ML20138K185
ML20138K185 | |
Person / Time | |
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Site: | Wolf Creek |
Issue date: | 05/06/1997 |
From: | Gwynn T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
To: | Maynard O WOLF CREEK NUCLEAR OPERATING CORP. |
References | |
50-482-97-04, 50-482-97-4, NUDOCS 9705120236 | |
Download: ML20138K185 (4) | |
See also: IR 05000482/1997004
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UNITED ST ATES
.,.m 71 NUCLEAR REGULATORY COMMISSION
.. REGloN IV
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611 RY AN PLAZA DRIVE. SUITE 400
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( %" 9 ,0 AR LINGTON, T EXAS 76011 8064
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MAY - 6 1997
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Otto L. Maynard, President and
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Chief Executive Officer i
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Wolf Creek Nuclear Operating Corporation
i P.O. Box 411
Burlington, Kansas 66839 l
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SUBJECT: NRC INSPECTION REPORT 50-482/97-04
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Thank you for your letter of April 23,1997, in response to our letter and Notice of
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Violation dated March 10,1997. We have reviewed your reply and find it responsive to
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.e concerns raised in our Notice of Violation. We will review the implementation of your
corrective actions during a future inspection to determine that full compliance has been
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, achieved and will be maintained. !
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omas P. Gwy Jn, D' ect r
Division of Rea t oje ts
cc:
Chief Operating Officer
Wolf Creek Nuclear Operating Corp.
P.O. Box 411
Burlington, Kansas 66839
Jay Silberg, Esq.
Shaw, Pittman, Potts & Trowbridge
2300 N Street, NW
Washington, D.C. 20037 Ij
Supervisor Licensing
Wolf Creek Nuclear Operating Corp.
P.O. Box 411
Burlington, Kansas 66839
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9705120236 970506
gDR ADOCK 05000482
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Wolf Creek Nuclear -2- l
Operating Corporation l
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Chief Engineer
Utilities Division
Kansas Corporation Commission ,
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1500 SW Arrowhead Rd. l
Topeka, Kansas 66604-4027
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Office of the Governor !
State of Kansas
Topeka, Kansas 66612 I
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Attorney General j
Judicial Center )
301 S.W.10th j
2nd Floor i
Topeka, Kansas 66612-1597 '
County Clerk l
Coffey County Courthouse I
Burlington, Kansas 66839-1798 l
Vick L. Cooper, Chief
Radiation Control Pron am j
Kansas Department
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Salth
arid Environment
Bureau of Air and Radiation
Forbes Field Building 283
Topeka, t'.ansas 66620
Mr. Frank Mc . sa
Division of Em 'e PrepatNness
2800 SW Topeka th
Topeka, Kansas 66611- 287
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Wolf Creek Nuclear -3-
Operating Corporation MAY - 6 1997
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DOCUMENT NAME: R:\_WC\WC704AK.JFR
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Wolf Creek Nuclear- -3-
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DOCUMENT NAME: R:\ WC\WC704AK.JFR l
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NUCLEAR OPERATING CORPORATION .*
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Richard A. Muench ' " ~ " * '
Vice Prescent Engineenng ' I a' ' '
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April 23, 1997 ~ ~ - ~ ~ ~ ~ ~ ' --
ET 97-0044
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U. S. Nuclear Regulentory Commission
ATTN: Document Control Desk
Mail Station F1-137
Washington, D. C. 20555 -
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Reference: Letter dated March 10, 1997, from A. T. Howell,
NRC, to O. L. Maynard, WCNOC
Subject: Docket No. 50-482: Response to Notice of Violations
50-482/9704-01, -02, -03,-04, and -07
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Gentlemen:
This letter transmits Wolf Creek N2 clear Operating Corporation's (WCNOC)
, response to Notice of Violations 50-482/9704-01, -02, -03,- 04, and -07.
Violation 9704-01 concerns the f al '.u re of a Shift Supervisor to recognize
conditions requiring entry into Technical Specification Action. Statement 3.6.3,
and failure to log that entry. Violation 9704-02 involved manipulation of a
turbine-driven auxiliary feedwater pump governor valve while troubleshooting an
inadvertent overspeed trip without correct work controls, and without correct
authorization. Violation 9704-03 concerns WCNOC's failure to establish
procedure SYS AL-124 adequately to control the test activity. Violation 9704-04 l
occurred when an operator f ailed to follow procedure direction when attempting !
to trip the turbine-driven auxiliary feedwater pump. Violation 9704-07 occurred !
when a revision to a flow chart in the Emergency Plan inadvertently resulted in
a decrease in the effectiveness of the plan, without prior NRC approval.
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This response letter is being submitted after the 30 day due date with the
concurrence of the Senior Resident Inspector a r, discussed at the 50-482/97-08
Inspection Exit Meeting.
