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{{Adams | |||
| number = ML20148K715 | |||
| issue date = 01/19/1988 | |||
| title = Discusses 871230 Enforcement Conference Re Findings of Insp Repts 50-498/87-71 & 50-499/87-71 on 871101-30.Meeting Summary Encl.Meeting Beneficial | |||
| author name = Callan L | |||
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) | |||
| addressee name = Goldberg J | |||
| addressee affiliation = HOUSTON LIGHTING & POWER CO. | |||
| docket = 05000498, 05000499 | |||
| license number = | |||
| contact person = | |||
| document report number = EA-87-240, NUDOCS 8801280025 | |||
| document type = CORRESPONDENCE-LETTERS, NRC TO UTILITY, OUTGOING CORRESPONDENCE | |||
| page count = 17 | |||
}} | |||
See also: [[see also::IR 05000498/1987071]] | |||
=Text= | |||
{{#Wiki_filter:- | |||
, | |||
.. | |||
. | |||
/ | |||
- | |||
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l | |||
In Reply Refer To: | |||
Dockets: 50-498 M !O N | |||
50-499 | |||
EA 87-240 | |||
' | |||
Houston Lighting & Power Company | |||
ATTN: J. H. Goldberg, Group Vice | |||
President, Nuclear | |||
P.O. Box 1700 | |||
Houston, Texas 77001 | |||
Gentlemen: | |||
This refers to the enforcement conference conducted in the NRC Region IV | |||
office on December 30, 1987, with you and other members of your staff and | |||
Region IV staff members to discuss findings of'the NRC inspection conducted | |||
during the period of November 1-30, 1987, which were documented in NRC | |||
Inspection Report 50-498/87-71; 50-499/87-71, dated December 18, 1987. | |||
The topics covered are described in the enclosed meeting summary. | |||
It is our opinion that this meeting was beneficial and provided a | |||
better understanding of the concerns identified during the inspectiori. | |||
In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2, | |||
Title 10, Code of Federal Regulations, a copy of this letter will be placed in | |||
the NRC's Public Document Room. | |||
Should you have any questions concerning this letter, we will be pleased to | |||
discuss them with you. | |||
Sincerely, | |||
Original Signed By | |||
L J. Callan | |||
L. J. Callan, Director | |||
Division of Reactor Projects | |||
Enclosure: | |||
Meeting Suntnary | |||
cc: | |||
Houston Lighting & Power Company | |||
ATTN: M. Wisenberg, Manager | |||
Nuclear Licensing | |||
P.O. Box 1700 | |||
Houston, Texas 77001 | |||
c,b | |||
RIV:DRP/D % C:. RP E0 D:DR k | |||
HFBundy:gb stable DAP ers LJCallan | |||
/ //f/88 GL'q88 | |||
i/ i / 6 /88 I / ($ /88 - | |||
8801280025 880119 | |||
PDR | |||
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ADOCK 05000498 | |||
PDR | |||
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.. -. .. . . - - ~ - | |||
, | |||
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. | |||
Houston Lighting and Power Company 2 | |||
Houston Lighting & Power Company | |||
ATTN: Gerald E. Vaughn, Vice President | |||
Nuclear Operations | |||
P.O. Box 1700 | |||
Houston, Texas 77001 | |||
~ | |||
Central Power & Light Company | |||
ATTN: R. L. Range /R. P. Verret | |||
P.O. Box 2121 ' | |||
Corpus Christi, Texas 78403 | |||
City Public Service Board | |||
ATTH: R. J. Costello/M. T. Hardt | |||
P.O. Box 1771 | |||
San Antonio, Texas 78296 | |||
City of Austin | |||
ATTN: M. B. Lee /J.-E. Malaski | |||
P.O. Box 1088 | |||
Austin, Texas 78767-8814 | |||
Texas Radiation Control Program Director | |||
, | |||
bec distrib. by RIV: | |||
*DRP *RRI-0PS- | |||
R. D. Martin, RA *RRI-CONST. ' | |||
Section Chief (DRP/D) RPSB-DRSS | |||
*RIV File | |||
*Lisa Shea, RM/ALF *RSTS Operator | |||
R. Bachmann, 0GC *H. Bundy , | |||
*P. Kadambi, NRR Project Manager *R. Taylor | |||
*DRS D. Powers | |||
i | |||
t | |||
l | |||
) | |||
_-______ ___ _ _ _ _ _ - _ _ - _ _ - _ - _ _ _ _ _ _ __ . _ _ _. ._ ___ | |||
. . - _ . - . . __ _ .- ._ | |||
, | |||
I | |||
e | |||
. | |||
MEETING SUMMARY - DECEMBER 30, 1987 | |||
Licensee: Houston Lighting and Power Company (HL&P). | |||
Facility: South Texas Project (STP), Units 1 and 2 | |||
Dockets: 50-498 Operating License: NPF-71 | |||
50-499 Construction Permit: CPPR-128 | |||
Subject: Enforcement Conference | |||
Concerning NRC Inspection Findings (HRC Inspection | |||
