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{{#Wiki_filter:RIG RITY | {{#Wiki_filter:RIG RITY ACCELERATED RIDS PROCESSING), | ||
RIDS PROCESSING), REGULATORY | 1 REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) r 'ESSION NBR 9511210113 DOC ~ DATE'5/11/15 NOTARIZED NO DOCKET N FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME AUTHOR AFFILIATION GOLDBERG,J.H. Florida Power &'ight Co. | ||
INFORMATION | RECIP.NAME RECIPIENT AFFILIATION Document Control Branch (Document Control Desk) | ||
DISTRIBUTION | |||
SYSTEM (RIDS)r'ESSION NBR 9511210113 | ==SUBJECT:== | ||
DOC~DATE'5/11/15 | 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. | ||
NOTARIZED NO FACIL:50-335 | I DISTRIBUTION CODE: IE01D COPIES RECEIVED:LTR ENCL SIZE: | ||
St.Lucie Plant, Unit 1, Florida Power&Light Co.50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION | TITLE: General (50 Dkt)-Insp Rept/Notice of Violation Response NOTES RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 PD 1 1 NORRIS,J 1 1 INTERNAL: ACRS 2 AEOD/DEIB 1 1 AEOD/SPD/RAB 1 A'E. 1 1 DEDRO 1 FILE CENTER 1 1 NRR/DISP/PIPB 1 /'DRC8/H FB 1 1 NRR/DRPM/PECB 1 NUDOCS-ABSTRACT 1 1 OE DIR 1 'GC/HDS3 1 1 RGN2 FILE 01 1 EXTERNAL: LITCO BRYCE,J H 1 1 NOAC 1 1 NRC PDR 1 1 iNOTE TO ALL RIDS" RECIPIEYTS: | ||
GOLDBERG,J.H. | PLEASE HELP US TO REDUCE 4VASTE! CONTACT THE DOCL'!iIEYTCO."iTROL DESK, ROOiiI Pl-37 (EXT. 504-2083 ) TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY. LISTS FOR DOCL'IiIEi'I'S5'OU DOi "I'L'LD! | ||
Florida Power&'ight Co.RECIP.NAME | TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19 | ||
RECIPIENT AFFILIATION | |||
Document Control Branch (Document Control Desk)SUBJECT: Forwards response to NRC ltr re violations | 4 0' | ||
noted in insp repts 50-335/95-15 | |||
&50-389/95-15.Corrective | Florida Power L Light Company, 0 | ||
actions:MSIS | 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 95-15 Florida 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. | ||
was blocked&reset immediately | 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 | ||
following event on 950802.I DISTRIBUTION | |||
CODE: IE01D COPIES RECEIVED:LTR | FPL RESPONSE TO INSPECTION REPORT 95-15 | ||
ENCL SIZE: TITLE: General (50 Dkt)-Insp Rept/Notice | |||
of Violation Response NOTES | ==SUMMARY== | ||
DEDRO NRR/DISP/PIPB | |||
NRR/DRPM/PECB | 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. | ||
OE DIR RGN2 FILE 01 | 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. | |||
PLEASE HELP US TO REDUCE 4VASTE!CONTACT THE DOCL'! | 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. | ||
LISTS FOR DOCL'IiIEi'I' | 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. | |||
4 0' | 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. | |||
Commission | 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. | ||
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- | RESPONSE A: | ||
report and pursuant to 10 CFR 2.201 the response to the notice of violation is attached.Very truly yours, J.H.Goldberg President | 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. | ||
Attachment | : 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. | ||
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 | St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 | ||
FPL RESPONSE TO INSPECTION | : 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. | ||
REPORT 95-15 SUMMARY NRC Inspection | 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. | ||
Report 50-335/389/95-15 | C. This event will be incorporated into licensed operator requalification training to emphasize procedural compliance, proper communication among the Control Room | ||
considered | 'team, and the importance of supervision -in the control room maintaining an overall awareness, of activities. | ||
St.Lucie Plant performance | This action will be complete by January 1, 1996. | ||
during the six (6)week period from July 30, 1995 through September 16, 1995.The violations | D. St. Lucie Plant adopted verbatim compliance as the only acceptable of procedure compliance. | ||
below occurred during a relatively | means Procedures' This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, " "Preparation, Revision, Review/Approval of | ||
short period of time, as described in the inspection | : 4. Full compliance was achieved on August 2, 1995 with the completion of item 2 above. | ||
report, and several of the corrective | |||
actions were instituted | 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: | ||
following an analysis of the events, collectively. | 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. | ||
The corrective | Contrary to the above, procedures were not adhered to strictly in the following examples: | ||
steps to avoid further violations | OP 1-0120020, Rev. 72, "Filling and Venting the RCS," | ||
were in some cases determined | precaution 4.2, required that Reactor Coolant System (RCS) venting, described in the procedure, not be attempted temperature was above 200'F. | ||
