ML17228B327
| ML17228B327 | |
| Person / Time | |
|---|---|
| Site: | Saint Lucie  |
| Issue date: | 11/15/1995 |
| From: | GOLDBERG J H FLORIDA POWER & LIGHT CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| L-95-306, NUDOCS 9511210113 | |
| Download: ML17228B327 (23) | |
See also: IR 05000335/1995015
Text
RIGRITY1ACCELERATED
RIDSPROCESSING),
REGULATORY
INFORMATION
DISTRIBUTION
SYSTEM(RIDS)r'ESSIONNBR9511210113
DOC~DATE'5/11/15
NOTARIZED
NOFACIL:50-335
St.LuciePlant,Unit1,FloridaPower&LightCo.50-389St.LuciePlant,Unit2,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION
GOLDBERG,J.H.
FloridaPower&'ightCo.RECIP.NAME
RECIPIENT
AFFILIATION
DocumentControlBranch(Document
ControlDesk)SUBJECT:ForwardsresponsetoNRCltrreviolations
notedininsprepts50-335/95-15
&50-389/95-15.Corrective
actions:MSIS
wasblocked&resetimmediately
following
eventon950802.IDISTRIBUTION
CODE:IE01DCOPIESRECEIVED:LTR
ENCLSIZE:TITLE:General(50Dkt)-Insp
Rept/Notice
ofViolation
ResponseNOTESDOCKETN0500033505000389INTERNAL:
RECIPIENT
IDCODE/NAME
PD2-1PDACRSAEOD/SPD/RAB
DEDRONRR/DISP/PIPB
NRR/DRPM/PECB
OEDIRRGN2FILE01COPIESRECIPIENT
LTTRENCLIDCODE/NAME
11NORRIS,J2AEOD/DEIB
1A'E.1FILECENTER1/'DRC8/HFB1NUDOCS-ABSTRACT
1'GC/HDS31COPIESLTTRENCL11111111111111EXTERNAL:
LITCOBRYCE,JHNRCPDR1111NOAC11iNOTETOALLRIDS"RECIPIEYTS:
PLEASEHELPUSTOREDUCE4VASTE!CONTACTTHEDOCL'!iIEYT
CO."iTROL
DESK,ROOiiIPl-37(EXT.504-2083)TOELIiIINATEYOURNA!iIEFROiIDISTRIBUTIOY.
LISTSFORDOCL'IiIEi'I'S
5'OUDOi"I'L'LD!TOTALNUMBEROFCOPIESREQUIRED:
LTTR19ENCL19
40'
0FloridaPowerLLightCompany,P.O.Box14000,JunoBeach,FL334080420NOV15$995L-95-30610CFR2.201U.S.NuclearRegulatory
Commission
Attn:DocumentControlDeskWashington,
D.C.20555Re:St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15FloridaPowerandLightCompany(FPL)hasreviewedthesubjectinspection
reportandpursuantto10CFR2.201theresponsetothenoticeofviolation
isattached.
Verytrulyyours,J.H.GoldbergPresident
-NuclearDivisionJHG/DAS/EJB
Attachment
cc:StewartD.Ebneter,RegionalAdministrator,
USNRCRegionIISeniorResidentInspector,
USNRC,St.LuciePlant95ii210i13
'it5iii5PDRADOCK050003359PDRanFPLGroupcompany
FPLRESPONSETOINSPECTION
REPORT95-15SUMMARYNRCInspection
Report50-335/389/95-15
considered
St.LuciePlantperformance
duringthesix(6)weekperiodfromJuly30,1995throughSeptember
16,1995.Theviolations
belowoccurredduringarelatively
shortperiodoftime,asdescribed
intheinspection
report,andseveralofthecorrective
actionswereinstituted
following
ananalysisoftheevents,collectively.
Thecorrective
stepstoavoidfurtherviolations
wereinsomecasesdetermined
tobegenericfollowing
thisanalysis,
andaretherefore
repeatedinanumberoftheresponses.