Report 50-498/87-71; 50-499/87-71) and Related Concerns | |||
On December 30, 1987, representatives of HL&P met with NRC Region IV and NRR | |||
personnel in the NRC office in Arlington, Texas to discuss the findings | |||
documented in NRC Inspection Report 50-498/87-71; 50-499/87-71, dated | |||
December 18, 1987. Other recent events of mutual concern were also | |||
discussed. The attendance list and summary of the licensee presentatice are | |||
attached. The meeting was held at the request of the NRC, Region IV. | |||
The licensee discussed root causes for selected events, corrective actions | |||
taken to preclude recurrence, and results achieved to-date. | |||
The NRC staff expressed particular concern regarding the two events discussed | |||
below: | |||
a. Plant Entered Mode 4 on October 31, 1987, with High Head Safety Injection | |||
(HHSI) System Valves Shut | |||
The licensee agreed that this was the most serious of the events selected | |||
for discussion. There was no direct safety impact because the reactor | |||
core has not been operational and no decay heat was present. Accordingly, | |||
the major NRC concern was with regard to the evident weaknesses in the | |||
licensee operating practices which allowed this condition to continue for | |||
51 hours prior to discovery. Many operators, supervisors and managers had | |||
opportunities to question the off-normal valve positions during this | |||
period. | |||
b. Pressurizer Pressure-Low Trip Septpoint Was Set lass Conservatively than | |||
Technical Specification (TS) Requirement on November 24, 1987 | |||
' | |||
This setpoint error had the effect of rendering all four. channels of the | |||
safety injection actuation system inoperable. The staff questioned the | |||
efficiency of the licensee's procedure review and approval process in | |||
allowing the incorrect setpoint to be inserted in the procedure. This | |||
setpoint had been changed as result of engineering analysis by the vendor | |||
and HL&P had requested the TS change as a result of this analysis. NRC | |||
Inspection Report 50-498/87-27 discussed this change as a followup to HL&P | |||
Incident Review Committee Item 333. Also NRC Inspection Report 50-498/ | |||
87-39, Open Item 498/8739-10, identified specific TS setpoint errors for | |||
annunciators and suggested further verification of instrument setpoints. | |||
Despite these references and subsequent TS audits performed by the | |||
licensee, the setpoint error was not corrected prior to entry into Mode 3. | |||
Another concern the NRC staff had was the fact that HL&P in Licensee Event | |||
Report (LER) 87-017, dated December 21, 1987, failed to recognize the ; | |||
change to Mode 3 with incorrect setpoints as a TS violation. This point | |||
was clarified in the meeting. | |||
. _ ___ __ _ _ ___ | |||
_ _ _ _ _ _ _ _ _ _ . _ . _ _ | |||
. | |||
. | |||
. | |||
2 | |||
The NRC staff explained to licensee representatives the enforcement policy. | |||
The licensee was commended for his candor in reporting and discussing the | |||
above described events. | |||
Attachments: | |||
A. Enforcement Conference Attendance | |||
B. Outline of HL&P's Presentation | |||
; | |||
l | |||
l | |||
1 | |||
, | |||
.. . | |||
. | |||
Attachment A | |||
Enforcement Conference Attendance | |||
December 30, 1987 | |||
Name Title Organization | |||
J. H. Goldberg Group VP Nuclear HL&P | |||
G. E. Vaughn VP Nuclear Operations ' 'HL&P | |||
W. H. Kinsey Plant Manager, STP HL&P | |||
-M. Wisenburg Manager, Engineering & Licensing HL&P | |||
M. A. McBurnett Manager, Operations Support HL&P | |||
Licensing | |||
L. Joe Callan Director, Division of Reactor NRC, RIV | |||
Projects | |||
J. L. Milhoan Director, Division of Reactor NRC, RIV | |||
Safety | |||
A. Bill Beach Deputy Director, Division or NRC, RIV | |||
Reactor Projects | |||
H. L. Scott Enforcement Staff NRC, RIV | |||
G. L. Constable Chief, Reactor Projects Section D NRC, RIV- | |||
D. M. Hunnicutt Chief, Test Programs Section NRC, RIV | |||
M. T. Hardt Director, Nuclear Division City Public Service | |||
San Antonio | |||
D. R. Carpenter Senior Inspector-STP NRC, RIV | |||
H. F. Bundy Project Engineer NRC, RIV | |||
N. P. Kadan61 Project Manager NRC, NRR | |||
J. 1. Tapia ProjectEngineer(SectionA) NRC, RIV | |||