to be generic following this analysis, and are therefore repeated in a number of the responses. | if RCS 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. | ||
The Inspection | : 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. | ||
Report identified | On August 2, 1995, restaging of the 1A2 RCP seal package was attempted without seal injection aligned to the seal package. | ||
seven (7)violations | As a result, design temperatures of RCP seal components were approached or exceeded. | ||
which are listed below.Violation A: Failure to Follow Procedures | RESPONSE B: | ||
and Block MSIS Actuation Violation B: Failure to Follow Procedures | 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. | ||
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 | 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 | ||
on Containment | : 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. | ||
Spray Valve Surveillance | B. The damaged 1A2 RCP seal package was replaced prior to returning Unit 1 to operation. | ||
Test Procedure Violation F: Failure to Initial Maintenance | : 3. CORRECTIVE STEPS TO AVOID FURTHER VXOLATXONS A. The licensed operator involved in this event was disciplined in accordance with plant policy. | ||
Procedure Steps as Work was Completed Violation G: Failure to Follow Procedures | B. The procedure appendix which was used for performing the restaging of the RCPs was deleted and is no longer available for use. | ||
During Venting of ECCS System Resulted in Containment | 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. | ||
Spraydown Additionally, both Florida Power and Light (FPL)and the NRC evaluated plant events to identify common underlying | 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." | ||
themes.FPL presented a summary of events to the NRC on August 29, 1995.Weaknesses | : 4. Full compliance was achieved on August 2, 1995 with the completion of item 2A, above. | ||
identified | |||
in this summary included procedure content and use, as well as management | 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: | ||
oversight of eguipment performance. | 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, 5.13 ', | ||
FPL's Plan to Improve the Operational | "Preparation, Revision, Review/Approval of Procedures," Section states that all procedures shall be strictly adhered to. | ||
Performance | 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. | ||
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 | 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. | ||
according to the improvement | RESPONSE C: | ||
plan schedule. | 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. | ||
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 | : 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. | ||
6.8.1.a requires that written procedures | |||
be established, implemented, and maintained | St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 | ||
covering the activities | : 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. | ||
recommended | B. 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." | ||
in Appendix A of Regulatory | C. Management is conducting a daily review of Control Room chronological logs to reinforce the expectation for detail and completeness. | ||
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1.d includes administrative | I D. Plant administrative procedures have been revised to provide for increased reviews by plant staff of the logs controlling valve repositioning. | ||
procedures | Full compliance was achieved on August 10, 1995, with the completion of item 2 above. | ||
for procedural | |||
adherence. | 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: | ||
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval | 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. | ||
of Procedures," Section 5.13.2, states that all procedures | 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. | ||
shall be strictly adhered to.OP 1-0030127, Rev 68,"Reactor Plant Cooldown | 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. | ||
annunciations | RESPONSE D: | ||
were received.ONOP 1-0030131, Rev 60,"Plant Annunciator | 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. | ||
Summary," required that, upon valid receipt of annunciators | : 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. | ||
Q-18 and Q-20, operators immediately | 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. | ||
block channels A and B, respectively. | 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. | ||
Contrary to the above, on August 2, 1995, during a cooldown of St.Lucie Unit 1, valid block.permissive | |||
annunciators | St. Lucie Units .1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 | ||
were received, however, operators failed to establish the required MSIS blocks, resulting in A and B channel MSIS actuations. | : 3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. The licensed operator involved in this event was disciplined in accordance with plant policy. | ||
