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| number = ML20058M995 | | number = ML20058M995 | ||
| issue date = 08/08/1990 | | issue date = 08/08/1990 | ||
| title = Responds to NRC | | title = Responds to NRC Re Violations Noted in Insp Repts 50-352/90-15 & 50-353/90-14.Corrective Actions:Personnel Counseled on Importance of Procedure Compliance & Operations Manual Revised | ||
| author name = Leitch G | | author name = Leitch G | ||
| author affiliation = PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC | | author affiliation = PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC | ||
Line 11: | Line 11: | ||
| contact person = | | contact person = | ||
| document report number = NUDOCS 9008130157 | | document report number = NUDOCS 9008130157 | ||
| title reference date = 07-06-1990 | |||
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE, UTILITY TO NRC | | document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE, UTILITY TO NRC | ||
| page count = 9 | | page count = 9 | ||
Line 16: | Line 17: | ||
=Text= | =Text= | ||
{{#Wiki_filter:}} | {{#Wiki_filter:' | ||
. . 10 CFR-20201- | |||
< l 3 | |||
o . | |||
PF.ilLADELPHIA ELECTRIC: COMPANY 'I l L,lMERICK GENER ATING S*fATION ' | |||
l} P. O. BOX A - | |||
p .. | |||
S AN ATOG A, PENNSYLV ANI A 19444 - | |||
(218) 3271200, EXT. 3000 GM v,.......... | |||
AH AM M. LEl,TCH u..................,,*a Docket No. 50-352 9 License No. NPF-39 | |||
{ | |||
1 | |||
.U.S. Nuclear Regulatory Commission ATTH: Document Control Desk Washington, D.C. 20555. | |||
L j | |||
L | |||
==SUBJECT:== | |||
Limerick Generating Station, Unit 1 11 Reply to a Notice of Violation- , | |||
NRC_ Inspection Report Hos. 50-352/90-15 and 50-353/90-14 i | |||
==Dear' Sirs:== | |||
i | |||
" Attached.is Philadelphia Electric Company's reply to a Notice of Violation for | |||
-Limerick Generating Station-(LGS). Unit 1 which was contained in the combined NRC Inspection Report.Nos. 50-352/90-15 and 50-353/90-14 for LGS, Units 1 and 2 --dated July 6,:1990. .Due to: delays in finalizing the corrective actions to-prevent recurrence, we have regeested a two day extension for responding to this Notice _of i: - | |||
Violation. This extension was approved by Mr. W. R. Butler, who was contacted on l August'8, 1990, at NRC Region 1. -l | |||
[ 'The attachment to this letter provides a restatement of the violation-followed I p< by our response. | |||
This Notice of Violation pertains to the-failure to. follow an approved | |||
-procedure which resulted in a Radwaste resin spill..and was noted during an NRC ' | |||
-inspection conducted between April 10, 1990 through May 21, 1990, at LGS, Unit 1. I | |||
~If-'you have any questions, or require additional .information, please contact-us. l | |||
-l Very truly ours, | |||
/f . | |||
1 DMS:rgs- | |||
, Attachment ' | |||
cc: .T. T. Martin, Administrator, Region I, USNRC i T. J. Kenny, USNRC Senior Resident inspector, LGS c 7 9 | |||
o | |||
- .9008130157 90080s | |||
,PDR O ADOCK 05000352 , i PDC | |||
\ | |||
n'_- .. . | |||
? | |||
g , - . | |||
; bec: D. M. Smith - 52C-7. | |||
_ G. M. Leitch - 200- | |||
: 0. R. Helwig - 63C-1 J. W. Durham - S26-1 ' | |||
M. J. McCormick, Jr. - AS-1 L.;A.'Hopkins - A5-l' R. W. Dubiel - AS-1 , | |||
J.-A. Muntz.- 336 t | |||
. G. J. Madsen - 583-4. | |||
J. M. Madara 53A-1 .'. | |||
J. F. O'Rourke1 SB4-3 1l | |||
- Gt A. Hunger,'Jr. - 52A-5 j' Secretary, NCB"- 51A-13 , | |||
- Ceiimitment Coordinator - 52A-5 Correspondence Release Point - T2-4 : | |||
DAC PA DERBRP Inspector - 334 , | |||
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. Attachment | |||
* ' Page 1 of 5 Inspection Report No. 50-352/90-15 Reply to a Notice of-Violation Restatement of the Violation ! | |||
As a result of an inspection conducted on April 10, 1990 through May 21, 1990, and in-accordancewithNRCEnforcementPolicy(10CFR2.AppendixC),thefollowing i violation was identified: | |||
- Plant Technical Specification 6.8.1 requires written procedures to be established. [ | |||
implemented and maintained to control various plant activities. | |||
-Procedure S66.8.G, " Transfer of Waste Sludge Tank to Condensate Phase Separator," | |||
requires.that the waste sludge to condensate phase separator isolation valve, , | |||