_ | |||
- | |||
; - - , . | |||
i - | |||
. | |||
! | |||
! | |||
! | |||
! | |||
! | |||
SOUTNTEHR$ | |||
. | |||
PROJECT | |||
! | |||
NRC ENFORCEMENT CONFERENCE , | |||
. | |||
i i | |||
i ARLINGTON, TEXAS | |||
i | |||
, | |||
DECEMBER 30,1987 i | |||
i | |||
! | |||
_ _ _ _ _ _ _ _ - _ _ _ _ __ _ _ _ _ _ _ _ | |||
_--- | |||
. . | |||
. | |||
AGENDA | |||
~ | |||
e Introduction - J. H. Goldberg | |||
e Technical Specification - W. H. Kinsey | |||
Violations | |||
e Management initiatives - W. H. Kinsey | |||
e Questions / Answers | |||
. | |||
-- - - - -__-- - - | |||
-_ -- . - - . .- | |||
.. | |||
_ | |||
. | |||
. | |||
EVENT | |||
e Plant entered Mode 4 on 10-31-87 with HHSI system valves isolated. | |||
* Discovered during shift tumover on 11-02-87. | |||
e immediately opened Train "B" and "C" valves. | |||
ROOT CAUSE | |||
e Poorly planned evolution. Operations Management in effort | |||
to verify plant lineup did not understand procedural relationships | |||
and operator performing evolution did not understand "big picture." | |||
CORRECTIVE ACTION | |||
e Remedial training for operators and management on compliance with | |||
procedures, selection of procedures, proper planning and attention to detail. | |||
* Revise specific involved procedures and review others for | |||
similar weakness. | |||
O Enhance shift tumover information on status of Safety Related equipment. | |||
e Simulator training with emphasis on mode changes and accompanying | |||
requirements. | |||
------------ ----_- ---- - _ _ - . - - | |||
. __ | |||
_ | |||
l . | |||
l | |||
1 - | |||
l | |||
l | |||
, | |||
EVENT | |||
e Plant staff discovered that Reactor Containment Building (RCB) | |||
Atmosphere monitor 1-131 channel was not tested in accordance with | |||
, | |||
technical specifications on 09-18-87. | |||
e Grab sampling of RCB initiated and the channel tested within | |||
24 hours. | |||
ROOT CAUSE | |||
e Process for review of last minute technical specification changes | |||
and incorporation of technical specifications into surveillance procedures | |||
was not ngorous. Management relied on responsible individuals to perform | |||
last minute changes without verification. | |||
: CORRECTIVE ACTION | |||
' | |||
e Review technical specification surveillances and LCO numbers, | |||
with exception of ESF and RTS setpoints, against surveillances. | |||
i | |||
e implementation of future technical specification changes will be | |||
performed using a detailed process that incorporates independent verification. | |||
' | |||
. | |||
- - _ - - - - - _ _ _ _ - -- - - _ _ _ _ - - - _ _ _ _ _ - - _ _ | |||
- _ - - _ - - - - - - - - - _ _ _ - - _ _ _ - _ - _ _ - - _ | |||
_ | |||
. | |||
. | |||
EVENT | |||
e Plant staff discovered Pressurizer Pressure-Low Trip Setpoint was | |||
set less conservatively than technical specification requirement on 11-24-87. | |||
* Plant conditions required for function never achieved. | |||
e Instruments recalibrated within 24 hours. | |||
ROOT CAUSE ' | |||
e Process for review of last minute technical specification changes | |||
and incorporation of technical specifications into surveillance procedures ! | |||
was not ngorous. Management relied on responsible individuals to perform | |||
last minute changes without verification. | |||
CORRECr1VE ACTION | |||
e Review Engineered Safety Features and Reactor Trip System | |||
setpoints against surveillance procedures to ensure no other items | |||
were missed. | |||
e implementation of future technical specification changes will be , | |||
performed using a detailed process that incorporates independent verification. | |||
< | |||
l | |||
-_ | |||
A . | |||
. | |||
l . | |||
EVENT | |||
e Plant staff discovered that the slave relay contact for train "A" | |||
containment spray actuation was not tested on 11-24-87. | |||
* Performed test within 24 hours. | |||
ROOT CAUSE | |||
e Superficial review of procedure field change and absence of written | |||
interpretation of technical specification requirements. | |||
CORRECTIVE ACTION | |||
e Reviewed trains "B" and "C" to ensure identical error was not made. | |||
e Remedial training for I&C Division Supervision on independent | |||
verification of procedure changes and on attention to detail. | |||