WCNOC's response to these violations is in the attachment. If you have any j
questions regarding this response, please contact me at (316) 364-8831,
extension 4034, or Mr. Richard D. Flannigan at extension 4500.
Ve tru y yours, j
Richard A. Muench
RAM /jad
Attachment I
cc: E. W. Merschoff (NRC), w/a
W. D. Johnson (NRC), w/a
J. F. Ringwald (NRC), w/a
J. C. Stone (NRC), w/a
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PO. Box 411/ BAngton, KS 6687 * hone: (316) 364 8831
g g'g_ An Eque Opportunety Einstoyer M F HC VET
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Attachment to ET 97-0044
Page 1 of 14
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Violation 50-482/9704-01: The Shift Supervisor did not recognize that a
Containment : solation Valve failure resulted in
entry into Technical Specification Action l
Statement 3.6.3, and failed to log entry into
Technical Specification Action Statement 3.6.3.
" Technical Specification 6.8.1.a states, in part, that written
procedures shall be established and implemented covering the applicable
procedures recommended in Appendix A of Regulatory Guide 1.33, Revision
2.
Regulatory Guide 1.33, Appendix A, Section 1.h, requires administrative
procedures for log entries.
Administrative Procedure AP 21-001, " Operations Watchstanding
Practices," Revision 4, Step 6.2.3.d, requirt- a log entry for entry
into Technical Specification action statements c.a to equipment failure. ;
Contrary to the above, on July 28, 1996, at 5:15 p.m., the Shift
Supervisor logged a failure of Containment Isolation Valve EF HV0034 to
close on demand, but failed to recognize that this valve failure
resulted in entry into Technical Specification Action Statement 3.6.3
and failed to log entry into Technical Specification Action Statement
3.6.3."
Admission of Violation:
Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that
a violation of Technical Specification 6.8.1 occurred when the Shift
Supervisor failed to recognize that the EF HV0034 Containment Isolation Valve
l failure resulted in entry into Technical Specification Action Statement 3.6.3,
and f ailed to log entry into Technical Specification Action Statement 3.6.3.
All Limiting Concition for Operations (LCO) actions were adequately addressed
but not logged.
Reason for Violation:
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Two concerns were identified during the evaluation of the items identified in
violation 9704-01.
- 1. The Shift Supervisor did not enter Technical Specification 3.6.3 on July
l 26, 1996. He neglected to consider the containment isolation function of
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EF HV0034, instead he concentrated on the safeguards required position of
i the valve. (EF HV0034 is a motor operated containment isolation valve
i located within the containment structure.) The safeguards required
position is "open". The Shift Supervisor's concentratiot. on the "open"
safeguards position combined with: 1) Dual indication problems that
occurred in the " closed" position; 2) Technical Specification Table 3.6-1
( specifying "N/A" for the maximum EF HV0034 isolation time; and 3)
l Subsequent stroking of the valve that did not .:esult in problem recurrence,
l caused the Shift Supervisor to incorrectly determine that the containment
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isolation requirements of Technical Specification 3.6.3 did not apply.
The root cause for not entering Technical Specification 3.6.3 was personal
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error. The root cause of personal error by the Shift Supervisor appeared to
! be an isolated 'mstance, not having generic implications; however, on March
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6, 1997, two Fes.ormance Improvement Requests (PIR 97-0715 and PIR 97-0716)
were issued. Both PIRs dealt with the failure to either properly enter, or
to properly log the entry into, Technical Specification 3.6.3.
2. LER 96-010-00, wnich reported the failure of F.F HV0034 to properly operate
from March 10, 1996, through October 9, 1996, did not discuss operability
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Attacnment to ET 47-0044
Page 2 of 14
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Of EF MV0034 in relation to honnical Specification 3.6.3. LER 96-010-00
dic scuss events surrounding tne inoperability of E,F HV0034, but stated
tne cas s for reportacility was Tecnnical Spe :fication 3.7.4, which states
"At ' east two independent essential serviv water (ESW) loops shall be
operarle.' LER 96-010 did not consider noncompliance with Technical
Speci ication 3. 6. 3, which pertains to containnent isolation, and states:
"The containment isolation valves specifiea in Tacle 3.6-1 shall be
OPERABLE with is .ation t mes as shown in Table 3.6-1."
The root cause for failing to identify in LER 96-010 that Technical
Specification 3.6.3 was not properly entered was an incomplete
investigation of Performance Improvement Request (PIR) 96-2528. The root
cause for this problem was inadequate interface among organizations. This
event, and the LER reporting it, were mainly evaluated by WCNOC Engineering
without sufficient participation by Operations.
The failure of the PIR 96-2528 investigation to identify the failure to
address Technical Specification 3.6.3 was determined to have generic
implications. The generic implications are that a PIR, such as 96-2528,
has multiple issues af fecting various work groups. In the specific case of
PIR 96-2528, this PIR was evaluated by Engineering, and the issue of
Technical Specifications compliance was not given sufficient in-depth
attention.
