JAFP-98-0074, Responds to NRC Re Violations Noted in Insp Rept 50-333/97-08 on 971027-1221.Corrective Actions:Operations Manager Has Reviewed Results of Root Cause Evaluation W/ Operations Shift Personnel

Responds to NRC Re Violations Noted in Insp Rept 50-333/97-08 on 971027-1221.Corrective Actions:Operations Manager Has Reviewed Results of Root Cause Evaluation W/ Operations Shift Personnel

ML20203J322
Person / Time
Site:	FitzPatrick
Issue date:	02/25/1998
From:	Michael Colomb POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
50-333-97-08, 50-333-97-8, JAFP-98-0074, JAFP-98-74, NUDOCS 9803040054
Download: ML20203J322 (12)

Text

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Jemer. A. FitzTatrick Nuclear Power Plant e

208 Ltk3 Ro:d PO Don 41 t ysormng New York 13093 T.16 342 3840

1. > NewYorkPower uichaei a. Coiome 4# Authority St. t ecute o=~

February 25,1998 JAFP 98 0074 United States Nuclear Regulatory Commission Attn: Document Control Desk Mail Station P1 137 Washington, DC 20055

SUBJECT:

James A. FitzPatrick Nuclear Power Plant Docket No. 50 333 Reply to Notice of Violation NRC Intearated Inspection Report 50 333/97 08

Dear Sir:

In accordance with the provisions of 10 CFR 2.201, Notice of Violation, the New York Power Authority submits a respense to the notice transmitted by your letter dated January 20,1998. Your letter refers to the results of the integrated inspection conducted from October 27,1997 through December 21,1997 at the Jameo A. FitzPatrick Nuclear Power Plant.

Also discussed in yvur letter are indications that additional focus and attention are warranted to improve work control activities. The Authority has ir:entified our need to improve in this area and initiated a formal root cause analysis. We believe the results of this analysis will be effective in further improving our performance.

Attachment I, Reply to Notice of Violation, proddes the description of the violations, reasons for the violations, corrective actions that have been taken and the results achieved, corrective actions to be taken to avoid further violations, and the dates of full compliance.

There is one commitment contained in this submittal.

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• United S)nt:s Nuclxt Regulatory Comrnission Attn: Document Control Desk

Subject:

Reply to Notice of Violation NRC Integrated inspection Report 50 333/97 08 Page 2-11 you have any ouestions, please contact Mr. Arthur Zaremba, Licensing Manager, at (315) 349 6365.

Very truly yours, QQ MICHAEL J. COLOMB Site Executive Of ficer MJC:GJB:las STATE OF NEW YORK COUNTY OF OSWEGO Attachments as stated Subscribed and sworn to before me Thisgday of Feb.

1998 ok A. kou, Ndtary Pu61ic NANCY B. CZEROW W

cc:

Regional Administrator

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• h*Mu U.S. Nuclear Regulatory Commission conwntee6en aspiree 1 -a e-94 475 /illendale Road King of Prussia, PA 19406 Office of the Resident inspector U.S. Nuclear Regulatory Commission P.O. Box 136 f

Lycoming, NY 13093 James A. FitzPatrick NPP Project Manager Project Directorate 11 Division of Reactor Projects - 1/11 U.S. Nuclear Regulatory Commission Mail Stop 14 82 Washington, DC 20555 Attachments:

Reply to Notice of Violation J

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Att:chment I

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Reply to N:tice cf Violation NRC integrated Inspection Report 50 333/97 08 i

ylOLATIQNA Technical Specification 6.8.(All requires that written procedures and administrative.

policles shall be estak"ched, implemented and maintained that meet or exceed the i

requirements and rec.rs. 1dations of Section 5 of American Natlanal Standards Institute (ANSli 18.7 - 1972 "Fecnny Administrative Policles and Procedures."

Section 5.1.2 of ANSI 18. 7 - 1972 states in part, that procedures shallbe followed, and the requirements i

for use of procedures shallbe prescribed in writing. Abnormal Operating Procedure (AOPI

~23, Direct Current (DC) Power System GroundIsolation specified th? sequence that breakers thallbe opened to isolate system grounds.

Contrary to the above, on Octobar 23,1997, procedures were not followed while performing AOP-23, DC Power System Ground Isolation, in that the sequence that breakers shallbe opened to Isciato system grounds was not followed. Specifically, j

71DCB2 Breaker No. 6, was opened prior to opening the breakers for 23MOV 57 and

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23MOV 58, the high pressure coolant injection !HPCI) booster pump suction from the suppression pool downstream and upstream Isolation valves, respectively, which caused the valves *.o open inadvertently.

