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{{#Wiki_filter: | {{#Wiki_filter:1 | ||
.. | |||
* | |||
. | |||
NOV 2 5 1992 | |||
Docket No.: 50-325 Pl = | |||
3 | |||
License No.: DPR 62 | |||
EA 92-208 fll('"" J | |||
Carolina Power and Light Company ' | |||
ATTN: Mr. R. A. Watson | |||
Senior Vice President | |||
Nuclear Generation | |||
Post Office Box 1551 | |||
Raleigh, North Carolina 27602 | |||
Gentlemen: | |||
SUBJECT: NOTICE OF VIOLATION | |||
(NRC INSPECTION REPORT NOS. 50-325/92-35 AND 50-324/92-35) | |||
This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by | |||
Mr. D. Nelson on October 2 - 30, 1992, at the Brunswick Steam Electric Plant. . | |||
The inspection included a re'tiew of the facts and circumstances related to the | |||
inadequately controlled Unit I reactor water level draining evolution which | |||
resulted in the inadvertent low level isolation of shutdown cooling on | |||
October ;',1992. The report documenting this inspection was sent to you by | |||
letter dated November 9, 1992- As a resalt of this inspection, violations of | |||
NRC requit ments were identified. An enforcement conference was held on | |||
November 21 1992, in the NRC Region 11 office, Atlanta, Georgia, to discuss | |||
the violations, their causs, and your corrective actions to preclude | |||
recurrence. A list of attendees at the enforcement conference and a copy.of | |||
your handout are enclosed. | |||
The violations in the-enclosed-Notice of Violation (Notice) resulted from the | |||
October 2, 1992 event. At the time of the event, Unit I was in operational | |||
condition 4 (cold shutdown) as a result of a forced outage which began on | |||
April 21, 1992. The event involved an inadvertent decrease of reactor vessel | |||
water level to the Reactor Protecticn System (RPS) actuation level setpoint of | |||
165 inches which caused automatic RPS trip and Primary Containment Isolation | |||
- | |||
System (PCIS) group isolations that secured the level decrease, but resulted | |||
in a. loss of shutdown cooling. Although the event was a direct result of- | |||
operator inattentiveness due to distractions during critical plant operations.- | |||
there were other significant contributing factors that preceded.the final | |||
personnel error which caused the actual event. Even though these contributing | |||
factors developed sequentially, a collective evaluation of those ; actors | |||
strongly indicates that the root cause of the event war inadequate management | |||
control of facility licensed.'activJties. The inspection _ report provides the- | |||
specific details associated with these contributing factors such as the loss | |||
of a level alarm due to a plant modif.ication installation; excessive control- | |||
room distractions; insufficient command, control and communication; and | |||
inadequate outage planning and scheduling. | |||
y | |||
9212170205-921125 | |||
e PDR- | |||
G ADOCK.05000324 | |||
PDR | |||
\\ | |||
_ Mbi | |||
. | |||
. | |||
: | |||
: NOV 2 51992 | |||
' | |||
Carolina Power and Light Company 2 | |||
Violation A in the Notice involved failure to follow a procedure wherein the | |||
inattentiveness of the reactor operator (i.e., he was reviewing a documcnt | |||
unrelated to plant operations) resulted in the reduction of reactor vessal | |||
water level to the point of RPS and PCIS actuation on Low Level 1. | |||
Contributing to the reactor operator's actions was the indirect | |||
inattentiveness of the senior reactor operator due to excessive administrative | |||
. | |||
duties and the continuing tolerance by Operations management to allow long | |||
standing control room distractions. Additionally, the inadequate scheduling | |||
and planning of outage activities put the operators in a challenging situation | |||
that could have been avoided. | |||
Violation B in the enclosed Notice involved the failure to effectively | |||
communicate to the operators ' hat equipruent and instrumentation had been | |||
disabled as a result of clearances associated with a plant modification. | |||
Specifically, an on going modification to the Feedwater Control System | |||
disabled the only audible high/ low reactor vessel water level alarm in the | |||
control room. In addition, there had been no positive communication to | |||
control room operators that the modification installation caused the audible | |||
alarm not to function. This was a significant oversight because reactor | |||
vessel level control was being maintained manually by the operators and the- | |||
low level alarm would have lessened the potential for inadvertent draining of | |||
the reactor vessel. The operator who was involved in the event of October 2, | |||
1992, was not aware that the low level alarm had been disabled. | |||
The staff acknowledges the comments received during the enforcement conference | |||
with regard to the broader underlying cause of Violation B and considers those | |||
, | |||
comments indicative of your thorough analysis of this event. However, the | |||
l | |||
staff considers that in this event the clearance process should have provided | |||
the communication mechanism and therefore, the characterization of the | |||
violation has not chan;;ed. The staff recognizes that other process procedures | |||
l may exist to addrass this issue and your response to this violation should not | |||