Corrective Steps Taken and Results Achieved:
- Perfcrmance Improvement Request (PIR) 96-2528 served as the basis for
information for the description, root cause, and corrective action for
the event reported in Licensee Event Report (LER) 96-10-00. The WCGS
Corrective Action Review Board (CARB) was not in existence when the
evaluation for significant ?;R 96-2528 was performed. The CARB now
provides upper level management and multi-discipline review of PIRs
involving significant issues, prior to the PIR's closure. The
procedurally required review by the CARB is now a practice that will
help ensure all applicable issues are evaluated when addressing
significant PIRs. Because LER content is based on significant PIR
evaluation, CARB review will aid in preventing inaccurate or incomplete
i LERs from being issued.
Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be
Achieved:
will be revised by May 10, 1997, to provide guidance for when a m21ti-
discipline team approa'h should be used to perform evaluations of
significant PIRs. This will ensure that knowledgeable organizations are
given the opportunity to provide input into the evaluation process for
significant issues.
- A rev13 ion to LER 96-C10-00 will be issued by April 30, 1997, to correct
the f ailure to identif y entry into Technical Specification 3.6.3.
ADDITIONAL EVENTS IDENTIFIED:
On March 5, 1997, at 0900, the "B" train Containment Cooler was isolated by
Clearance Order (C/0) 97-0302-EF to support abbreviated Valve Operation Test
and Evaluation System (VOTES) testing on EF HV0034. Technical Specification 3.6.3 requires an action when specific containment isolation valves, such as
EF HV0034, become inoperable. EF HV0034 became inoperaole during the
abbreviated VOTES testing, when the valve's operator rotor cover was removed;
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Page 3 of 14
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however, the Snift Supervisor did not enter Tecnnical Specification 3.6.3, as
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required.
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' misunderstanding occurred concerning the work scope. Interviews with the
Shift Supervisor revealed that he understood that the limit switch
- compartment cover (rotor cover) would be removed, as is stated in the
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Maintenance Work Package Summary. However, the Supervising Operator did not
l understand that the cover would be removed. Although the Shift Supervisor and
l Supervising Operator each had a different understanding of the work scope,
! neither identified the need to enter Technical Specification 3.6.3. This is
due to the following:
1. The Shift Supervisor understood the cover was being removed as was stated
in the Work Package Summary. The Shift Supervisor did not enter Technical
Specification 3.6.3 because Clearance Order 97-0302-EF closed the outside
containment isolation valve (EF HV0032). The Shift Supervisor understood
that this met the action for Technical Specification 3.6.3 , and therefore
he thought it was not necessary to log entry of the Technical Specification
into the Shift Supervisor log.
2. The Supervising Operator misunderstood the scope of work and thought the
cover would remain installed. The Supervising Operator therefore had no
reason to believe operability would be affected and he subsequently did not
enter Technical Specification 3.6.3.
Based on the facts reviewed, the following were causes of the identified
problems:
1. There was no clear expectation of Equipment Out-of-Service Log (EOL) or
Control Room Log entries when a Clearance Order meets the Technical
Specification action. The Shift Supervisor and Supervising Operator to
believe that it was not necessary to log the Technical Specifications that
are considered whenever a Clearance Order satisfies the Technical
Specification action statement. At that time, Operations did not log all
Technical Specifications being considered when the Technical Specification
action statement was met by a Clearance Order. This is part of the pre-job
planning and satisfies the LCO. The expectations for the future will be to
log all Technical Specifications that apply and which are being considered;
including those Technical Specifications in which the action statement is
met by a Clearance Order. Logging of all applicable and considered
Technical Specifications will indicate that all appropriate Technical
Specifications have been considered.
l 2. Verbal and written communication resulted in the misinterpretation of the
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words "non-intrusive" and "cperability" used in the Work Package Task work
l scope.
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Corrective Steps Taken to " ADDITIONAL EVENTS IDENTIFIED" and Results Achieved:
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- Control Room Log entries were amended.
- PIR 97-0716, which documents the description, root cause, and corrective
actions for this event, has been placed in Operations required reading .
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Attachment to ET 97-0044
Page 4 of 14
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Corrective Steps That Will Be Taken to " ADDITIONAL EVENTS IDENTIFIED" And The
Date When Full Compliance Will Be Achieved:
- Operations Management will issue a written expectation stating that, even
when an action statement is met, reference needs to be made in both the
control rocm logs, and in the EOL. This action will be completed by May 16,
1997
- Confusion surrounding the meaning of the words "non-intrusive" and
" operability" will be addressed in training. This training will develop a
consistent definition for each word that is acceptable to both Maintenance
and Operations. Training will alert personnel to the different
connotations words can carry and that words can have multiple definitions
based on the organizational perspective. Consideration to other words will
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also be given. This training will be given to both Maintenance and
Operations. Completion date for the training is July 5, 1997.