This I? a Severity levelIV violation (Supplement ll i

ADMISSION _0R. DENIAL OF THE VIOLATION.

The Authority agrees with the violation.

MdftQNS FOR VIOLATION The cause for this violation was personnel error. The performance f actor leading to this error was ineffective worker practices. The Nuclear Control Operator (NCO) assigned the duties associated with the performance of AOr 23 did not adequately utilize the practice of self checking during the work evolutions associated with the procedure. This resulted in procedural steps being performed out of sequence.

Contributing human performance f actors which influenced the NCO's actions were:

Task interruptions and perceived pressure to complete task. Following the pre-job brief, delays were encountered prior to performance of the procedure step.

This, combined with an increasing ground condition, caused concern on the part of the NCO to focus his attentior on actions which would eliminate the ground.

Additionally, the NCO became focused on getting the correct breaker (71DCB2

1. 6) due to the recognized plant impact of opening the wrong breaker. These distractions contributed to the oversight by the NCO for not opening power supply breakers tor 23MOV 57 and 23MOV 58.

Lack of phys l cal, orderly procedure place keeping contributed to performing the 4

AOP 23 procedure step out-of sequence.

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Att:chment l Reply to Notice of Violation NRC Integratcd Inspection Report 50 333/97 08 CORRECTIVE ACTIONS THAT HAVE BEEI' TMfal A root cause evaluation was perftstmed on the events associated with this violation to s

identify specific cause, evaluate the extent of conditions that contributed to the occurrence of the violation relative to recent similar plant occurrences, and develop lessons learned. The Operations Manager has reviewed the results of this evaluation with Operations shif t personnel. The Operations Manager emphasized, during this review and in night order entries, the importance of good procedure place keeping to ensure proper procedure use.

The NCO responsible for the error has been counseled.

Abnormal Operating Procedurer AOP 22, DC Power System A Ground Isolation, and AOP 23, DC Power System B dround Isoletion, have been revised to improve the human f actors associated whn performing this procedure.

RESULTS ACHIEVED Actions taken have: 1) increased operator sensitivity to the issues associatec' with the cause of this violation; 2) raised operator awareness to potential task distractions or interruptions which may result in errors, and 3) increased emphasis to operators on proper procedure place keeping.

CORRECTIVE ACTIONS TO BE TAKEN Administrative Procedure AP 12.03, Administration of Operatio.D.g, will be revised to formally state management's expectations for procedure place keeping and provide examples of acceptable techniques. (Scheduled Completion Date - March 15,1998)

DATE WHEN FULL CONIPLIANCE WAS ACHIEVED Full compliance was achieved on October 23,1997, subsequent to Control Room recognition that missed steps to AOP 23 had occurred. Control Room actions included re-closure of breaker 71DCB2 #6 and restoration of HPCI suction paths to normallineup, i

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Att=hment 1 Reply to Notice of Violation NRC Integrated inspection Report 50 333/97 08 VIOLATION 8 Technicalspecification 3.7.D.2 states, in part, that, with one or more of the containment Isolation valves Inoperable, maintain at least one Isolation valve operable in each affected penetration that is open and restore the Inoperable valvels) to operable status within 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />s: or Isolate each affectedpenetration witnin 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> by use of at least one deactivated automatic valve securedin the closedposition.

Contrary to the above, on October 24,1997, maintenance activities to repair a ground problem were conducted which rendered the primary containment isolation function of the outboard higa pressure coolant injection steam isolation volve Inoperable and Technical Specification 3.7.D.2 requirements were not taken. After a maintenance error caused an invalid engineered safeguards feature actuation signal to occur in the same logic circuitry, operators recognized the failure to complete TS requirements andIsol.,ted the valve approximately 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> later.

This is a Severity levelIV violation (Supplement I).

ADMISSION OR DETAL OF THE VIOLATION The Authority agrees with the violation.

BEASON FOR VIOLATION The cause for this violation was personnel error. When listing the required Tet.nical Specification actions to be taken for testing on the "B" HPCI logic circuit in support of DC ground troubleshooting activities, operators f ailed to recognize that the "B" HPCI logic

.o imary Containment isolation System (PCIS) function of the outboard HPCI steam isolation r

valve was also being rendered inoperable. This resulted in failure to take the appropriate actions required by Technical Specification 3.7.D.2. LCO action statement.

Contributing causal f actors loading to this human performance error were:

Less than adequate development of the Work Planning Package. Th9 work planning package assessment and development was not ccmmensurate with the level of risk associated with the maintenance activities.

