ML20125E538

Discusses Insp Rept 50-325/92-35 on 921002-30 & Forwards Notice of Violation.Violation Involved Inadvertent Decrease of Reactor Vessel Water Level to RPS Actuation Level Setpoint of 165 Inches

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: IR 05000325/1992035 ML20125E545
References
EA-92-208, NUDOCS 9212170105
Download: ML20125E538 (4)

See also: IR 05000325/1992035

Text

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NOV 2 5 1992

Docket No.: 50-325 Pl =

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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

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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.

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NOV 2 51992

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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

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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

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comments indicative of your thorough analysis of this event. However, the

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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

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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. ,

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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

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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)

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Carolina Power and Light Company 4

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(cc w/encls cont'd)

l Chrys Baggett

State Clearinghouse

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Budget and Management

! 1.16 West Jones Street

j Raleigh, NC 27603

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Dayne H. Brown, Director

Division of Radiation Protection

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N. C. Department of Environment, i

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j Health & Natural Resources '

P. O. Box 27687

Raleigh, NC 27611-7687

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H._A. Cole __ _

! Special Deputy Attorney General

l State of North Carolina '

i P. O. Box 629

Raleigh, NC- 27602

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! Robert P. Gruber

1 Executive Director

l Public Staff - NCUC

i P. O. Box 29520

{ Raleigh, NC 27626-0520

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! Ms.- Gayle B. Nichols

! Staff Counsel

l SC Public Service Commission

P. O. Box 11649 -

l Columbia, SC- 29211

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' bec w/encls:

Document Control Desk

! H. Christensen, RII .

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R. Lo, NRR -

l NRC Resident Inspecter

l U.S.- Nuclear Regulatory Commission.- -

i Star Route-1, Box 208

Southport, NC .28461 '

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