- The Superintendent of Operations will discuss with the operating crews the
importance of clear, concise and detailed communication with Maintenance
personnel. Operating crews will be reminded that different terms can have
different meanings to various organizations. Clear communication ensures
that the sender and receiver each have a common understanding. These
discussions will be completed by May 16, 1997.
to reflect that if a Clearance Order meets the requirements of a Technical
Specification action statement, the Equipment Out-of-Service Log (EOL) must
state this, se it is understood that the Technical Specification is not
being violated. This revision will be completed by May 16, 1997.
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Attachment to ET 97-0044
Page 5 of 14
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Violation 50-4s2/9704-02: A System Engineer manipulated the turbine-
driven auxiliary feedwater pump governor
valve FC FVO313 while troubleshooting an
inadvertent overspeed trip without a work
package task and without authorization
from the Shift Supervisor, and control
room operators manipulated the speed of
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the turbine-driven auxiliary feedwater
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pump to below 3850 rpm.
" Technical Specification 6.8.1.a states, in part, that written
procedures shall be established and implemented covering the applicable
procedures recommended in Appendix A of Regulatory Guide 1.33, Revision
2.
Regulatory Guide 1.33, Appendix A, Section 9, requires procedures for ;
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performing maintenance that can affect the performance of safety-related
equipment.
Administrative Procedure AP 16C-002, " Work Controls," Revision 4,
Attachment C, Step C.2.1, requires workers to perform troubleshooting
activities using a work package task with authorization from the Shift
Supervisor.
System operating Procedure SYS AL-124, " Venting the Turbine-Driven
Auxiliary Feedwater Pump Oil System," Step 6.1.4, requires operators to
open Valve FC HV0312, a turbine-driven auxiliary feedwater pump trip-
throttle valve, until the turbine operates between 3850 and 3900 rpm,
then slowly open the valve while verifying that the governor valve
maintains control of the turbine.
Contrary to the above, on January 24, 1997, system engineers failed to
comply with procedures for performing maintenance. Specifically:
1. The system engineer manipulated Valve FC FV0313, the
turbine-driven auxiliary feedwater pump governor valve while
troubleshooting an inadvertent overspeed trip without a work
package task and without authorization from the Shift
Supervisor.
2. Under the direction of the system engineer, control room
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operators manipulated the speed of the turbine-driven
l auxiliary feedwater pump to below 3850 rpm."
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Adatission of violatig
i Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that
a violation of Technical Specification 6.8.1 occurred when a System Engineer
failed to comply with procedures for performing maintenance by manipulating
valve FC FV0313, without a work package task, and without authorization from
the Shift Supervisor. WCNOC also agrees that, under the direction of the
l system engineer, Control Room operators manipulated the speed of the turbine-
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driven auxiliary feedvater pump to below 3850 rpm.
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Attacnment to ET '7-0044
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Page 6 of 14 ;
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Reason for Violation 9~04-02: ;
Two examples were identified for Violation 9704-02. These two examples are
addressed separately below. l
Reason for Violation --- Example One
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The root cause for this inappropriate action by the system engineer was the I
system engineer's mindset to identify and resolve the Turbine Driven Auxiliary
Feedwater Pump (TDAFWP) overspeed trip problem, at the expense of his duties
as Team Leader. The system engineer did not consider the procedural direction
provided in AP16C-002, " Work Controls," that defines the limits of
investigation. ]
Following overspeed trip of the TDAFW P, the system engineer became fully
engaged with resolving the trip. The system engineer discussed concerns about ;
the possible cause of the trip with the Shift Supervisor. The Shift Supervisor
understood that the system engineer was planning to visually investigate the
cause of the trip, but the Shift Supervisor was unaware that the system ;
engineer would actuate components. The system engineer's responsibility to !
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identify the cause of the overspeed trip became his primary focus, and being !
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aware of the need to check for Governor Control Valve (GVC) binding while the )
equipment was still warm, and the time constraint associated with the Limiting
Condition For Operation (LCO), he acted inappropriately.
The system engineer felt that because the system was out of service, and he
thought he had the Shift Supervisor's permission, no further controls were
necessary. The system engineer, being inexperienced in the area of
troubleshooting, responded inappropriately by not stopping and considering the
procedural requirements identified in AP16C-002 as they relate to
troubleshooting. Additional investigation, documented in PIR 97-0363,
provides evidence that the problen at hand is not global within the system
engineering organization.
It was also identified that the Shift Supervisor delayed AR initiation later
than the " Work Controls" procedure allcws. This conclusion is based on the
interview with the Shift Supervisor which revealed that he was attempting to
determine the cause for the trip for information prior to AR initiation. The
Shift Supervisor is knowledgeable of the work controls process, but did not
know this level of activity is outside of the limits for investigation. The
Work Controls procedure is a " reference use" category procedure which requires
it to be readily available, but not in hand. The Shift Supervisor did not
consult the procedure before making his decision.