Inadequate work practices. The pre work technical reviews by Operations staff of the planned DC ground troubleshoot;ng efforts failed to identify the Primary Containment Isolation System (PCIS) function that was affected. Operators incorrectly concluded that the HFCI seven day -hutdown LCO, declared on 10/22/97 its support of ongoing scheduled HPCI work, would envelope the DC ground troubleshooting activity.

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Att: chm:nt I Reply to Notice of Violation NRC Integrated inspection Report 50 333/97 08 Procedure deficiency. Surveillance Test Procedure ST 2M, ECCS Trip System Bus e

Power Monitors Functional Test, and Abnormal Operating Procedure AOP 23, DC Power System B Ground Isolation, used to de energize the HPCIlogic, did not contain guidance associated with entry into T.D LCO 3.7.D.2.

Drawing deficiency. The electrical elementary drawing for the HPCI PCIS logic contained a misleading label (i.e.; the logic was described as " manual steam valve isolation" not PCIS isolation) which contributed to operaters f ailing to recognize that HPCI PCIS isolation logic was being de-energized.

J CORRECTIVE ACTIONS THAT HAVE 8EEN TAKEN A root cause evaluation was completed to identify the cause for the violation, contributing conditions, and develop lessons learned. The results of this evaluation were reviewed with alllicensed shift personnel. Included in the review was the need for operators to reassess special work evolutions for new LCOs as emergent work occurs and assure they understand the potential consequence of work being released.

Surveillance Test Procedure ST-2M, was revised to identity the Containment isolation function (s) being placed in the inoperable condition as a result of fuse removalin various trip logic circuitry.

Procedure revisions have been completed to Abnormal Operating Procedures AOP 22, DC Power System A Ground Isolation, and AOP 23. Changes included revising DC ground isolation circuit procedure Attachment 2 to include functions effected by the breaker, and inclusion of T.S. LCOs required to be taken prior to isolation of the breaker to properly bound the extent of the activity.

HPCI elementary drawing number 1.61-142 was revised to accurately reflect that relay 23A K3G is associated with PCIS isolation logic.

Persons designated as Qualified Technical Reviewers (OTRs) and/or Qualified Safety Reviewers (OSRs) within the Technical Services, Operations, Maintenance, and instrument and Controls Departments, whose responsibilities include conducting procedure reviews, were counseled on the results of the root cause evaluation.

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Included was reinforcement of management's expectations regarding OTR and OSR responsibilities for procedure technical accuracy and completeness.

Deviation Event rieport (DER 971649)) was generated following completion of the root cause evaluatit.1 to review and identify additional potential weaknesses in the work package planning and development process that were not addressed by the root cause evaluation. Corrective astions resulting from this DER included:

The Work Control Center supervisor has discussed management expectations for recognizing and understanding the potential plant impact and consequences of all work being released by Work Week Managers.

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.I Reply to Notice of Violation NRC integrated inspection Report 50 333/97 08 CORRECTIVE.AQllONS THAT HAVE BEEN TAKEN (cont'd.)

The issues associated with the f ailure(s) within the work package planning and development process to perform a detailed review of the HPCI PCIS logic prior to the issuance of the work to the field were reviewed with the Work Package Planners during the Central Planning Department Manager's weekly tailgate meeting.

BESULTS ACHIEVED The results of the actions taken have reinforced management's expectations for:

maintaining independence when involved in procedure and process technical reviews to ensure compliance with Technical Specifications and NYPA commitments during special evolutions; and that emergent work must be methodically assessed for compliance with Technical Specifications.

CORRECTIVE ACTIONS TO BE TAKEE A review is being conducted of other Surveillance Test Procedurec and Operating Procedures to identify conditions where fuse removal occurs, and assure resulting T.S.

impact is captured.

(Scheduled Completion Date - March 31,1998) 4 The licensed operator initial training and continued training programs are being updated to include scenarios involving fuse isolation, circuit analysis and assessment of its impact with respect to T.S. compliance.

(Scheduled Completion Date - March 15,1998)

Administrative Procedure AP 10.03, Work Packane Plannina, is being revised to provide added guidance for work package planning and preparation. Specifically, the level of detail and instruction, and depth of review used in the work control package planning and preparation process should be dr. pendent on the impact of the work on high risk or potential high risk evolutions.

(Scheduled Completion Date - April 15,1998)

Actions will be taken to formally establish the responsibilities of the Operations Plannsr for review of work packages.

(Scheduled Completion Date - March 31,1998)

DATE WHEN FULL COMPLIANCE WAS ACHIEVED Full compliance was achieved on October 25,1997, following the reinsertion of fuses, re-energizing the HPCI PCIS trip logic, and exiting from the HPCI LCO.