valve no. 66-0009, be closed prior to'the transfer of waste sludge (resin). | |||
~ | |||
Contrary to the above on May 10, 1990, valve 66-0009 was not closed prior to the transfer of waste sludge resulting in a spill of radioactive resin over a large percentage of the centrifuge' fill and decontamination station room floor. | |||
ThisisaSeverityLevelIVviolation_(SupplementI). | |||
1 | |||
===RESPONSE=== | |||
Admission of Alleged Violation | |||
-I Philadelphia Electric Company acknowledges the violation. | |||
t Reason for the Violation The primary causes of this violation are as follows. | |||
: 1. A personnel error on the part of a'non-licensed operator. | |||
: 2. Procedural compliance in accordance with Administrative Procedure A-7, . | |||
"ShiftOperations,"whenperformingRadwaste(RW)systemoperationshas i l- not been sufficiently stressed by Operation Management. | |||
n in addition, several secondary causes contributed to this violation, and are as ? | |||
; follows. q i | |||
1.. The System (S) Operating Procedure S66.8.G, " Transfer of Waste Sludge Tankuto Condensate Phase Separator," did not adequately address the k | |||
it | |||
O . | |||
_. . Attachment L | |||
Page 2 of'5-Inspection Report No. 50-352/90-15 y. | |||
potential flowpath created by the implementation of Modification 6027-0, which was installed in the Solid Radwaste Processing Facility. | |||
: 2. The degree of supervision of RW Operations has not been commensurate with the complexity and importance of these operations. Increased' involvement is required by Shift Supervision to ensure the quality of RW Operations.' | |||
: 3. RW Procedure RW-140 Appendix C, " Fuel Pool and Radwaste Filter /0emin - | |||
or Mixed Bed Demineralizer. Resin Blend and Slurry Concentration Notification Sheet," is intended to be used only to provide details of the resin blends and slurry concentrations that operators are to prepare during their shift. Howeverr RW Engineering Supervision improperly used | |||
'this notification sheet to provide operating guidance for transfer of the contents of the Waste Sludge Tank. | |||
'In addition, there are several contributing causes that led to the resin spill following the failure to close the Waste Sludge to Condensate Separator Isolation | |||
, Valve, 66-0009. | |||
: 1. As a result of a less than adequate initial design review by engineering and site personnel, a design deficiency existed for Modification 6027-0. | |||
.This modification installed a cross tie pipe to increase the N acity of the: Solid Radwaste Processing Facility (see Diagram 1), 'Th h deficiency created a potential flowpath during recirculation and transrer operations of the Waste Sludge Tank and allowed backflow-through the new-crosstiepipe'intotheunisolated'B' Centrifuge (0BS313). | |||
: 2. The RW operators were not fully aware of the design deficiency and of the potential flow path created by Modification 6027-0. A Modification Training Bulletin was not issued to RW Operators describing the design deficiency. | |||
: 3. -The changes implemented by Modification 6027-0 were not reflected in the system mimic in the RW Control' Room. | |||
The.descrjption below provides information which helps to explain the interrelationships of the primary, and contributing causes for this violation. | |||
On May 10, 1990, contents of the Waste Sludge Tank were scheduled to be transferred to the '1A' Condensate Phase Separator, during the midnight shift, for processing. The Solid RW Operator was assigned to complete the RW transfer during the. turnover from the a#ternoon shift. Guidance for completing this transfer was provided on the notification sheet of Procedure RW-140,-Appendix C, by the RW En;;aeering group and given to the RW Operator during turnover. Following turnover,theoperator,withHealthPhysics(HP) support,workingundera RadiationWorkPermit(RdP),ensuredthattheCentrifugeEffluentValves 67-0044A and 67-00448, were clost.d. These valves are required to be closed by System | |||
-Procedure S66.8.G prior to transferring resin from the Waste Sludge Tank to the Condensate Phase Separator to ensure that waste sludge is not transferred to the I | |||
Attachment' 4; | |||
Page 3 of 5-Inspection Report No. 50-352/90 1 1 | |||