1 | |||
_ _ _ _ ________ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ . . _ _ _ _ _ _ _ | |||
, - | |||
- - - _ | |||
-l | |||
l | |||
l | |||
. | |||
EVENT | |||
e Plant staff discovered the 4160 degraded voltage and the degraded | |||
voltage coincident with safety injections contacts were not tested | |||
on 12-12-87. | |||
* Performed tests within 24 hours | |||
ROOT CAUSE | |||
e Technical preparation and independent review were not rigorous. | |||
Absence of written interpretation of technical specification requirements. | |||
l | |||
CORRECTIVE ACTION | |||
e Established station policy on relay testing. | |||
* Performed two independent reviews of al! I&C and electrical | |||
surveillance tests for compliance with technical specifications. | |||
_- ___ _ - - _ - _ - - - - - - - _ - - - - - - - - - | |||
. | |||
.. | |||
. | |||
EVENT | |||
e Plant staff discovered both toxic gas monitors out of service | |||
on 12-06-87. | |||
* Placed control room in recirculation mode and restored monitors to | |||
service. | |||
ROOT CAUSE | |||
e insufficient supervision and training of reactor operator student | |||
conducting routine log readings. | |||
C_ORRECnVE ACTION | |||
e Conduct Plant Operations and Chemical Operations staffs crew | |||
briefings, stressing importance of conducting thorough indoctrination /tmining | |||
for students. Reemphasize responsibility for student actions. | |||
* Reprogram toxic gas monitors such that operators are only required | |||
to read computer printouts to perform channel operation checks. | |||
e Review and revise OJT training program for operator rounds. | |||
* Review and revise operator logs for channel check recording requirements. | |||
* Complete technical specification equipment "positive statusing" review. | |||
__ _ _ _ _ - _ _ _ _ _ _ . _ _ _ - __ ___ _ _. _-_ | |||
_ - | |||
_ | |||
. | |||
! . | |||
EVEXT | |||
e NRC Resident insp'ector informed Plant Manager that, contrary to | |||
commitment, "A train Auxiliary Feedwater cross-connect volve was not | |||
tagged closed when plant entered mode 3. | |||
ROOT CAUSE | |||
e Insufficient written guidance and training provided to shift | |||
personnel on implementation of "Night Order" assignments. | |||
1 | |||
t | |||
CORRECnVE ACTION | |||
. e Revise "Night Order" administrative procedure and train shift | |||
! personnel on changes. | |||
i | |||
: | |||
: | |||
_ _ - _ _ _ _ ____ _ __ _ - - _ _ _ - - _ . _. . . . . _ -- | |||
. _ _ . | |||
_ | |||
. | |||
. | |||
. | |||
EVENT | |||
e Two fire protection dampers were found to be blocked open with | |||
electrical tie wraps and wire. These dampers were designed to be held | |||
open with fusible links. | |||
* Fire watches immediately established in affected areas. | |||
ROOT CAUSE | |||
o Uakown. Quality assurance records indicate adequate installation. | |||
No evidence can be found of maintenance or in situ testing on the affected | |||
dampers following installation. | |||
CORRECTIVE ACTION | |||
e One damper has been restored to full service. Other damper is | |||
still inoperative awaiting replacement parts. | |||
i | |||
_ . _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ - _ -. | |||
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MANAGEMENT INITIATIVES | |||
O PLANNED | |||
e Executive management briefings with all supervision and management | |||
* Additional review of recent plant startup events | |||
e increase emphasis on use of simulator for normal evolution training | |||
* Peer involvement on personnel error investigations | |||
1 | |||
e Root cause determination training for representative Department personnel | |||
e Continued high level management involvement in Station Operation | |||
/ Plan of Day Meetings | |||
/ Station Problem Reports | |||
. | |||
, | |||
.- .._ _ ___. _ _ . _ _ .. . - ._ ., , _ . | |||
}} | |||
Revision as of 21:47, 7 August 2022
| ML20148K715 | |
| Person / Time | |
|---|---|
| Site: | South Texas |
| Issue date: | 01/19/1988 |
| From: | Callan L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | Goldberg J HOUSTON LIGHTING & POWER CO. |
| References | |
| EA-87-240, NUDOCS 8801280025 | |
| Download: ML20148K715 (17) | |
See also: IR 05000498/1987071
Text
-
,
..