TheInspection
Reportidentified
seven(7)violations
whicharelistedbelow.Violation
A:FailuretoFollowProcedures
andBlockMSISActuation
Violation
B:FailuretoFollowProcedures
DuringRCPSealRestaging
Violation
C:FailuretoFollowProcedure
andDocumentAbnormalValvePositionintheValve,SwitchDeviation
logViolation
D:FailuretoFollowProcedures
duringAlignment
ofShutdownCoolingSystemViolation
E:FailuretoFollowProcedure
andDocumentaDeficiency
onContainment
SprayValveSurveillance
TestProcedure
Violation
F:FailuretoInitialMaintenance
Procedure
StepsasWorkwasCompleted
Violation
G:FailuretoFollowProcedures
DuringVentingofECCSSystemResultedinContainment
Spraydown
Additionally,
bothFloridaPowerandLight(FPL)andtheNRCevaluated
planteventstoidentifycommonunderlying
themes.FPLpresented
asummaryofeventstotheNRConAugust29,1995.Weaknesses
identified
inthissummaryincludedprocedure
contentanduse,aswellasmanagement
oversight
ofeguipment
performance.
FPL'sPlantoImprovetheOperational
Performance
atSt.Luciewasdeveloped
asaresultoftheAugust29,1995,meetingandsubmitted
totheNRConSeptember
15,1995.Todate,FPLhascompleted
theactivities
according
totheimprovement
planschedule.
S=.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
A:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
inAppendixAofRegulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
1.dincludesadministrative
procedures
forprocedural
adherence.
Procedure
QI5-PR/PSL-1,
Rev.62,"Preparation,
Revision,
Review/Approval
ofProcedures,"
Section5.13.2,statesthatallprocedures
shallbestrictlyadheredto.OP1-0030127,
Rev68,"ReactorPlantCooldown-HotStandbytoColdShutdown,"
required,
inpart,thatoperators
blockMainSteamIsolation
System(MSIS)actuation
whenblockpermissive
annunciations
werereceived.
ONOP1-0030131,
Rev60,"PlantAnnunciator
Summary,"
requiredthat,uponvalidreceiptofannunciators
Q-18andQ-20,operators
immediately
blockchannelsAandB,respectively.
Contrarytotheabove,onAugust2,1995,duringacooldownofSt.LucieUnit1,validblock.permissive
werereceived,
however,operators
failedtoestablish
therequiredMSISblocks,resulting
inAandBchannelMSISactuations.
RESPONSEA:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofautilitylicensedoperatorwhofailedtoblocktheactuation
ofthemainsteamisolation
signal(MSIS)inaccordance
withtherequirements
oftheapprovedplantoperating
procedure.
2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.Themainsteamisolation
signal(MSIS)wasblockedandresetimmediately
following
theeventonAugust2,1995.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-153.CORRECTXVE
STEPSTOAVOXDFURTHERVXOLATXONS
A.Thelicensedoperatorwhowasinvolvedintheeventwascounseled
ontheneedtofollowprocedures
andreceiveddiscipline
inaccordance
withplant'policy.
B.AllOperations
NuclearPlantSupervisors
(NPS)heldmeetingswiththeircrewssubsequent
tothiseventtoreiterate
FPL'sgoalforerrorfreeperformance.
C.Thiseventwillbeincorporated
intolicensedoperatorrequalification
trainingtoemphasize
procedural
compliance,
propercommunication
amongtheControlRoom'team,andtheimportance
ofsupervision
-inthecontrolroommaintaining
anoverallawareness,
ofactivities.
ThisactionwillbecompletebyJanuary1,1996.D.St.LuciePlantadoptedverbatimcompliance
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures'~
"4.Fullcompliance
wasachievedonAugust2,1995withthecompletion
ofitem2above.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
B:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
inAppendixAofRegulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
1..dincludesadministrative
procedures
forprocedural
adherence.
Procedure
QI5-PR/PSL-1,
Rev.62,"Preparation,
Revision,
Review/Approval
ofProcedures,"
Section5.13.2,statesthatallprocedures
shallbestrictlyadheredto.Contrarytotheabove,procedures
werenotadheredtostrictlyinthefollowing
examples:
OP1-0120020,
Rev.72,"FillingandVentingtheRCS,"precaution
4.2,requiredthatReactorCoolantSystem(RCS)venting,described
intheprocedure,
notbeattempted
ifRCStemperature
wasabove200'F.OnAugust2,1995,ReactorCoolantPump(RCP)sealventing,performed
inanattempttocorrectsealpackageleakageinthe1A2RCPinaccordance
withAppendixEofthesubjectprocedure,
wasperformed
whileRCStemperature
wasapproximately
370'F.Asaresult,designtemperatures
ofRCPsealcomponents
wereapproached
orexceeded.