' | |||
be limited to the clearance process. | |||
After careful consideration of this matter, the NRC staff has concluded that | |||
the safety significance of this event was mitigated by the fact that automatic | |||
Emergency Core Cooling Systert, injection was available had the reactor vessel- | |||
water level continued to decrease, and because of the low initial temperature | |||
and low decay heat rate due to the plant being-in cold shutdown conditions. | |||
Therefore, the violations are categorized at Severity Level IV. However, the | |||
i distraction of control room personnel with non-operational duties is of | |||
significant concern. Excessive _ senior reactor. operator administrative duties | |||
was also identified as a contributing cause to previous operating events. | |||
Additionally, the act of manipulating critical reactor parameters warrants | |||
undivided attention and failure to do so represents an error in fundamental | |||
watchstanding operating practices. This requires prompt management | |||
attention. | |||
The ' staff recognizes that immediate corrective action was taken wher, the event | |||
occurred and that a Site Incident Investigation Team was established to review | |||
the event and develop a Root Cause Analysis. ' Also viewcd as significant was | |||
! the fact that independent outside participation was requested and provided by i | |||
l - the Institute ~of Nuclear Power _ Operations. , | |||
i. | |||
1 | |||
m | |||
_ _ ~ _ _ - _ _ -. __. . _ _ .___ . _ . __ __. _ .__ | |||
. | |||
: | |||
Carolina Power and Light Company 3 I!DV 2 5 992 | |||
You are required to respond to this letter and should follow the instructions | |||
specified in the enclosed Notice when preparing ynur response. In your | |||
response, you should document the specific actions taken and any additional | |||
actions you plan to prevent recurrence. After reviewing your response to this | |||
Notice, including your proposed corrective ac' ions and the results of future | |||
inspections, the NRC will determine whether fuither NRC enforcement action is | |||
- | |||
necessary to ensure compliance with NRC regulatory requirements. | |||
In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of | |||
this letter and its enclosures will be placed in the NRC Public Document Room. | |||
The responses directed by this letter and the enclostd Notice are not subject | |||
to the clearance procedures of the Office of Management and Budget as required | |||
by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. | |||
Should you have any questions concerning this letter, please contact us. | |||
Sincerely, | |||
original signed by: | |||
-Jon R. Johnson /for | |||
Ellis W. Merschoff, Director | |||
Division of Reactor Projects | |||
Enclosures: | |||
1. Notice of Violation | |||
i 2. Enforcement Conference | |||
l Attendees | |||
3. Licensee Handout | |||
! cc w/encls: | |||
R. E. Morgan | |||
Interim Manager | |||
Brunswick Nuclear Project | |||
P. O. Box 10429 | |||
Southport, NC 28461 | |||
H. Ray Starling | |||
Vice President - Legal Department | |||
Carolina Power and Light Co. | |||
P. O. Box 1551 | |||
Raleigh, NC 27602 | |||
Kelly Holden | |||
Board of Commissioners | |||
P. O. Box 249 | |||
Bolivia, NC 28422 | |||
(cc w/encls cont'd - See page 4) | |||
-- .. .- . .. . . - -. | |||
- | |||
; | |||
; .. , | |||
! - | |||
. | |||
I | |||
Carolina Power and Light Company 4 | |||
uv 2 5 P-r | |||
i | |||
' | |||
(cc w/encls cont'd) | |||
l Chrys Baggett | |||
; State Clearinghouse | |||
' | |||
Budget and Management | |||
! 1.16 West Jones Street | |||
j Raleigh, NC 27603 | |||
, | |||
, | |||
' | |||
Dayne H. Brown, Director | |||
Division of Radiation Protection | |||
5 | |||
N. C. Department of Environment, i | |||
' | |||
j Health & Natural Resources ' | |||
P. O. Box 27687 | |||
; Raleigh, NC 27611-7687 | |||
' | |||
H._A. Cole __ _ | |||
! Special Deputy Attorney General | |||
l State of North Carolina ' | |||
i P. O. Box 629 | |||
Raleigh, NC- 27602 | |||
- | |||
! Robert P. Gruber | |||
1 Executive Director | |||
l Public Staff - NCUC | |||
i P. O. Box 29520 | |||
{ Raleigh, NC 27626-0520 | |||
. | |||
! Ms.- Gayle B. Nichols | |||
! Staff Counsel | |||
l SC Public Service Commission | |||
: P. O. Box 11649 - | |||
l Columbia, SC- 29211 | |||
, | |||
' | |||
' bec w/encls: | |||
Document Control Desk | |||
! H. Christensen, RII . | |||
, | |||
R. Lo, NRR - | |||
; | |||
l NRC Resident Inspecter | |||
l U.S.- Nuclear Regulatory Commission.- - | |||
i Star Route-1, Box 208 | |||
; Southport, NC .28461 ' | |||
. | |||
f' O _ | |||
Cl | |||
l L | |||
1 | |||
4 | |||
, | |||
1- | |||
.h | |||
. | |||
, , | |||
) | |||
, | |||
i RII- - RII:DR RII:DRP- RII:DRP RII: 1 T2E ' A. | |||
R ar all:tj hChristensen- | |||
' | |||
DVer elli JJoh on n fu | |||
:11/g/92 11/r./92 11/gg/92 11/ig92 1 Igg /!2 jgg | |||
: | |||
; | |||
t. _ . . _ ._ _ _ . = . _ .a _. _ . _ . - . . _ . . _ _ _ _ _ . _ _ . . _ . | |||
}} | }} |
Revision as of 02:11, 24 July 2020
ML20125E538 | |
Person / Time | |
---|---|
Site: | Brunswick ![]() |
Issue date: | 11/25/1992 |
From: | Merschoff E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
To: | Watson R CAROLINA POWER & LIGHT CO. |
Shared Package | |
ML20125E541 | List: |
References | |
EA-92-208, NUDOCS 9212170105 | |
Download: ML20125E538 (4) | |
See also: IR 05000325/1992035
Text
1
..