Equipment Drain System. At 0115 hours, the operator returned to the RW Control l Room and started the Waste Sludge Tank recirculation process by opening the Waste ! | |||
Sludge. Discharge Mixing Pump Suction Valve. HV-66-006, and opening the Waste l Sludge Tank Pump Recirculation Valve, HV-66-004, and starting the Waste Sludge > | |||
Discharge Mixing Pump. At the time the pump was started, the operator received a call from the. Shift Clerk, notifying him to pick up his required reading in the. | |||
Main Control Room (MCR). At approximately 0121 hours, he informed the Liquid RW ; | |||
Operator that the Waste Sludge Tank was in recirculation mode and that he would ' | |||
return shortly from the MCR. Approximately 20 minutes later, RW personnel noted water seeping from under Door 335 which leads into the Decontamination Station i room. Shift Supervision was notified and went to the RW Control Room along with 'l the Solid RW Operator. At-0145 hours, the operator lmmediately secured the Waste 1 Sludge Discharge Mixing Pump and isolated valves HV-66-006 and HV-66-004. Review ' | |||
of the system alignment revealed that valve 66-0009 was not closed prior to placing the Waste Sludge Tank in recirculation mode, as directed by System , | |||
Procedure S66.8.G and the guidance provided by RW Engineering on the notification ' | |||
sheet of Procedure RW-140, Appendix C. | |||
The actual flow path for the radioactive resin slurry (See Diagrams 1 and 2) was from the Waste Sludge Tank through the open 66-0009 valve, rather than the H intended recirculation back to the tank. The 66-0009 valve is normally closed in accordance with System Procedure S66.B.G during recirculation operations. The expected flow path during' resin slurry transfer.would be to the '1A' Condensate Phase Separator. However, since the system was. intended to be in recirculation, the Condensate Phase Separator inlet valves HV-67-005A and HV-67-107A were both closed. Therefore, the resin slurry flowed through valve 66-0009, through the 'B' Centrifuge.;and into the 'B' High Integrity Container (HIC)-Fill Station. From the "B"' HIC Fill Station, the resin slurry flowed through a sluice pan located belowthe'B' Centrifuge,andintothe'B'ReactorWaterCleanup(RWCU) Phase Separator. As a result of the Waste Sludge Discharge Mixing Pump pressurizing the system and forcing resin slurry to backflow through the 'B' Centrifuge, the''B' i RWCU Phase Separator-rapidly filled with resin slurry causing the floor drain system to back up into the Decontamination Station room and into both the 'A' and | |||
'B' HIC Fill Station rooms. A small amount of sludge leaked from the | |||
:Decontaml. nation Room through the floor slab penetrations into two rooms ~on the lower elevations of the RW Enclosure. | |||
Upon further investigation into this event, we have determined that procedural compliance in accordance with procedure A-7 when performing RW system operations , | |||
has not been sufficiently stressed by Operations Management. Additionally, the degree of supervision of RW Operations has not been commensurate with the complexity and importance of these operations. Increased involvement is required by Shift Supervision to ensure the quality of RW Operations. | |||
I l | |||
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-Attachment Page 4 of 5 Inspection Report No. 50-352/90-15 t | |||
Corrective A6tions'Taken and Results Achieved L | |||
On May 10. 1990, at 0145 hours, after being notified of the resin slurry seeping fromunderDoor335(SeeDiagram2),aShiftSupervisorandRWOperations personnel secured the Waste Sludge Discharge Mixing Pump and isolated valves HV-66-006 and HV-66-004. The cleanup decontamination of normally accessible areas began immediately following the spill and was completed by May 11, 1990, with a total of 0.202 man-rem expended during the resin spill cleanup. The other areas that were contaminated have' inactive equipment and access to these areas-is unnecessary. These rooms are on the RW decontamination open item list for cleanup and decontamination. These areas are isolated with the ventilation filtered and will not contribute to any further contamination spread. . | |||
Corrective Actions to Avoid Future Non-Compliance | |||