.
/
-
.lh8/f
l
In Reply Refer To:
Dockets: 50-498 M !O N
50-499
EA 87-240
'
Houston Lighting & Power Company
ATTN: J. H. Goldberg, Group Vice
President, Nuclear
P.O. Box 1700
Houston, Texas 77001
Gentlemen:
This refers to the enforcement conference conducted in the NRC Region IV
office on December 30, 1987, with you and other members of your staff and
Region IV staff members to discuss findings of'the NRC inspection conducted
during the period of November 1-30, 1987, which were documented in NRC
Inspection Report 50-498/87-71; 50-499/87-71, dated December 18, 1987.
The topics covered are described in the enclosed meeting summary.
It is our opinion that this meeting was beneficial and provided a
better understanding of the concerns identified during the inspectiori.
In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2,
Title 10, Code of Federal Regulations, a copy of this letter will be placed in
the NRC's Public Document Room.
Should you have any questions concerning this letter, we will be pleased to
discuss them with you.
Sincerely,
Original Signed By
L J. Callan
L. J. Callan, Director
Division of Reactor Projects
Enclosure:
Meeting Suntnary
cc:
Houston Lighting & Power Company
ATTN: M. Wisenberg, Manager
Nuclear Licensing
P.O. Box 1700
Houston, Texas 77001
c,b
RIV:DRP/D % C:. RP E0 D:DR k
HFBundy:gb stable DAP ers LJCallan
/ //f/88 GL'q88
i/ i / 6 /88 I / ($ /88 -
8801280025 880119
G
ADOCK 05000498
/(
) h
g g
L
.. -. .. . . - - ~ -
,
, I
.
Houston Lighting and Power Company 2
Houston Lighting & Power Company
ATTN: Gerald E. Vaughn, Vice President
Nuclear Operations
P.O. Box 1700
Houston, Texas 77001
~
Central Power & Light Company
ATTN: R. L. Range /R. P. Verret
P.O. Box 2121 '
Corpus Christi, Texas 78403
City Public Service Board
ATTH: R. J. Costello/M. T. Hardt
P.O. Box 1771
San Antonio, Texas 78296
City of Austin
ATTN: M. B. Lee /J.-E. Malaski
P.O. Box 1088
Texas Radiation Control Program Director
,
bec distrib. by RIV:
- DRP *RRI-0PS-
R. D. Martin, RA *RRI-CONST. '
Section Chief (DRP/D) RPSB-DRSS
- RIV File
- Lisa Shea, RM/ALF *RSTS Operator
R. Bachmann, 0GC *H. Bundy ,
- P. Kadambi, NRR Project Manager *R. Taylor
- DRS D. Powers
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MEETING SUMMARY - DECEMBER 30, 1987
Licensee: Houston Lighting and Power Company (HL&P).
Facility: South Texas Project (STP), Units 1 and 2
Dockets: 50-498 Operating License: NPF-71
50-499 Construction Permit: CPPR-128
Subject: Enforcement Conference
Concerning NRC Inspection Findings (HRC Inspection
Report 50-498/87-71; 50-499/87-71) and Related Concerns
On December 30, 1987, representatives of HL&P met with NRC Region IV and NRR
personnel in the NRC office in Arlington, Texas to discuss the findings
documented in NRC Inspection Report 50-498/87-71; 50-499/87-71, dated
December 18, 1987. Other recent events of mutual concern were also
discussed. The attendance list and summary of the licensee presentatice are
attached. The meeting was held at the request of the NRC, Region IV.