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 | B. Operations implemented procedure changes which require the use of a dedicated procedure reader to assist in the implementation of SDC related evolutions. | ||
with the requirements | 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. | ||
of the approved plant operating procedure. | 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." | ||
2.CORRECTIVE | E. This event will be included into licensed operator, requalification training. This action will be completed by January 1, 1996. | ||
STEPS TAKEN AND THE RESULTS ACHIEVED A.The main steam isolation signal (MSIS)was blocked and reset immediately | : 4. Full compliance was achieved on August 29, 1995 with the completion of item 2A and 2B above. | ||
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 | 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: | ||
STEPS TO AVOXD FURTHER VXOLATXONS | 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. | ||
A.The licensed operator who was involved in the event was counseled on the need to follow procedures | QI 16-PR/PSL-2, Rev. 1, "St. Lucie Action Report (STAR) Program," | ||
and received discipline | 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. | ||
in accordance | RESPONSE E: | ||
with plant'policy. | : 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. | ||
B.All Operations | 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. | ||
Nuclear Plant Supervisors (NPS)held meetings with their crews subsequent | 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. | ||
to this event to reiterate FPL's goal for error free performance. | B. Temporary changes were issued to plant surveillance procedures on September 2, 1995 to remove the practice of | ||
C.This event will be incorporated | 'pre-lubricating valves prior to surveillance testing. | ||
into licensed operator requalification | 10 | ||
training to emphasize procedural | |||
compliance, proper communication | St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 | ||
among the Control Room'team, and the importance | : 3. CORRECTIVE STEPS TO AVOID FURTHER VIOLATIONS A. 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 B. On October 25, 1995, a second meeting was held between the site Quality Manager and St. Lucie QA personnel. | ||
of supervision-in the control room maintaining | 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. | ||
an overall awareness, of activities. | C. 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 complete by January 1, 1996.D.St.Lucie Plant adopted verbatim compliance | This action will be completed by December 1, 1995. | ||
as the only acceptable | : 4. Full compliance was achieved on September 7, 1995 with the completion of item 2A above. | ||
This requirement | 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: | ||
has been incorporated | Technical Specification 6.8 1.a requires that written procedures be | ||
into plant Quality Instruction | ~ | ||
QI 5-PR/PSL-1,"Preparation, Revision, Review/Approval | 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. | ||
of | 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. | |||
was achieved on August 2, 1995 with the completion | RESPONSE F: | ||
of item 2 above. | : 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. | |||
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 | B. The EDG circuitry was subsequently tested following completion of the work on August 31, 1995, and performed satisfactorily. | ||
6.8.1.a requires that written procedures | 12 | ||
be established, implemented, and maintained | |||
covering the activities | 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 | ||
recommended | : 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. | ||
in Appendix A of Regulatory | 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. | ||
Guide 1.33, Rev.2, February 1978.Appendix A, paragraph 1..d includes administrative | 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." | ||
procedures | : 4. Full compliance was achieved on August 31, 1995 with the completion of item 2A and 2B above. | ||
for procedural | 13 | ||
adherence. | |||
Procedure QI 5-PR/PSL-1, Rev.62,"Preparation, Revision, Review/Approval | 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: | ||
of Procedures," Section 5.13.2, states that all procedures | 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. | ||
shall be strictly adhered to.Contrary to the above, procedures | 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. | ||
were not adhered to strictly in the following examples: OP 1-0120020, Rev.72,"Filling and Venting the RCS," precaution | 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. | ||
4.2, required that Reactor Coolant System (RCS)venting, described in the procedure, not be attempted | RESPONSE G: | ||
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 | 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. | ||
with Appendix E of the subject procedure, was performed while RCS temperature | 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. | ||
was approximately | 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. | ||