: 1. The RW operator invo ved in this event was counseled by Operations Management on May 11,.1990, on the importance of procedure compliance. | |||
.2.- AShiftTrainingNotebook(STN)itemdiscussingthiseventandemphasizing the importance of procedure compliance was issued on May 22, 1990, to all 4 | |||
' plant operators. The purpose of the STN'is to inform plant operatort of special items which require. operator awareness-(e.g., Licensee Event Reports, NRC. Violations, Modification Training Bulletins, procedure revisions, equipment operating concerns). Additionally, this event is being . | |||
discussed ic the Operator Requalification Training Program. This training commenced on July 9, 1990, and is on-going as a part of continuing operator | |||
-training. | |||
: 3. A separate chapter further defining Operations Management expectations on procedure compliance will be written and incorporated into the Operations Manual. This Manual defines the Operations organization and its policies. | |||
This item will be completed by November 30, 1990. | |||
: 4. -The new Operations Manual chapter described in Item 3 above, will be incorporated into the non-licensed and licensed operator requalification training programs. This topic will be covered during the first cycle of training in.1991. | |||
: 5. Modification 6027-0 was revised to include a new isolation valve, 67-132, which was installed on May 30,1990(SeeDiagram1). Also, a Scope / Schedule ChangeRequest(SSCR),SSCR-6027-0-004, was issued on June 6, 1990, to | |||
. install a blank flange instead of an isolation valve downstream of the 'B' Centrifuge. The blank flange will isolate the 'B' Centrifuge (not currently used) and will be installed by September 21, 1990. | |||
( .: . | |||
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. = | |||
Attachment ; | |||
Page 5 of 5 Inspection Report No.-50-3Zi30-15 1 | |||
1 I | |||
: 6. :The RW System Operating Procedures affected by Modification 6027-0,- 1 including S66.8.G were reviewed to assure that these procedures correctly ! | |||
reflect the system configuration and operation. This review along with the procedure revisions were completed by June 6,.1990. | |||
.'7.- A~ memo to'all RW Operators requesting their assistance in identifying specific problems with RW procedures will be issued by August 13, 1990. Any problems that are identified by the D9 cperators will be tracked via the ProcedureProblem'IdentificationSystem(PPIS), RW Engi_neering will then review these PPIS items and incorporate procedure changes as necessary. | |||
This item will be completed by June 1, 1991. j | |||
: 8. Operations Management will heigaten Shift Supervision awareness of RW -1 operations. A memo defining Operations Management expectations of RW ' | |||
supervision will be issued to all Shift Supervisions by August ~24, 1990. | |||
: 9. RW management will ensure that Procedure RW-140, Appendix C. is-only used for its intended purpose, and will ensure that other guidance provided to- - | |||
the RW operators is in accordance with approved procedures. This item will j be completed by October 1, 1990. 1 10.- A training module is being developed to address this event and discuss the importance of a proper modification design review prior to having the-modification approved'and installed. This module is presently being , , | |||
developed for the Fall 1990 Continuing Training Session for all plant s Technical' Staff personnal.. This training is scheduled to begin on August- ' | |||
29, 1990, ano the training sessions are scheduled'through September-1990. | |||
This training module will also be provided to. Nuclear Engineering for;use in training their personnel. | |||
: 11. A training module was incorporated into the Spring 1990 Continuing Training Session for all plant Technical Staff personnel. This module discussed the importance of' assuring that Modification Training Bulletins are completed and issued to plant operators in a fashion that provides all of the information they need to operate a modified system. This training module -; | |||
also stressed the immediate need for re-issue of a' Modification Training. | |||
Bulletin if any deficiencies-are identified after a modification has been installed. This training session ended on June 13, 1990. 4 | |||
: 11. The current installation of Modification 6027-0 has been reflected on the system mimic in the RW Control Room. | |||
