictly adhered to.OP 1-0410022, Rev 22,"Shutdown Cooling," step 8.3.7, required that V3652, the B Shutdown Cooling (SDC)hot leg suction isolation valve, be locked open while placing the B SDC loop in service.Contrary to the above, on August 29, a control room operator failed to place V3652 in a locked open condition while placing the B SDC loop in service.As a result, the 1B Low Pressure Safety Injection Pump was operated with its suction line isolated.RESPONSE D: REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of a utility licensed operator who failed to properly verify the alignment of the shutdown cooling (SDC)system flowpath in accordance

with the approved plant procedure, prior to starting the 1B Low Pressure Safety Injection (LPSI)Pump.This resulted in the failure to open the 1B LPSI Pump suction isolation valve.2.CORRECTIVE

STEPS TAKEN AND THE RESULTS ACHIEVED A.The Control Room operators noted the error in valve alignment and the LPSI pump was secured approximately

5 minutes after being started.A subsequent

inspection

determined

that no damage had occurred during the short period of pump operation.

B.The system was realigned in accordance

with the approved procedure and the LPSI pump was restarted.

Subsequent

operation of the LPSI pump was satisfactory.

C.An ASME Section XI code run was performed satisfactorily

on the 1B LPSI Pump and a subsequent

Engineering

assessment

concluded that pump operability

had not been adversely affected.

St.Lucie Units.1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE

STEPS TO AVOID FURTHER VIOLATIONS

A.The licensed operator involved in this event was disciplined

in accordance

with plant policy.B.Operations

implemented

procedure changes which require the use of a dedicated procedure reader to assist in the implementation

of SDC related evolutions.

C.All Operations

Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent

to this event to reiterate FPL's goal for error free performance.

D.The plant has adopted verbatim compliance

as the only acceptable

means of procedure compliance.

This requirement

has been incorporated

into plant Quality Instruction

QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval

of Procedures." E.This event will be included into licensed operator, requalification

training.This action will be completed by January 1, 1996.4.Full compliance

was achieved on August 29, 1995 with the completion

of item 2A and 2B above.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION E: Technical Specification 6.8.1.a requires that written procedures

be established, implemented, and maintained

covering the activities

recommended

in Appendix A of Regulatory

Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative

procedures

for procedural

adherence.

Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval

of Procedures," Section 5.13.2, states that all procedures

shall be strictly adhered to.QI 16-PR/PSL-2, Rev.1,"St.Lucie Action Report (STAR)Program," required that STARs be initiated for Quality Assurance audit findings and independent

technical review recommendations'ontrary

to the above, a STAR was not generated when a Quality Assurance review of an inadvertent

Unit 1 containment

spraydown, documented

in interoffice

correspondence

JQQ-95-143, identified

the practice of prelubricating

FCV-07-1A, Containment

Spray header A flow control valve, when performing

valve stroke time testing.RESPONSE E: 1.REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of utility Quality Assurance (QA)personnel.

QA personnel were in the process of conducting

an independent

review focusing on the contributing

factors associated

with a Unit 1 containment

spray down event.The practice of pre-lubricating

Containment

Spray header flow control valve FCV-07-lA prior to surveillance

testing was identified

during this.review, but was not determined

to be a contributing

factor to this event.Recommendations

to correct this deficiency

were therefore not contained in the resulting QA report, nor was a St.Lucie Action Request (STAR)generated in a timely manner.2.=CORRECTIVE

STEPS TAKEN AND THE RESULTS ACHIEVED A.A St.Lucie Action Request (STAR 951048)was generated on September 7, 1995 to document the deficient practice of pre-lubricating

Unit 1 and Unit 2 containment

spray flow control valves prior to surveillance

stroke time testing.B.Temporary changes were issued to plant surveillance

procedures

on September 2, 1995 to remove the practice of'pre-lubricating

valves prior to surveillance

testing.10

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE

STEPS TO AVOID FURTHER VIOLATIONS

A.B.C.A meeting was held on September 13, 1995 between the Vice President of Nuclear Assurance and all St.Lucie Quality Assurance and Quality Control personnel.

During this meeting, clear expectations

were provided regarding the threshold for identification

and documentation

of deficiencies

by Quality personnel.

E On October 25, 1995, a second meeting was held between the site Quality Manager and St.Lucie QA personnel.

During this meeting, the requirements

of the Quality Instruction

QI 16-PR/PSL-2,"St.Lucie Action Report (STAR)Program" were reviewed.The responsibility

of QA personnel for timely identification

and documentation

of deficiencies

in accordance

with this procedure was reinforced.

Permanent changes will be made to plant surveillance

procedures

to discontinue

the practice of pre-test lubrication

of the valves prior to surveillance

testing.This action will be completed by December 1, 1995.4.Full compliance

was achieved on September 7, 1995 with the completion

of item 2A above.

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION F: Technical Specification

6.8~1.a requires that written procedures

be established, implemented, and maintained

covering the activities

recommended

in Appendix A of Regulatory

Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative

procedures

for procedural

adherence.

Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval

of Procedures," Section 5.13.2, states that all procedures

shall be strictly adhered to.ADM-08.02, Rev 7,"Conduct of Maintenance," Appendix 5, step 5, required that procedures

be present during work and that individual

steps be initialed once performed.

Contrary to the above, inspection

of work in progress revealed that individual

steps were not initialed once performed upon completion

for work conducted in accordance

with Plant Change/Modification

11-195.RESPONSE F: 1.REASON FOR VIOLATION The root cause of this violation was cognitive personnel error on the part of an Electrical

Department

journeyman

who failed to properly document the completion

of steps while performing

work activities

associated

with the trip solenoids on the 1B Emergency Diesel Generator (EDG).The steps were not initialed as they were being performed, in accordance

with approved plant procedure.