Discussions with other Shift Superviscrs have indicated that they would not
have allowed this troubleshooting to occur without initiation of an AR and
subsequent approval of a Work Package. This provides evidence that this lack
of understanding is not global to all Shift Supervisors. The root cause for
the inappropriate action by the Shift Supervisor was an error in Judgment
concerning the limits of investigation provided in AP16C-002, " Work Controls".
Corrective Steps Taken and Results Achieved For Violation 9404-02 --- Example
One
- Immediate corrective action resulted in appropriate counseling and
discipline of System Engineering personnel by System Engineering
management.
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Attachment to ET 97-G044 l
Page 7 of 14 1
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- Following this event, ne saperintendent :. f Operations met with all
cperating crews and re-ccmmunicated the req.irements identified in the work l
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co r.t r o l process, emphasicing proceaural, compliance, the limitations of
investigation, requi:ements for Shift Supervisor initiation, and the l
thresnold of troubleshooting as defined in AP16C-002.
- The Manager of System Engineering reviewed issues associated with )
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procedures AP15C-002, " Procedure use and Adherence," and AP16C-002, " Work
Controls," and discussed issues related to this event with all System
Engineers. This action was ccmpleted on April 22, 1997. I
Corrective Steps That Will Be Taken and the Date When Full Compliance Will Be 1
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Achieved For Violation 9704-02---Example One:
- The Manager System Engineering will develop a qualification standard to
include specific training, as a minimum, on procedure AP15C-002, " Procedure
Use and Adherence" and procedure AP16C-002 " Work Controls". This standard
will ensure the pertinent information of each procedure is understood as it
applies to System Engineering responsibilities. Training to this standard
will be completed by July 1, 1997.
- Additional interim corrective action requires the Manager Syste.m
Engineering to review this event with other Engineering Managers for
identification of information that relates to other engineering groups.
This review will determine the need for a qualification standard for other
engineering groups. This action will be complete by May 30,1997.
- The Manager Integrated Plant Scheduling 'IPS) will collect information
relative to Team Leader responsibilities and ensure that it is included in
an existing procedure, or a new procedure. Those persons acting as Team
Leaders will be qualified only after meeting the requirements for these
roles as specified in the procedure. The Manager IPS will maintain and
update the qualified list of personnel who can fulfill the role. These
actions are to be complete by May 30, 1997
Reason for Violation 9704-02 --- Example Two
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The root cause of the second example was inadequate work practices in the
use of procedure SYS AL-124. The system engineer and the Supervising ,
Operator made judgment errors in the use of the procedure. Contributing )
causes included ineffective communications between the system engineer and '
the Shift Supervisor, failure to perform a second pre-job brief of the
procedure, and a procedure that was inadequate to the task.
The system engineer had been involved with SYS AL-124 in the past. The
system engineer also thought that some operator intervention of lowering
the speed control had taken place in past runs. This condition has been
substantiated during a previous run of SYS AL-124, in December of 1996. ,
The system engineer was also aware that what he recommended was not
specifically in the procedure, but felt that the procedure was being
followed.
The Operations group was responsible for performing SYS AL-124. The
Supervising Operator, when presented with the decision at completing step
6.1.4.3, had two options: continue with the procedure as written, possibly
resulting in anotner overspeed trip, or halt the procedure and place the
equipment in a safe condition. The Supervising Operator chose to intervene
by lowering the spee1 controller setpoint, avoiding another possible ,
overspeed trip, rather than tc ilt the procedure and notify the Shift )
Supervisor.
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. Attacnment to ET'91-0044
Page'B of 14
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j ':t is evident that botn the system engineer and the Supervising . Operator
. were. cognizant of .their procedural: perfortnance responsibilities. They both .
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knew: that manipulation of the speed controller was not specifically
. addressed by procedure step 6.1.4.3. They were aware of management
j expectations regaroing procedure use, but did not perform- to this
- expectation,
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( Corrective Steps Taken and Resultis Achieved For Violation 9404-02 --- Example
] Two -
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'*- Immediate corrective action ,resulted in appropriate. counseling and
', discipline of Operations and System Engineering personnel' by their
!' management.
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i * Tollowing- this event, the Superintendent of Operatict;s met with all
j operating crews and re-emphasized his expectations for procedural
compliance. These meetings were completed by March 15, 1997.
- The Manager of System Engineering conducted a training session with the
system engineers to emphasize the tole of the Shift Supervisor in regards
to-direction and performance of work in the plan. Special emphasis was
placed on effective three-way communication between the requester and the
Shift Supervisor, ' prior to the start of any activity.