Date When Full Compliance Will Be Achieved FulicompliancewasachievedonMay 10, 1990, when the resin spill was terminated. | |||
i | |||
: sa | |||
.. w . | |||
m a x ; ;a a; . . | |||
m | |||
: - . o DIAGRAM 1 ' | |||
S!MPLIF'ED FLOW. PATH i . | |||
= | |||
t IrJPt/T5 FROM ~ | |||
~ | |||
CENTRIFUGE PRECOAT TANK FLOOR DRAIN FILTER BACKWASH | |||
~ | |||
EQUIP DRAIN FILTER DACKWASH FILTER DEMIN VEllT HEADER CONDENSA E - | |||
PHASE SEPAR \ TOR'1AI | |||
" h EQUIPMENT I. Hv- av- HV-67-005A HV-67-107A | |||
~ | |||
r y DPAIN 66-006,,n J66-004 x x ag mcRhmt. Flow S(YSTEPTSou 66 TOM I - | |||
g7_g 7_o,,, | |||
^ ~~~~ | |||
~ ~ ~ ~ ~3 0 ' ~ ~ ~l - ' | |||
M'''***"* | |||
EN- fthE - | |||
RESIN SLUMY , | |||
'67-131A '- FLowPATM | |||
->l StANKFlmesE was mer SATE FLUSH DISCHARGE MIXING FLOWPATH o | |||
wunctosen I) ,- - i g g 9.asimo ED LINE PUMP A - | |||
: f. 3 | |||
'g l | |||
/ | |||
C,*t- 132. | |||
] CENTFbFUGE 0'.S313 f | |||
q, hf | |||
~ | |||
' t 'fr RisD - "I . | |||
'St4 G f N *3 G I o VAtvE , , | |||
wAs N67 WSTw1Eb ' | |||
106 '8 206A,6 e~@ DW"1 I | |||
~~~~~~~ | |||
AT ts*46 of EVE 4T .A* HIC MTATION O CROSS TsE FtPE w As | |||
_TusTAtLED AT TIME - --- | |||
OF EVEMY - | |||
L- .. . . . . .- | |||
: r. p DIAGRAM 2 . | |||
) | |||
1 i 4 | |||
*D' CENTRIFUGE ROOM RESIN SLURRY FLOW OBS313, y Cottr!NUEb FRcM ' DIAGRAM i NORsW._ | |||
i'' I y SYSTEM | |||
', y f'LO W | |||
)'f 4 | |||
,J f | |||
d | |||
' (SouD Astnows) 237 ELEV | |||
; * -- , ! / | |||
i | |||
; ,'Resto y DECONTAMINATION STATION ROOM | |||
-~, t u . ', PATM ,- | |||
1 -- | |||
I 1 | |||
-w i | |||
SLU!CE PAN: , DRfP POT | |||
{'c^6 ^^; , | |||
, ~j | |||
+ RESIM | |||
; j swm I 4 | |||
' I l* 'M- RE514 SLURR.T '2000R 335 | |||
, I 13' HIC FILL STATION ROOM REsna stpRK1 Anwth our V= - ' - - =--- Y - ,- - | |||
-~ # OF N N FRoM'A' tuC. ,' 217 ELEV ' | |||
I RLL STATIOM j ---q ,g ROOM N_ __ - | |||
floor DRAIN SYSTEM AS A KESUL7~ Of T//E WASYF | |||
>f - | |||
-$ SLUME yyy SySygg 7MKgh PUMP ggc;Wgfggy! PEES 57 | |||
""^TO"**"^"^' | |||
o nwCu SLURRY TD BACKFlotal 77/4t106H , | |||
77MCEArrRin/SE THE 8'WCU ' | |||
l - | |||
PUM DWDL FMEb w/ SL Y 77F~ | |||
SYS. ~TO BACK UP . | |||
_ -}} |
Latest revision as of 05:20, 3 June 2023
ML20058M995 | |
Person / Time | |
---|---|
Site: | Limerick ![]() |
Issue date: | 08/08/1990 |
From: | Leitch G PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC |
To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
References | |
NUDOCS 9008130157 | |
Download: ML20058M995 (9) | |
Text
'
. . 10 CFR-20201-
< l 3
o .
PF.ilLADELPHIA ELECTRIC: COMPANY 'I l L,lMERICK GENER ATING S*fATION '
l} P. O. BOX A -
p ..
S AN ATOG A, PENNSYLV ANI A 19444 -
(218) 3271200, EXT. 3000 GM v,..........
AH AM M. LEl,TCH u..................,,*a Docket No. 50-352 9 License No. NPF-39
{
1
.U.S. Nuclear Regulatory Commission ATTH: Document Control Desk Washington, D.C. 20555.
L j
L
SUBJECT:
Limerick Generating Station, Unit 1 11 Reply to a Notice of Violation- ,
NRC_ Inspection Report Hos. 50-352/90-15 and 50-353/90-14 i
Dear' Sirs:
i
" Attached.is Philadelphia Electric Company's reply to a Notice of Violation for
-Limerick Generating Station-(LGS). Unit 1 which was contained in the combined NRC Inspection Report.Nos. 50-352/90-15 and 50-353/90-14 for LGS, Units 1 and 2 --dated July 6,:1990. .Due to: delays in finalizing the corrective actions to-prevent recurrence, we have regeested a two day extension for responding to this Notice _of i: -
Violation. This extension was approved by Mr. W. R. Butler, who was contacted on l August'8, 1990, at NRC Region 1. -l
[ 'The attachment to this letter provides a restatement of the violation-followed I p< by our response.
This Notice of Violation pertains to the-failure to. follow an approved
-procedure which resulted in a Radwaste resin spill..and was noted during an NRC '
-inspection conducted between April 10, 1990 through May 21, 1990, at LGS, Unit 1. I
~If-'you have any questions, or require additional .information, please contact-us. l
-l Very truly ours,
/f .
1 DMS:rgs-
, Attachment '
cc: .T. T. Martin, Administrator, Region I, USNRC i T. J. Kenny, USNRC Senior Resident inspector, LGS c 7 9
o
- .9008130157 90080s
\
n'_- .. .
?
g , - .