The licensee discussed root causes for selected events, corrective actions
taken to preclude recurrence, and results achieved to-date.
The NRC staff expressed particular concern regarding the two events discussed
below:
a. Plant Entered Mode 4 on October 31, 1987, with High Head Safety Injection
(HHSI) System Valves Shut
The licensee agreed that this was the most serious of the events selected
for discussion. There was no direct safety impact because the reactor
core has not been operational and no decay heat was present. Accordingly,
the major NRC concern was with regard to the evident weaknesses in the
licensee operating practices which allowed this condition to continue for
51 hours5.902778e-4 days <br />0.0142 hours <br />8.43254e-5 weeks <br />1.94055e-5 months <br /> prior to discovery. Many operators, supervisors and managers had
opportunities to question the off-normal valve positions during this
period.
b. Pressurizer Pressure-Low Trip Septpoint Was Set lass Conservatively than
Technical Specification (TS) Requirement on November 24, 1987
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This setpoint error had the effect of rendering all four. channels of the
safety injection actuation system inoperable. The staff questioned the
efficiency of the licensee's procedure review and approval process in
allowing the incorrect setpoint to be inserted in the procedure. This
setpoint had been changed as result of engineering analysis by the vendor
and HL&P had requested the TS change as a result of this analysis. NRC
Inspection Report 50-498/87-27 discussed this change as a followup to HL&P
Incident Review Committee Item 333. Also NRC Inspection Report 50-498/
87-39, Open Item 498/8739-10, identified specific TS setpoint errors for
annunciators and suggested further verification of instrument setpoints.
Despite these references and subsequent TS audits performed by the
licensee, the setpoint error was not corrected prior to entry into Mode 3.
Another concern the NRC staff had was the fact that HL&P in Licensee Event
Report (LER)87-017, dated December 21, 1987, failed to recognize the ;
change to Mode 3 with incorrect setpoints as a TS violation. This point
was clarified in the meeting.
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The NRC staff explained to licensee representatives the enforcement policy.
The licensee was commended for his candor in reporting and discussing the
above described events.
Attachments:
A. Enforcement Conference Attendance
B. Outline of HL&P's Presentation
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Attachment A
Enforcement Conference Attendance
December 30, 1987
Name Title Organization
J. H. Goldberg Group VP Nuclear HL&P
G. E. Vaughn VP Nuclear Operations ' 'HL&P
W. H. Kinsey Plant Manager, STP HL&P
-M. Wisenburg Manager, Engineering & Licensing HL&P
M. A. McBurnett Manager, Operations Support HL&P
Licensing
L. Joe Callan Director, Division of Reactor NRC, RIV
Projects
J. L. Milhoan Director, Division of Reactor NRC, RIV
Safety
A. Bill Beach Deputy Director, Division or NRC, RIV
Reactor Projects
H. L. Scott Enforcement Staff NRC, RIV
G. L. Constable Chief, Reactor Projects Section D NRC, RIV-
D. M. Hunnicutt Chief, Test Programs Section NRC, RIV
M. T. Hardt Director, Nuclear Division City Public Service
San Antonio
D. R. Carpenter Senior Inspector-STP NRC, RIV
H. F. Bundy Project Engineer NRC, RIV
N. P. Kadan61 Project Manager NRC, NRR
J. 1. Tapia ProjectEngineer(SectionA) NRC, RIV
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NRC ENFORCEMENT CONFERENCE ,
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DECEMBER 30,1987 i
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AGENDA
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e Introduction - J. H. Goldberg
e Technical Specification - W. H. Kinsey
Violations
e Management initiatives - W. H. Kinsey
e Questions / Answers
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EVENT
e Plant entered Mode 4 on 10-31-87 with HHSI system valves isolated.
- Discovered during shift tumover on 11-02-87.
e immediately opened Train "B" and "C" valves.
ROOT CAUSE
e Poorly planned evolution. Operations Management in effort
to verify plant lineup did not understand procedural relationships
and operator performing evolution did not understand "big picture."
CORRECTIVE ACTION
e Remedial training for operators and management on compliance with
procedures, selection of procedures, proper planning and attention to detail.
- Revise specific involved procedures and review others for
similar weakness.