.
NOV 2 5 1992
Docket No.: 50-325 Pl =
3
License No.: DPR 62
EA 92-208 fll('"" J
Carolina Power and Light Company '
ATTN: Mr. R. A. Watson
Senior Vice President
Nuclear Generation
Post Office Box 1551
Raleigh, North Carolina 27602
Gentlemen:
SUBJECT: NOTICE OF VIOLATION
(NRC INSPECTION REPORT NOS. 50-325/92-35 AND 50-324/92-35)
This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by
Mr. D. Nelson on October 2 - 30, 1992, at the Brunswick Steam Electric Plant. .
The inspection included a re'tiew of the facts and circumstances related to the
inadequately controlled Unit I reactor water level draining evolution which
resulted in the inadvertent low level isolation of shutdown cooling on
October ;',1992. The report documenting this inspection was sent to you by
letter dated November 9, 1992- As a resalt of this inspection, violations of
NRC requit ments were identified. An enforcement conference was held on
November 21 1992, in the NRC Region 11 office, Atlanta, Georgia, to discuss
the violations, their causs, and your corrective actions to preclude
recurrence. A list of attendees at the enforcement conference and a copy.of
your handout are enclosed.
The violations in the-enclosed-Notice of Violation (Notice) resulted from the
October 2, 1992 event. At the time of the event, Unit I was in operational
condition 4 (cold shutdown) as a result of a forced outage which began on
April 21, 1992. The event involved an inadvertent decrease of reactor vessel
water level to the Reactor Protecticn System (RPS) actuation level setpoint of
165 inches which caused automatic RPS trip and Primary Containment Isolation
-
System (PCIS) group isolations that secured the level decrease, but resulted
in a. loss of shutdown cooling. Although the event was a direct result of-
operator inattentiveness due to distractions during critical plant operations.-
there were other significant contributing factors that preceded.the final
personnel error which caused the actual event. Even though these contributing
factors developed sequentially, a collective evaluation of those ; actors
strongly indicates that the root cause of the event war inadequate management
control of facility licensed.'activJties. The inspection _ report provides the-
specific details associated with these contributing factors such as the loss
of a level alarm due to a plant modif.ication installation; excessive control-
room distractions; insufficient command, control and communication; and
inadequate outage planning and scheduling.
y
9212170205-921125
e PDR-
G ADOCK.05000324
\\
_ Mbi
.
.
- NOV 2 51992
'
Carolina Power and Light Company 2
Violation A in the Notice involved failure to follow a procedure wherein the
inattentiveness of the reactor operator (i.e., he was reviewing a documcnt
unrelated to plant operations) resulted in the reduction of reactor vessal
water level to the point of RPS and PCIS actuation on Low Level 1.
Contributing to the reactor operator's actions was the indirect
inattentiveness of the senior reactor operator due to excessive administrative
.
duties and the continuing tolerance by Operations management to allow long
standing control room distractions. Additionally, the inadequate scheduling
and planning of outage activities put the operators in a challenging situation
that could have been avoided.
Violation B in the enclosed Notice involved the failure to effectively
communicate to the operators ' hat equipruent and instrumentation had been
disabled as a result of clearances associated with a plant modification.
Specifically, an on going modification to the Feedwater Control System
disabled the only audible high/ low reactor vessel water level alarm in the
control room. In addition, there had been no positive communication to
control room operators that the modification installation caused the audible
alarm not to function. This was a significant oversight because reactor
vessel level control was being maintained manually by the operators and the-
low level alarm would have lessened the potential for inadvertent draining of
the reactor vessel. The operator who was involved in the event of October 2,
1992, was not aware that the low level alarm had been disabled.