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Att=hment 1 Reply to Notice of Violation NRC Integrated Inspection Report 50 333/97 08 VJOLATION C

- 10 CFR 50.4Dif) requires each item of electrical equipment important to safety to be environmentally qualified by testing nr by cornb! nation of testing and analysis.

10 CFR 50.49(J) requires that a record of the environmental qualification be maintainedin an auditable form to permit verification that each item of electrical equipment important to

- safety is qualified for its application and meets its specified performance requirements i

when it is subjected (J the Conditions predicted to be present when it must perform its safety function.

Contrary to the above, from March 3,1993, to November 4,1997 electrical equipment important to safety was improperly removed from the environmental qualification program.

Specifically, high pressure coolant injection system pressure switches located in Junction y

box JB-R2250E were removed from the environmental qualification program based on a nonconservative assumption in the calculations prepared to document the basis for the removalof certain components from the environmentalqualification program.

This is a Severity levelIV violation (Supplement I).

ADMISSION OR QENIAL OF THE VIOLATION The Authority agrees with the violation. However, details provided in the text of the violation summary require correction and/or additional clanfication.

The closing paragraph provides the location of the HPCI prsssure switches, it should be noted that the subject switches are installed on Instrument Rack 25 50, located in Reactor Building olevation 242', adjacent to junction box JB R2250E.

This paragraph also states that "... pressure switches..,were removed from the environmental qualific.ation program based on a non-conservative asJumption in the -

calculation prepared to document the basis for the removal of certain components from the-environmental qualification orogram." It should be noted that the non-conservative assumption in Calculation JAF CALC HPCI-OO820 related to an assumed post accident operating time for the HPCI components and did not impact the conclusion made with regards to the subject components being removed and remaining off the Environmental Qualification Component List (EQCL). The cause for the removal was that the component i'

safoty function to maintain electricalintegrity following a HPCllRHR steam line break was not recognized. Details of this cause cre provided in the following Reason For Violation summary.

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Attzhment I Reply to Notice of Violation NRC Integrated Inspection Report 50 333/97 08 BEASONS FOR VIOLATION In 1L, ao Authority completed an Environmental Qualification Component List validation effort. The process was proceduralized in a NYPA approved vendor procedure. The validation effort confirmed that H7Cl pressure switches 23PS 86A, B, C, and D were required to be EQ. This was based on the safety function of these switches to initiate HPCI steam line isolation on high turbino exhaust pressure.

This is not an accident mitigating safety function, however, false actuation of these switches during HPCI

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operation following a small break Loss of Coolant Accident (LOCA) would cause an inadvertent HPCI system isolation.

A 1993 JAF calculation (JAF-CALC HPCI-00820) was performed to support the basis for removal of several HPCI components from the EOCL, including pressure switches 23PS-80A, B, C, and D. The calculation considered that a small break LOCA does not create a harsh environment in the Reactor Building (RB) crescent area where the switches are located and therefore, the subject pressure switches were removed from the EOCL in 1996, a Deviation Event Report was initiated due to an identified non conservative l

assumption made in calculation JAF CALC-HPCI-00820. The non-conservative assumption was evaluated and the calculation revised. As a result, several HPCI motor operated valves (MOVs) that were deleted from the EQCL in 1993 were added back to the List, it should be noted that the non-conservative assumption did not impact the original conclusions made with regard to the removal of the subject pressure switches from the EQ Program.

The consideration (EQ basis) lacking in both the 1993 and 1996 reviews was the requitement that the switches must maintain electricalintegrity following a HPCl/RHR steam line break in the RB because the switches share common circuitry with the HPCI steam line auto isolation logic. They are not separately fused, therefore, it is postulated that a common mode f ailure (short to ground) caused by a HPCl/RHR steam line break and a single f ailure will disable the steam line auto isolation logic and prevent iso!stion of the breaker. Had this "not fail" safety function consideration been included in the EQ evaluations for the subject switches, they would bsve remained in the EQ Program in 1993.

The cause for the violation was personnel error. A root cause analysis of this event identified the following human performance causal f actors:

Worker Practices -Incorrect interoretation of drawino information. During the EQ component evaluation effort in 1988, the consequence of the f ailure of the pressure switches to maintain electrical integrity (a "Not-Fail" safety function) following a reactor building HELB was not reco0nized. As a result, this "Not-Fail" safety function" was not identified in evaluation.

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l Att=hment 1 Reply to Notice of Violation NRC Integrated Inspection Report 60 333/97 08 MASONS FOR VIOLATION (cont'd.)