_
This action was
completed on April 22, 1997.
- Interim corrective action resulted in "On the Spot Change" (OTSC)97-024 to
procedure SYS AL-124. This procedure change was .ef fective 'in preventing
recurrence of an overspeed trip
- The Manager of Operations provided long-term corrective. action by revising i
.SYS AL-124, to provide an optimal way of regulating the TDAFWP control
system. This procedure change was completed April 22, 1997.
Corrective Steps That Will Be Talren And The Date When Full Compliance Will Be
Achieved For Violation 9704-02---Example Two:
- AP15C-002, Revision 8, " Procedure Use and Adherence" will be revised
to include a definition for literal compliance to better aid personnel
in the field. The PSRC Chairman (Manager IPS) is responsible for
incorporating this definition into the procedure. This action will be
complete'by May 8, 1997.
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Attachment to ET 97-0044
Page 9 of 14-
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Violata.on 50-402/9704-03: Pe r s orme l - failea to properly est & ish procedure
SYS AL-124. Specifically the procedure failed to
define icw speec and oi. pressure parameters, and
failed to specify actions sboald those parameters
be exceeoed. In addition, a change was made to SYS
AL-124 that required operators to manually open the
trip-throttle valva and control turbine speed at
approximately 2500 rpm. This could not be
- accomplisned due to the design of the ramp
a
generator circuit.
" Technical Specification 6.8.1 a states, in part, that written
procedures shall be established and implemented covering the applicable
procedures recommended in Appendix A of Regulatory Guide 1.33, Revision
2.
Regulatory Guide 1.33, Appendix A, Section 9, requires procedures for
performing maintenance.
System operating Procedure SYS AL 124, " Venting the Turbine-Driven
Auxiliary Feedwater Pump 031 Syrtem," i<evi s ion 1, provides guidance for
post maintenance testing of the turbine-driven auxiliary feedwater pump.
'
Contrary to the above, on January 24, 1997, licensee personnel failed to
properly establish Procedure SYS AL-124. Specifically:
1. The procedure contained a precaution to closely monitor the
E
bearing oil pressure when operating the turbine at low
speeds, but failed to define low speeds and low oil
pressure, and tailed to specify what actio,ns were to be
taken when low oil pressure was reached. S
2. On-The-Spot Change 97-0023 to the prNedure required
operators to manually open the trip-throttle valve and
control turbine speed at approximately 2500 rpm. With the
- governor controller set at the normal position of
approximately 3850 rpm, this could not be accomplished due
to the design of the ramp generator circuit tnat attempted
,
to accelerate the turbine from approximately 1100 rpm t> the
s normal setting of the controller, 3850 rpm."
Admission of Violation:
Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that a
violation of Technical Specificat; on 6.8.1 occurred when licensee personnel
failed to properly establish procedure SYS AL-124 by failing to define low
speed and oil pressure parameters, and failing to specify actions should those
parameters be exceeded. In addition, personnel it. correctly established and
attempted to implement a change to SYS AL-124 that could not be accomplished
due to the design of the equipment.
Reason for Violation:
The 2: cot cause of these two examples war failure to recr;gnize t:e correlation
between LIMIT SWITCH 6 (LS-6), TTV position, and the speed of the TDAFWP
resulted in selection of an unachievable speed. This resulted in additional
idle speed operation, not anticipated by the procedure change, and subsequent
normal low oil pressure (above the low pressure alarm) due to idle operation.
The Manager Operations placed a stop work order on future performances of SYS ,
AL-124, to remove any perceived time constraint pressure associated with J
completion of the LCO. A group, consisting of the Central Work Authority
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Attacnment to ET 97-0044 i
P arie 10 of 14
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( CNM , Ih. tit Supe r v:. s o r , v/ sten Engineering Sacer.71sor, Operations Procedures
? W.n te r , System Engineer, ano 15C, was then tasked with changing the procedure.
A Centrol Rocr cr:ef 't tre cnangea procedure was then conducted by the system !
enginee:. The system enaineer would be tne local lead test performer with the
4 Supervising Operator ' c eing me responsible lead with the procedure. ;
,
LS-6 actuation is at a tn:cttle position aoove 3000 rpm. Below this position, I
the control circuitry controis at idle speed of 1100 rpm. The change thus
caused longer operation ut idle speec, because achieving 1500 rpm was not
obtainable. This resulteu in subsequent idle speed oil pressure The OTSC
would have been snecessful if LS-6 were located lower in the throttle position
' of the TTV. This was not known by the group that changed the procedure, nor
, is this key information captured by any documantation.
Had the procedure change recogni:'ed the correlation of LS-6 and TTV position, l
prolonged idle speed operation would not have oc-curred. The unanticipated
'
prolonged idle speed gave tne appearance that the oil pressure concern was not
'
addressed. The caution had no explicit speed for low oil pressure. The
procedure performers, conscious of the caution, took the appropriate action.