- bec
- D. M. Smith - 52C-7.
_ G. M. Leitch - 200-
- 0. R. Helwig - 63C-1 J. W. Durham - S26-1 '
M. J. McCormick, Jr. - AS-1 L.;A.'Hopkins - A5-l' R. W. Dubiel - AS-1 ,
J.-A. Muntz.- 336 t
. G. J. Madsen - 583-4.
J. M. Madara 53A-1 .'.
J. F. O'Rourke1 SB4-3 1l
- Gt A. Hunger,'Jr. - 52A-5 j' Secretary, NCB"- 51A-13 ,
- Ceiimitment Coordinator - 52A-5 Correspondence Release Point - T2-4 :
DAC PA DERBRP Inspector - 334 ,
L -r a
lsi I
,1 1.
t
(
t I
r s l
t 4
l 4
( +
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. Attachment
- ' Page 1 of 5 Inspection Report No. 50-352/90-15 Reply to a Notice of-Violation Restatement of the Violation !
As a result of an inspection conducted on April 10, 1990 through May 21, 1990, and in-accordancewithNRCEnforcementPolicy(10CFR2.AppendixC),thefollowing i violation was identified:
- Plant Technical Specification 6.8.1 requires written procedures to be established. [
implemented and maintained to control various plant activities.
-Procedure S66.8.G, " Transfer of Waste Sludge Tank to Condensate Phase Separator,"
requires.that the waste sludge to condensate phase separator isolation valve, ,
valve no. 66-0009, be closed prior to'the transfer of waste sludge (resin).
~
Contrary to the above on May 10, 1990, valve 66-0009 was not closed prior to the transfer of waste sludge resulting in a spill of radioactive resin over a large percentage of the centrifuge' fill and decontamination station room floor.
ThisisaSeverityLevelIVviolation_(SupplementI).
1
RESPONSE
Admission of Alleged Violation
-I Philadelphia Electric Company acknowledges the violation.
t Reason for the Violation The primary causes of this violation are as follows.
- 1. A personnel error on the part of a'non-licensed operator.
- 2. Procedural compliance in accordance with Administrative Procedure A-7, .
"ShiftOperations,"whenperformingRadwaste(RW)systemoperationshas i l- not been sufficiently stressed by Operation Management.
n in addition, several secondary causes contributed to this violation, and are as ?
- follows. q i
1.. The System (S) Operating Procedure S66.8.G, " Transfer of Waste Sludge Tankuto Condensate Phase Separator," did not adequately address the k
it
O .
_. . Attachment L
Page 2 of'5-Inspection Report No. 50-352/90-15 y.
potential flowpath created by the implementation of Modification 6027-0, which was installed in the Solid Radwaste Processing Facility.
- 2. The degree of supervision of RW Operations has not been commensurate with the complexity and importance of these operations. Increased' involvement is required by Shift Supervision to ensure the quality of RW Operations.'
- 3. RW Procedure RW-140 Appendix C, " Fuel Pool and Radwaste Filter /0emin -
or Mixed Bed Demineralizer. Resin Blend and Slurry Concentration Notification Sheet," is intended to be used only to provide details of the resin blends and slurry concentrations that operators are to prepare during their shift. Howeverr RW Engineering Supervision improperly used
'this notification sheet to provide operating guidance for transfer of the contents of the Waste Sludge Tank.
'In addition, there are several contributing causes that led to the resin spill following the failure to close the Waste Sludge to Condensate Separator Isolation
, Valve, 66-0009.
- 1. As a result of a less than adequate initial design review by engineering and site personnel, a design deficiency existed for Modification 6027-0.
.This modification installed a cross tie pipe to increase the N acity of the: Solid Radwaste Processing Facility (see Diagram 1), 'Th h deficiency created a potential flowpath during recirculation and transrer operations of the Waste Sludge Tank and allowed backflow-through the new-crosstiepipe'intotheunisolated'B' Centrifuge (0BS313).
- 2. The RW operators were not fully aware of the design deficiency and of the potential flow path created by Modification 6027-0. A Modification Training Bulletin was not issued to RW Operators describing the design deficiency.
- 3. -The changes implemented by Modification 6027-0 were not reflected in the system mimic in the RW Control' Room.
The.descrjption below provides information which helps to explain the interrelationships of the primary, and contributing causes for this violation.