Worker Practices - Document use Dragligg. The 1993 and 1996 EQ evaluations were performed using Engineering and Design Procedure EDP 20, Procsdure For Establishing if Plant Electrical Equipment is Within The Scope Of 10 CFR 50.49 (FO) Section 3 of the instructions for the evaluation (EDP 20, Attachment 1 form) provides apecific instructions to identif y component safety functions and designates "not fail" as the safety function of components whose frHure will prevent the accomplishment of the safety functhn of other safety related components due to fusing and circuit configuration. ~.,e evaluations did not correctly identify the "not f ail" safety function to maintain electricalintegrity for the subject pressure switches. The engineers utilized a 1988 EQ component list evaluation report as a basis for the EDP 20 evaluation and did not review the applicable drawings to the extent that the error h the 1988 report was caught, Worker Practices - Less than adeauste review /veHfication process.

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The review processes used following the 1988,1993, and 1996 EO evaluations were inadequate in that they did not identify the f ailure of the evaluations in identify the safety function to maintain electrical integrity for the subject switches.

CORRECTIVE ACTIONS THAT HAVE BEEN TAKEli A root cause evaluation was perk,rmed to identify the conditions that caused or e

contributed to the occurrence of this violation, the recommended corrective actions and identification of lessons learned. The evaluation was prepared by and reviewed with Engineering Department personnel responsible for implementation of the EQ program.

Individuals involved in the 1988,1993, and 1996 inadequate worker practices are no longer involved in the implementation of the EQ Program, Work Activity Control Procedure WACP-10.1.11, Environmental Qualification Proaram o

For Harsh Environment Plant Electrical Eauioment, Attachment 1, " Environmental Qualification (EO) Component List", was revised to include HPCI pressure switches 23PS 86A, B, C and D.

Er$gineering and Desig, r$rocedure EDP-20, Procedure For Establishina if Plant Electrical Eauioment is Within the Scope of 10 CFR 50.49 (EO), Attachment 1, " Evaluation Form For Identification of Plant Electrical Equipment Requiring Environmentel Qualification",

was ccmpleted for HPCI pressure switches 23PS-86A, B, C, and D, Addendum No. 7 to EQ Reference No. 310, " Addition of Component ID's 23PS-e 86A/B/C/D which were inadvertently deleted from the EO Component List by WACP-10.1.11, Revision 17-1" was generated to reinstate the subject switches in the EO file for Static-O Ring pressure switches.

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e Att:chment I Reply to Notice of Violation NRC Integrated inspection Report 50 333/97 08 RESULTS ACHIEVED An ongoing extent of condition review has identified four additional components having "not f ail" safety functions that were incorrectly removed from the EOCL, These components are being reinstated into the Program. The DER process will be used to report and track component EQ classificction revisions resulting from this review.

_PORREclLVE ACTIONS TO BE TAKEN Complete the extent of condition review to identify similar control circuit e

configuration (s) that may involve components not being included in the EQ Program.

(Scheduled Completion Date March 15,1998)

To improve worker practices for selection of appropriate input for use with EDP 20 ovaluations, a revision will be made to EDP 20 to: (1) list the root ;suse evaluation for this violation > a manegement expectation under the Requirements Section of the procedure; and (2) provide additional clarification to emphasize that a review of the plant drawings must be performed to ensure that safety function of components whose failure will prevent the accomplishment of the safety function of other safety related components due to fusing and circuit configuration is identified.

(Scheduled Completion Date April 30,1998)

This violation and its root cause evaluation are being included as tr'1uired reading on Engineering Department personnel Task Qualification Sheets for performance of Engineering Department Procedure EDP 20. This will assure that al' prospective engineers, and all engineers presently qualified to perform EDP 20, will have reviewed the conditions associated with this violation.

(Scheduled Completion Date - March 15,1998)

The Engineering Support Personnel (ESP) Tsaining Program Review Committee (TPRC) will review this violation for possible inclusion into the ESP Training Program.

l (Scheduled Completion Date - June 30,1998)

L DATE WHEN FULL COMPLIANCE WAS ACHIEVED.

Full compliance will be achieved upon completion of the current ongoing EQ review, scheduled to be completed by March 15,1998. Should reviews identify additional EQ l

Program revisions requiring an extension to this date, the Authority will submit a revised l

response to this violation.

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Attachm:nt ll Reply to Nc'::e of Violation NRC Integrated inspection Report 50 333/97 08 List of CotDmitments Commitment No.

Action Due Date 7

JAFP 98 0074-01 Should EO reviews identify additional EQ March 15,1998 Program revisions requiring an extension to the i

scheduled full compliance date of March 15, 1998, the Authority will submit a revised response to this violation.

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