.This operation time at idle had no adverse affect on the TDAFWP.
Corrective Stops Taken and Results Achieve _d1
,
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- Procedure SYS AL-124 was revised. The procedure revision included
information detailing the actuation of LS-6 while manually opening the TTV,
4 mixed with 4w omatic GCV function. The procedure re visi on also reviewed
- the oil pressure prc:;autions as they relate to idle speed operation. This
revision was completed on April 22, 1997.
- * Manager of System Engineering has supplemented the TDAFWP instruction
manual, I/M M-021-00086, via the Vendor Engineering Techr,1 cal Information
Program (VETIP), to clarify manual TrV operation, mixed with automatic GCV
control of the TDAFWP.
.
- Review of the OTSC process identified the process to be prudent and
appropriate. No programmatic deficiencies were identified, therefore no
'
additional corrective action is warranted.
Corrective Steps That Will Be Taken And The Date When E'ull Compliance Will Be
Achieved:
1
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- Training, detailing the actuation of LS-6, while manually opening the TTV,
i
mixed with automatic GCV function, will be included in the Operator
Training Instructions. This training will apply to both initial and re-
i qualifications and include ooth licensed and non-licensed operators. Re-
qualification training will be completed by June 30, 1997. Initial
training will be completed by January 30, 1998.
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Att~.cnment to ET 97-0044
Page 11 of 14
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Violation 50-402/5 04-04: An cpe:ator unsuccensfully atcempted to trip the !
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i taroine-ariven auxillary feedwater pump cy pulling j
On the trip linkage. j
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"Tecnnical Specification 6.8.1.a states, in part, that written j
- procedures shall be estaclished and implemented covering the l
applicable procedares recommended in Appendix A cf Regulatory l
l Guide 1.33, Be n s ion ') . j
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Regulatory Guide 1.33, Appendix A, Section 3.1, requires l
- procedures 'or operation of the auxiliary feeddater system.
.
dystem Operating krocedure SYS AL-124, " Venting the Turbine Driven
j Auxiliary Feedwater Pump Oil System," Step 6.1. 5, requires the
l operator to trip tre turbine driven auxiliary feedwater pump using ;
- the manual tric lever. ;
i
Contrary to the above, on January 24, 1997, the operator I
'
unsuccessfully attempted to trip the turbine-driven auxiliary )
feedwater pump by pulling on the trip linkage, causzng the turbine !
speed to increase."
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Admi.csion of Violat. ion:
.
l Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that
,
a violation of Technical Specification 6.8.1 c ': cu r red when an operator
attempted to trip tne turbine-dtiven auxiliary feedwater pump by pulling on ;
,
the mechanical overspeed connecting rod (trip linkage).
.
Reason for Violationt
. On January 24, 1997, during the third performance of SYS AL-124, a decision
was made to trip the TDAWP. When the Shift Supervisor entered the pump room,
d.
he directed the Nuclear Station Operator !NSO) to trip the TDAFWP. The NSO,
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controlling speed manually with the TTV, attempted to trip the TDANP by
p:alling on the mechanical overspeed cennecting rod. He chose this method
based on his physical location in the room, and also due to congestion in the
4 rcam. This attempt was not successful. A second NSO who was in the room,
4 made his way to the manual trip cush button, located on the other side of the
{ pump, and tripped the TDAFWP.
i
i Operators were taught to use the mechanical push button to trip the TDAFWP.
The method to utilize the connecting rod was used successfully in the past
- Evidence from interviewc indicates that tripping the pump by the connecting
j rod method was informally introduced during field training. The TDAFWP manual
. only discusses asing the trip button, and does not instruct the user to pull
3
on the connecting rod. A review of old lesson plans did not identify
- instruction for utilizing the connecting rod method. Subsequently, it was
. determined that the Electrical Trip / Reset on the FC219 panel was also an
acceptable method for tripping the TDAFWP.
The root cause of this event was inappropriate field training that fostered
the use of an ad hoc non-proceduralized trip method. A contributing factor
that fostered the use of the ad hoc method is the physical lay out of the
room and the d',fficult access tc the trip puch buttan. It was easier to
utilize the ad hoc rathod than to climb over, around, and through the
equipment in the room to access the mechanical trip push button.
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Attachment to ET 97-0044
Page 12 of 14
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- Correccive Steps Takea and Results Achieved:
- The Shift Supervisors, Superv.tsing Operators, as well as thtir operating
^
crews, were i.nediately informed of the proper methods for tripping the
TDAEWP.
- * Essential Reading was developed for Operating crews instructing tnat
! only the mechanical trip push button, or the electrical trip / reset
4 button on the FC219 panel, are acceptable methods to be used to trip the
TDAFWP. This Essential Reading was initiated on April 10, 1997.
a
Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be
Achieved:
i 4
- Additional communication to appropriate personnel that ad hoc operation l
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- is unacceptable, and that equipment is to be operated per procedures, or
j
per design will be completed by June 30, 1997
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Attachment to ET 97-0044
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Page 13 of '4.