2.CORRECTIVE

STEPS TAKEN AND THE RESULTS ACHIEVED A.The steps of the maintenance

procedure being worked were signed off by the journeyman

immediately

following the completion

of the work on August 31, 1995, and the completed procedure was reviewed by the chief electrician

and Electrical

supervisor.

B.The EDG circuitry was subsequently

tested following completion

of the work on August 31, 1995, and performed satisfactorily.

12

0

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 3.CORRECTIVE

STEPS TO AVOID FURTHER VIOLATIONS

A.Meetings were held following this event with Electrical

Maintenance

employees to review this incident and emphasize management

expectations

regarding the documentation

of w'ork activities.

B.Supervisors

from each Maintenance

discipline

have conducted meetings with their employees to reinforce the need for strict adherence to the administrative

requirements

related to procedure use.C.The plant has adopted verbatim compliance

as the only acceptable

means of procedure compliance.

This requirement

has been incorporated

into plant Quality Instruction

QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval

of Procedures." 4.Full compliance

was achieved on August 31, 1995 with the completion

of item 2A and 2B above.13

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 VIOLATION G: 10 CFR 50 Appendix B, Criterion V,"Instructions, Procedures, and Drawings," requires, in part, that activities

affecting quality shall be prescribed

by documented

procedures

of a type appropriate

to the circumstances.

Contrary to the above, on August 18, 1995, venting of the Low Pressure Safety Injection (LPSI)System was conducted in accordance

with a procedure which was inappropriate

to the circumstances.

Specifically, OP 1-0420060, Rev.0,"Venting of the Emergency Core Cooling and Containment

Spray Systems," did not require a verification

that the portions of the system being vented were hydraulically

isolated from adjacent systems and flowpaths.

As a result of this failure to establish proper initial conditions, water driven by the 1A LPSI pump was inadvertently

directed to the A Train Containment

Spray header, resulting in a spraydown of the Unit 1 Reactor Containment

Building.RESPONSE G: REASON FOR VIOLATION The root cause of this violation was procedural

deficiency

in that the ECCS venting procedure, OP 1-0420060, did not state the plant conditions

required to successfully

vent the ECCS but relied upon the RCS heatup procedure to set plant conditions.

Specifically, the venting procedure did not require operators to verify that the proper containment

spray header isolation valves were closed prior to recirculating

the water in the SDC system.A contributing

factor to this event was that the operations

personnel performing

the ECCS venting procedure did not recognize that the existing plant conditions

would result in flow to the'A'ontainment

spray header when flow was aligned through the Shutdown Cooling Heat Exchanger.

A second contributing

factor of this event was that FCV-07-1A was placed in the open position because this valve had failed its ASME stroke time test.Plant management

made the decision to defer the valve repair and position this normally closed valve to its engineered

safeguards

open position in lieu of repairing the valve prior to startup.14

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 2.CORRECTIVE

STEPS TAKEN AND THE RESULTS ACHIEVED A.Operators secured the 1A LPSI Pump and isolated, the flowpath to the containment

spray header from the LPSI Pump.The Reactor Cavity sump was drained to the Waste Management

System.B~Following the event, all nonessential

work at the site was placed on hold, and Unit 1 was maintained

stable in Mode 3 while senior plant management

conducted meetings with all available site personnel to stress the need for worker vigilance and attention to detail.The need to reduce equipment deficiencies

that impact operations

was also discussed.

C.Unit 1 was cooled down and depressurized

to Mode,5 and an inspection

and decontamination

of containment

was then conducted.

The event was evaluated under an Engineering

evaluation, which resulted in a comprehensive

inspection

of components

inside containment

to ensure future component reliability.

D.Operating procedure, OP 1-0420060,"Venting of the Emergency Core Cooling an'd Containment

Spray System", was revised September 1, 1995 to include the plant conditions

required to be present during venting.3.CORRECTIVE

STEPS TO AVOID FURTHER VIOLATIONS

A.Plant policy 105,"Plant Operation Beyond the Envelope of Approved Plant Operating Procedures", was revised to require a technical review of procedures

which are being implemented

for the first time or for which plant conditions

are different from those described in the procedure.

B.The Maintenance

Department

established

a team composed of plant staff and engineering

personnel, to determine the root cause for the Containment

Spray header isolation valve repeat failures and determine corrective

actions to eliminate this operator workaround.

FCV-07-1A was repaired prior to returning Unit 1 to service.15

St.Lucie Units 1 and 2 Docket Nos.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 C.Existing plant deficiencies

were reviewed by senior plant management.

Additional

deficiencies

which could impact operations

were added to the work scope of the Unit 1 shutdown.These deficiencies

were corrected prior to returning the unit to service.D.Administrative

procedure, AP-0010147,"Assessment

of Abnormal Plant Configurations

or Significant

Material Deficient'Conditions

on Plant Operation", was developed to enhance outage scope review and ensure that equipment deficiencies

are restored in a timely manner.E.St.Lucie management

instituted

a weekly review of appropriate

performance

indicators

and work backlog status, including the age of open items and operator workarounds.

F.All Operations

Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent

to this event to reiterate FPL's goal for erro'r free performance.

G.This event will be incorporated

into licensed operator requalification

training.This action will be complete by January 1, 1996.4.Full compliance

was achieved on August 18, 1995 with the completion

of items 2A, 2C and 2D above.16