The staff acknowledges the comments received during the enforcement conference
with regard to the broader underlying cause of Violation B and considers those
,
comments indicative of your thorough analysis of this event. However, the
l
staff considers that in this event the clearance process should have provided
the communication mechanism and therefore, the characterization of the
violation has not chan;;ed. The staff recognizes that other process procedures
l may exist to addrass this issue and your response to this violation should not
'
be limited to the clearance process.
After careful consideration of this matter, the NRC staff has concluded that
the safety significance of this event was mitigated by the fact that automatic
Emergency Core Cooling Systert, injection was available had the reactor vessel-
water level continued to decrease, and because of the low initial temperature
and low decay heat rate due to the plant being-in cold shutdown conditions.
Therefore, the violations are categorized at Severity Level IV. However, the
i distraction of control room personnel with non-operational duties is of
significant concern. Excessive _ senior reactor. operator administrative duties
was also identified as a contributing cause to previous operating events.
Additionally, the act of manipulating critical reactor parameters warrants
undivided attention and failure to do so represents an error in fundamental
watchstanding operating practices. This requires prompt management
attention.
The ' staff recognizes that immediate corrective action was taken wher, the event
occurred and that a Site Incident Investigation Team was established to review
the event and develop a Root Cause Analysis. ' Also viewcd as significant was
! the fact that independent outside participation was requested and provided by i
l - the Institute ~of Nuclear Power _ Operations. ,
i.
1
m
_ _ ~ _ _ - _ _ -. __. . _ _ .___ . _ . __ __. _ .__
.
Carolina Power and Light Company 3 I!DV 2 5 992
You are required to respond to this letter and should follow the instructions
specified in the enclosed Notice when preparing ynur response. In your
response, you should document the specific actions taken and any additional
actions you plan to prevent recurrence. After reviewing your response to this
Notice, including your proposed corrective ac' ions and the results of future
inspections, the NRC will determine whether fuither NRC enforcement action is
-
necessary to ensure compliance with NRC regulatory requirements.
In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of
this letter and its enclosures will be placed in the NRC Public Document Room.
The responses directed by this letter and the enclostd Notice are not subject
to the clearance procedures of the Office of Management and Budget as required
by the Paperwork Reduction Act of 1980, Pub. L. No.96-511.
Should you have any questions concerning this letter, please contact us.
Sincerely,
original signed by:
-Jon R. Johnson /for
Ellis W. Merschoff, Director
Division of Reactor Projects
Enclosures:
1. Notice of Violation
i 2. Enforcement Conference
l Attendees
3. Licensee Handout
! cc w/encls:
R. E. Morgan
Interim Manager
Brunswick Nuclear Project
P. O. Box 10429
Southport, NC 28461
H. Ray Starling
Vice President - Legal Department
Carolina Power and Light Co.
P. O. Box 1551
Raleigh, NC 27602
Kelly Holden
Board of Commissioners
P. O. Box 249
Bolivia, NC 28422
(cc w/encls cont'd - See page 4)
-- .. .- . .. . . - -.
-
- .. ,
! -
.
I
Carolina Power and Light Company 4
uv 2 5 P-r
i
'
(cc w/encls cont'd)
l Chrys Baggett
- State Clearinghouse
'
Budget and Management
! 1.16 West Jones Street
j Raleigh, NC 27603
,
,
'
Dayne H. Brown, Director
Division of Radiation Protection
5
N. C. Department of Environment, i
'
j Health & Natural Resources '
P. O. Box 27687
- Raleigh, NC 27611-7687
'
H._A. Cole __ _
! Special Deputy Attorney General
l State of North Carolina '
i P. O. Box 629
Raleigh, NC- 27602
-
! Robert P. Gruber
1 Executive Director
l Public Staff - NCUC
i P. O. Box 29520
{ Raleigh, NC 27626-0520
.
! Ms.- Gayle B. Nichols
! Staff Counsel
l SC Public Service Commission
- P. O. Box 11649 -
l Columbia, SC- 29211
,
'
' bec w/encls:
Document Control Desk
! H. Christensen, RII .
,
R. Lo, NRR -
l NRC Resident Inspecter
l U.S.- Nuclear Regulatory Commission.- -
i Star Route-1, Box 208
- Southport, NC .28461 '
.
f' O _
Cl
l L
1
4
,
1-
.h
.
, ,
)
,
i RII- - RII:DR RII:DRP- RII:DRP RII: 1 T2E ' A.
R ar all:tj hChristensen-
'
DVer elli JJoh on n fu
- 11/g/92 11/r./92 11/gg/92 11/ig92 1 Igg /!2 jgg
t. _ . . _ ._ _ _ . = . _ .a _. _ . _ . - . . _ . . _ _ _ _ _ . _ _ . . _ .