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viciation 50-482/9704-07: A change was made to the Emergency Plan, which
resulted in a decrease in the effectiveness of the
plan without prior NRC approval.
"10 CFR 50.54 (q) permits the licensee to make changes to tne
emergency plans without prior Commission approval only if the j
i
changes do not decrease the e f fc ctiveness of plans and meet the i
-
standards of 10 CFR 50.47(b),
, Contrary to the above, on February 23, 1996, the licensee changed
the emergency plan, which resulted in a decrease in the
effectiveness of their plan without prior NRC approval in tnat an
emergency action level form that would have previously classified I
a particular event as a site area emergency was changed to 1
classify it as an Alert."
Admission of Violation:
Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees
that a violation of 10 CFR 50,54 (q) occurred when an editorial error
'
during a revision procees inadvertently resulted in redirecting the flow
path of one decision box to the potential decla ra t. ion of an ALERT,
instead of leading to the intended declaration of a SITE AREA EMERGENCY
(SAE).
- Reason for the Violation
This incident occurred because an error was made during a change to the
" Safety System Failure or Malfunction" page of the Emergency Action
'
Level (EAL) flow charts. As part of this change, several. decision boxes
were re-sized and realigned.
During the process of reorganizing and changing this flow chart page, an
editorial error inadvertently resulted in redirecting the flow path of
one decision box from leading to a SAE to leading to an ALERT. This
error was not identified during the review and approval process.
Consequently, there was a reduction in the effectiveness of the
Emergency Plan without prior NRC approval.
.
The results of subsequent evaluation and interviews identified the root
cause to be inadequate reviews performed by the initiator and the
qualified reviewer.
There were two contributing factors:
a The guidance in AP 15C-004, Revision 9, " Preparation, Review, and
Approval of Documents," was unclear, and allowed for various
interpretations. This led to an inconsistent understanding and
application of the expectations concerning the required level of
de'. ail to be applied *" the document review process.
review of a flow chart. Compounding this, there was no tool
available which would allow the initiator, or other personnel
reviewing tne EALs, to verify that the logic for the blocks that led
to each level of classification was correct, and had not been
inadvertently changed on any of the EAL flow charts.
Interviews indicated that individuals involved in this review process
varied in their perception of procedural and management expectations
concerning the level of detail required. The evaluation also determined
that there was a disparity between the perceived expectations of
. .
4 Attachment to ET 97-0944
Page 14 of 14
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creparers and reviewers. This :. s Potentially a generic issue with the
' review process, extendina beyo:a ' 235 the review of Emergency Planning
Procedures.
The Inspection Report cover letter ana "Ob s e rva t l.o ns and Findings"
section of the inspection report did icentify that tne Shift Supervisor
was not notified in a timely manner. The root cause of this failure to
effect a timely notification of the Shift Supervisor was the incorrect
- celief by Emergency Planning personnel that other EAL emergency action
classification trees would have caused the correct classification of
this event scenario. This belief was corrected in discussions with the
Senior Resident Inspector on January 21, 1997. A demonstration of the
- effectiveness of corrective actions to this concern about timely
notification was given on January 23, 1997, when another error in the
EALs was identified. The inspection report " Observations and Findings"
section identified that immediate notification and corrective action
occurred .in this instance.
<
Corrective Steps Taken and Results Achieved
- The error in the " Safety System railure or Malfunction" page of the
Emergency Action Level (EAL) flow charts was corrected on January 22,
1997.
4
- * A matrix detailing all possible logical flow paths was developed.
5
Each classif2 cation has every possible combination of blocks listed.
2 This will allow a reviewer to ensure there are no undocumented a
'
changes which would alter an EAL classification. This matrix was
completed March 28, 1997
- The initiator of the form revision and the qualified reviewer were
given job performance counseling in accordance with the Management
Action Response Checklist (MARC) program. This action was completed I
on March 26, 1997
J
- Corrective Steps That Will Be Taken And The Date When Full, Compliance
Will Be Achieved
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e A new section is being added to procedure AP 15C-004, Attachment D, !
idenrifying the EAL matrix discussed above. The section will also
direct that the matrix be used to perform the review of the flow
chart in order to review each possible emergency classification.
! These changes will be incorporated by April 30, 1997 Until the
change is incorporated, the Ma na'je r Emergency Planning will assure
that the matrix is used for any revisions to the EALs.
- Information on possible generic issues, including the disparity in
perceptions of preparers and re"iewers about procedural requirements
< and management expectations concerning the level of detail required j
in raviews, wi '.1 . presented to the PSRC c.n April 23, 1997. j
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