O Enhance shift tumover information on status of Safety Related equipment.
e Simulator training with emphasis on mode changes and accompanying
requirements.
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EVENT
e Plant staff discovered that Reactor Containment Building (RCB)
Atmosphere monitor 1-131 channel was not tested in accordance with
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technical specifications on 09-18-87.
e Grab sampling of RCB initiated and the channel tested within
24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
ROOT CAUSE
e Process for review of last minute technical specification changes
and incorporation of technical specifications into surveillance procedures
was not ngorous. Management relied on responsible individuals to perform
last minute changes without verification.
- CORRECTIVE ACTION
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e Review technical specification surveillances and LCO numbers,
with exception of ESF and RTS setpoints, against surveillances.
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e implementation of future technical specification changes will be
performed using a detailed process that incorporates independent verification.
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EVENT
e Plant staff discovered Pressurizer Pressure-Low Trip Setpoint was
set less conservatively than technical specification requirement on 11-24-87.
- Plant conditions required for function never achieved.
e Instruments recalibrated within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
ROOT CAUSE '
e Process for review of last minute technical specification changes
and incorporation of technical specifications into surveillance procedures !
was not ngorous. Management relied on responsible individuals to perform
last minute changes without verification.
CORRECr1VE ACTION
e Review Engineered Safety Features and Reactor Trip System
setpoints against surveillance procedures to ensure no other items
were missed.
e implementation of future technical specification changes will be ,
performed using a detailed process that incorporates independent verification.
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EVENT
e Plant staff discovered that the slave relay contact for train "A"
containment spray actuation was not tested on 11-24-87.
- Performed test within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
ROOT CAUSE
e Superficial review of procedure field change and absence of written
interpretation of technical specification requirements.
CORRECTIVE ACTION
e Reviewed trains "B" and "C" to ensure identical error was not made.
e Remedial training for I&C Division Supervision on independent
verification of procedure changes and on attention to detail.
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EVENT
e Plant staff discovered the 4160 degraded voltage and the degraded
voltage coincident with safety injections contacts were not tested
on 12-12-87.
- Performed tests within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />
ROOT CAUSE
e Technical preparation and independent review were not rigorous.
Absence of written interpretation of technical specification requirements.
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CORRECTIVE ACTION
e Established station policy on relay testing.
- Performed two independent reviews of al! I&C and electrical
surveillance tests for compliance with technical specifications.
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EVENT
e Plant staff discovered both toxic gas monitors out of service
on 12-06-87.
- Placed control room in recirculation mode and restored monitors to
service.
ROOT CAUSE
e insufficient supervision and training of reactor operator student
conducting routine log readings.
C_ORRECnVE ACTION
e Conduct Plant Operations and Chemical Operations staffs crew
briefings, stressing importance of conducting thorough indoctrination /tmining
for students. Reemphasize responsibility for student actions.
- Reprogram toxic gas monitors such that operators are only required
to read computer printouts to perform channel operation checks.
e Review and revise OJT training program for operator rounds.
- Review and revise operator logs for channel check recording requirements.
- Complete technical specification equipment "positive statusing" review.
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EVEXT
e NRC Resident insp'ector informed Plant Manager that, contrary to
commitment, "A train Auxiliary Feedwater cross-connect volve was not
tagged closed when plant entered mode 3.
ROOT CAUSE
e Insufficient written guidance and training provided to shift
personnel on implementation of "Night Order" assignments.
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CORRECnVE ACTION
. e Revise "Night Order" administrative procedure and train shift
! personnel on changes.
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EVENT
e Two fire protection dampers were found to be blocked open with
electrical tie wraps and wire. These dampers were designed to be held
open with fusible links.
- Fire watches immediately established in affected areas.
ROOT CAUSE
o Uakown. Quality assurance records indicate adequate installation.
No evidence can be found of maintenance or in situ testing on the affected
dampers following installation.
CORRECTIVE ACTION
e One damper has been restored to full service. Other damper is
still inoperative awaiting replacement parts.
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MANAGEMENT INITIATIVES
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e Executive management briefings with all supervision and management
- Additional review of recent plant startup events
e increase emphasis on use of simulator for normal evolution training
- Peer involvement on personnel error investigations
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e Root cause determination training for representative Department personnel
e Continued high level management involvement in Station Operation
/ Plan of Day Meetings
/ Station Problem Reports
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