On May 10, 1990, contents of the Waste Sludge Tank were scheduled to be transferred to the '1A' Condensate Phase Separator, during the midnight shift, for processing. The Solid RW Operator was assigned to complete the RW transfer during the. turnover from the a#ternoon shift. Guidance for completing this transfer was provided on the notification sheet of Procedure RW-140,-Appendix C, by the RW En;;aeering group and given to the RW Operator during turnover. Following turnover,theoperator,withHealthPhysics(HP) support,workingundera RadiationWorkPermit(RdP),ensuredthattheCentrifugeEffluentValves 67-0044A and 67-00448, were clost.d. These valves are required to be closed by System
-Procedure S66.8.G prior to transferring resin from the Waste Sludge Tank to the Condensate Phase Separator to ensure that waste sludge is not transferred to the I
Attachment' 4;
Page 3 of 5-Inspection Report No. 50-352/90 1 1
Equipment Drain System. At 0115 hours0.00133 days <br />0.0319 hours <br />1.901455e-4 weeks <br />4.37575e-5 months <br />, the operator returned to the RW Control l Room and started the Waste Sludge Tank recirculation process by opening the Waste !
Sludge. Discharge Mixing Pump Suction Valve. HV-66-006, and opening the Waste l Sludge Tank Pump Recirculation Valve, HV-66-004, and starting the Waste Sludge >
Discharge Mixing Pump. At the time the pump was started, the operator received a call from the. Shift Clerk, notifying him to pick up his required reading in the.
Main Control Room (MCR). At approximately 0121 hours0.0014 days <br />0.0336 hours <br />2.000661e-4 weeks <br />4.60405e-5 months <br />, he informed the Liquid RW ;
Operator that the Waste Sludge Tank was in recirculation mode and that he would '
return shortly from the MCR. Approximately 20 minutes later, RW personnel noted water seeping from under Door 335 which leads into the Decontamination Station i room. Shift Supervision was notified and went to the RW Control Room along with 'l the Solid RW Operator. At-0145 hours, the operator lmmediately secured the Waste 1 Sludge Discharge Mixing Pump and isolated valves HV-66-006 and HV-66-004. Review '
of the system alignment revealed that valve 66-0009 was not closed prior to placing the Waste Sludge Tank in recirculation mode, as directed by System ,
Procedure S66.8.G and the guidance provided by RW Engineering on the notification '
sheet of Procedure RW-140, Appendix C.
The actual flow path for the radioactive resin slurry (See Diagrams 1 and 2) was from the Waste Sludge Tank through the open 66-0009 valve, rather than the H intended recirculation back to the tank. The 66-0009 valve is normally closed in accordance with System Procedure S66.B.G during recirculation operations. The expected flow path during' resin slurry transfer.would be to the '1A' Condensate Phase Separator. However, since the system was. intended to be in recirculation, the Condensate Phase Separator inlet valves HV-67-005A and HV-67-107A were both closed. Therefore, the resin slurry flowed through valve 66-0009, through the 'B' Centrifuge.;and into the 'B' High Integrity Container (HIC)-Fill Station. From the "B"' HIC Fill Station, the resin slurry flowed through a sluice pan located belowthe'B' Centrifuge,andintothe'B'ReactorWaterCleanup(RWCU) Phase Separator. As a result of the Waste Sludge Discharge Mixing Pump pressurizing the system and forcing resin slurry to backflow through the 'B' Centrifuge, theB' i RWCU Phase Separator-rapidly filled with resin slurry causing the floor drain system to back up into the Decontamination Station room and into both the 'A' and
'B' HIC Fill Station rooms. A small amount of sludge leaked from the
- Decontaml. nation Room through the floor slab penetrations into two rooms ~on the lower elevations of the RW Enclosure.
Upon further investigation into this event, we have determined that procedural compliance in accordance with procedure A-7 when performing RW system operations ,
has not been sufficiently stressed by Operations Management. Additionally, the degree of supervision of RW Operations has not been commensurate with the complexity and importance of these operations. Increased involvement is required by Shift Supervision to ensure the quality of RW Operations.
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-Attachment Page 4 of 5 Inspection Report No. 50-352/90-15 t
Corrective A6tions'Taken and Results Achieved L
On May 10. 1990, at 0145 hours0.00168 days <br />0.0403 hours <br />2.397487e-4 weeks <br />5.51725e-5 months <br />, after being notified of the resin slurry seeping fromunderDoor335(SeeDiagram2),aShiftSupervisorandRWOperations personnel secured the Waste Sludge Discharge Mixing Pump and isolated valves HV-66-006 and HV-66-004. The cleanup decontamination of normally accessible areas began immediately following the spill and was completed by May 11, 1990, with a total of 0.202 man-rem expended during the resin spill cleanup. The other areas that were contaminated have' inactive equipment and access to these areas-is unnecessary. These rooms are on the RW decontamination open item list for cleanup and decontamination. These areas are isolated with the ventilation filtered and will not contribute to any further contamination spread. .
