IR 05000325/1992035

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)

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NOV 2 5 1992 Docket No.: 50-325 Pl =

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 enclose 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.

y 9212170205-921125 e PDR-G ADOCK.05000324 PDR

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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 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 avoide 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 modificatio 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 disable 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 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

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be limited to the clearance proces 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 condition Therefore, the violations are categorized at Severity Level I 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 event 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 attentio 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 _ Operation ,

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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 requirement 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 Roo 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. 96-51 Should you have any questions concerning this letter, please contact u

Sincerely, original signed by:

-Jon R. Johnson /for Ellis W. Merschoff, Director Division of Reactor Projects Enclosures: Notice of Violation i Enforcement Conference l Attendees Licensee Handout

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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 C 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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I Carolina Power and Light Company 4 uv 2 5 P-r i

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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

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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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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