370'F.As a result, design temperatures | 14 | ||
of RCP seal components | |||
were approached | St. Lucie Units 1 and 2 Docket Nos. 50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-15 | ||
or exceeded.2.OP 1-0120020, Rev.72,"Filling and Venting the RCS," Appendix E,"Restaging | : 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. | ||
Reactor Coolant Pump Seals," required the use of RCP seal injection while restaging was attempted. | 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. | ||
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 | 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. | ||
of RCP seal components | 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. | ||
were approached | : 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. | ||
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 | 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. | ||
a restaging evolution on a Reactor Coolant'Pump (RCP)seal package.The operator did not strictly adhere to the conditions | 15 | ||
contained in the procedure which required that RCS temperature | |||
be no greater than 200'F, and that seal injection be in service. | 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. | ||
0 | 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. | ||
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 | 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. | ||
STEPS TAKEN AND THE RESULTS ACHIEVED A.The RCP'estaging evolution was discontinued, and Operations | 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. | ||
cooled and depressurized | G. This event will be incorporated into licensed operator requalification training. This action will be complete by January 1, 1996. | ||
the Reactor Coolant System (RCS)in accordance | : 4. Full compliance was achieved on August 18, 1995 with the completion of items 2A, 2C and 2D above. | ||
with approved plant procedure to lower RCP seal temperatures | 16}} | ||
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, | |||
of Procedures," Section | |||
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 | |||
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 | |||
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 | |||
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 | |||
}} |
Latest revision as of 22:03, 29 October 2019
ML17228B327 | |
Person / Time | |
---|---|
Site: | Saint Lucie |
Issue date: | 11/15/1995 |
From: | Goldberg J FLORIDA POWER & LIGHT CO. |
To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
References | |
L-95-306, NUDOCS 9511210113 | |
Download: ML17228B327 (23) | |
Text
RIG RITY ACCELERATED RIDS PROCESSING),
1 REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) r 'ESSION NBR 9511210113 DOC ~ DATE'5/11/15 NOTARIZED NO DOCKET N FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 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 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 PD 1 1 NORRIS,J 1 1 INTERNAL: ACRS 2 AEOD/DEIB 1 1 AEOD/SPD/RAB 1 A'E. 1 1 DEDRO 1 FILE CENTER 1 1 NRR/DISP/PIPB 1 /'DRC8/H FB 1 1 NRR/DRPM/PECB 1 NUDOCS-ABSTRACT 1 1 OE DIR 1 'GC/HDS3 1 1 RGN2 FILE 01 1 EXTERNAL: LITCO BRYCE,J H 1 1 NOAC 1 1 NRC PDR 1 1 iNOTE TO ALL RIDS" RECIPIEYTS:
PLEASE HELP US TO REDUCE 4VASTE! CONTACT THE DOCL'!iIEYTCO."iTROL DESK, ROOiiI Pl-37 (EXT. 504-2083 ) TO ELI iIINATE YOUR NA!iIE FROiI DISTRIBUTIOY. LISTS FOR DOCL'IiIEi'I'S5'OU DOi "I'L'LD!
TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19
4 0'
Florida Power L Light Company, 0
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 95-15 Florida 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 of procedure compliance.
means Procedures' This requirement has been incorporated into plant Quality Instruction QI 5-PR/PSL-1, " "Preparation, Revision, Review/Approval of
- 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 temperature was above 200'F.
if RCS 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, 5.13 ',
"Preparation, Revision, Review/Approval of Procedures," Section 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. 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."
C. Management is conducting a daily review of Control Room chronological logs to reinforce the expectation for detail and completeness.
I D. 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.
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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. 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 B. 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.
C. 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.
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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.
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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.
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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.
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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.
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