Corrective Actions to Avoid Future Non-Compliance
- 1. The RW operator invo ved in this event was counseled by Operations Management on May 11,.1990, on the importance of procedure compliance.
.2.- AShiftTrainingNotebook(STN)itemdiscussingthiseventandemphasizing the importance of procedure compliance was issued on May 22, 1990, to all 4
' plant operators. The purpose of the STN'is to inform plant operatort of special items which require. operator awareness-(e.g., Licensee Event Reports, NRC. Violations, Modification Training Bulletins, procedure revisions, equipment operating concerns). Additionally, this event is being .
discussed ic the Operator Requalification Training Program. This training commenced on July 9, 1990, and is on-going as a part of continuing operator
-training.
- 3. A separate chapter further defining Operations Management expectations on procedure compliance will be written and incorporated into the Operations Manual. This Manual defines the Operations organization and its policies.
This item will be completed by November 30, 1990.
- 4. -The new Operations Manual chapter described in Item 3 above, will be incorporated into the non-licensed and licensed operator requalification training programs. This topic will be covered during the first cycle of training in.1991.
- 5. Modification 6027-0 was revised to include a new isolation valve,67-132, which was installed on May 30,1990(SeeDiagram1). Also, a Scope / Schedule ChangeRequest(SSCR),SSCR-6027-0-004, was issued on June 6, 1990, to
. install a blank flange instead of an isolation valve downstream of the 'B' Centrifuge. The blank flange will isolate the 'B' Centrifuge (not currently used) and will be installed by September 21, 1990.
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Attachment ;
Page 5 of 5 Inspection Report No.-50-3Zi30-15 1
1 I
- 6. :The RW System Operating Procedures affected by Modification 6027-0,- 1 including S66.8.G were reviewed to assure that these procedures correctly !
reflect the system configuration and operation. This review along with the procedure revisions were completed by June 6,.1990.
.'7.- A~ memo to'all RW Operators requesting their assistance in identifying specific problems with RW procedures will be issued by August 13, 1990. Any problems that are identified by the D9 cperators will be tracked via the ProcedureProblem'IdentificationSystem(PPIS), RW Engi_neering will then review these PPIS items and incorporate procedure changes as necessary.
This item will be completed by June 1, 1991. j
- 8. Operations Management will heigaten Shift Supervision awareness of RW -1 operations. A memo defining Operations Management expectations of RW '
supervision will be issued to all Shift Supervisions by August ~24, 1990.
- 9. RW management will ensure that Procedure RW-140, Appendix C. is-only used for its intended purpose, and will ensure that other guidance provided to- -
the RW operators is in accordance with approved procedures. This item will j be completed by October 1, 1990. 1 10.- A training module is being developed to address this event and discuss the importance of a proper modification design review prior to having the-modification approved'and installed. This module is presently being , ,
developed for the Fall 1990 Continuing Training Session for all plant s Technical' Staff personnal.. This training is scheduled to begin on August- '
29, 1990, ano the training sessions are scheduled'through September-1990.
This training module will also be provided to. Nuclear Engineering for;use in training their personnel.
- 11. A training module was incorporated into the Spring 1990 Continuing Training Session for all plant Technical Staff personnel. This module discussed the importance of' assuring that Modification Training Bulletins are completed and issued to plant operators in a fashion that provides all of the information they need to operate a modified system. This training module -;
also stressed the immediate need for re-issue of a' Modification Training.
Bulletin if any deficiencies-are identified after a modification has been installed. This training session ended on June 13, 1990. 4
- 11. The current installation of Modification 6027-0 has been reflected on the system mimic in the RW Control Room.
Date When Full Compliance Will Be Achieved FulicompliancewasachievedonMay 10, 1990, when the resin spill was terminated.
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- - . o DIAGRAM 1 '
S!MPLIF'ED FLOW. PATH i .
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CENTRIFUGE PRECOAT TANK FLOOR DRAIN FILTER BACKWASH
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EQUIP DRAIN FILTER DACKWASH FILTER DEMIN VEllT HEADER CONDENSA E -
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- D' CENTRIFUGE ROOM RESIN SLURRY FLOW OBS313, y Cottr!NUEb FRcM ' DIAGRAM i NORsW._
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-~ # OF N N FRoM'A' tuC. ,' 217 ELEV '
I RLL STATIOM j ---q ,g ROOM N_ __ -
floor DRAIN SYSTEM AS A KESUL7~ Of T//E WASYF
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