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{{Adams
#REDIRECT [[IR 05000325/1992035]]
| number = ML20125E538
| issue date = 11/25/1992
| title = 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
| author name = Merschoff E
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
| addressee name = Watson R
| addressee affiliation = CAROLINA POWER & LIGHT CO.
| docket = 05000325
| license number =
| contact person =
| document report number = EA-92-208, NUDOCS 9212170105
| package number = ML20125E541
| document type = CORRESPONDENCE-LETTERS, OUTGOING CORRESPONDENCE
| page count = 4
}}
See also: [[see also::IR 05000325/1992035]]
 
=Text=
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    ..
  *
  .
                                            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
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}}

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