2.OP1-0120020,
Rev.72,"FillingandVentingtheRCS,"AppendixE,"Restaging
ReactorCoolantPumpSeals,"requiredtheuseofRCPsealinjection
whilerestaging
wasattempted.
OnAugust2,1995,restaging
ofthe1A2RCPsealpackagewasattempted
withoutsealinjection
alignedtothesealpackage.Asaresult,designtemperatures
ofRCPsealcomponents
wereapproached
orexceeded.
RESPONSEB:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofautilitylicensedoperatorwhofailedtofollowanapprovedplantprocedure
whileperforming
arestaging
evolution
onaReactorCoolant'Pump(RCP)sealpackage.Theoperatordidnotstrictlyadheretotheconditions
contained
intheprocedure
whichrequiredthatRCStemperature
benogreaterthan200'F,andthatsealinjection
beinservice.
0
St.LucieUnits1and2DocketNos.50-335and50-389Reply'oNoticeofViolation
InsectionReort95-152.CORRECTXVE
STEPSTAKENANDTHERESULTSACHIEVEDA.TheRCP'estaging
evolution
wasdiscontinued,
andOperations
cooledanddepressurized
theReactorCoolantSystem(RCS)inaccordance
withapprovedplantprocedure
tolowerRCPsealtemperatures
towithintheacceptable
range.The1A2RCPwassecured.B.Thedamaged1A2RCPsealpackagewasreplacedpriortoreturning
Unit1tooperation.
3.CORRECTIVE
STEPSTOAVOIDFURTHERVXOLATXONS
A.Thelicensedoperatorinvolvedinthiseventwasdisciplined
inaccordance
withplantpolicy.B.Theprocedure
appendixwhichwasusedforperforming
therestaging
oftheRCPswasdeletedandisnolongeravailable
foruse.C.Plantmanagement
performed
anassessment
ofthedecisionmakingprocessthatledtotherestaging
oftheRCPsealundertheexistingplantconditions.
Basedonthisassessment,
Plantpolicy105,"PlantOperation
BeyondtheEnvelopeofApprovedPlantOperating
Procedures",
wasrevisedtorequireatechnical
reviewofprocedures
whicharebeingimplemented
forthefirsttimeorforwhichplantconditions
aredifferent
fromthosedescribed
intheprocedures
D.AllOperations
NuclearPlantSupervisors
(NPS)heldmeetingswiththeircrewssubsequent
tothiseventtoreiterate
FPL'sgoalforerrorfreeperformance.
E.St.LuciePlantadoptedverbatimcompliance
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures."
4.Fullcompliance
wasachievedonAugust2,1995withthecompletion
ofitem2A,above.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
C:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
inAppendixAofRegulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
1.dincludesadministrative
procedures
forprocedural
adherence.
Procedure
QI5-PR/PSL-1,
Rev.62,"Preparation,
Revision,
Review/Approval
ofProcedures,"
Section5.13',statesthatallprocedures
shallbestrictlyadheredto.AP1-0010123,
Rev99,"Administrative
ControlsofValves,Locks,andSwitches,"
step8.1.6,required,
inpart,thatallvalvepositiondeviations
bedocumented
intheValveSwitchDeviation
Log.Contrarytotheabove,onoraboutAugust1,1995,HCV-25-1through7wererepositioned
andleftintheclosedpositionwithouttherequiredentriesbeingmadeintheValveSwitchDeviation
Log.TheValves'ositions
complicated
alossofRCSinventory.
RESPONSEC:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofutilitylicensedoperators
whodidnotproperlydocumenttheclosedstatusofthesubjectvalvesintheValveSwitchDeviation
Log,asrequiredbytheapprovedplantprocedure.
2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDTheSafeguards
PumpRoomSumpIsolation
valves,HCV25-1throughHCV25-7,wererealigned
totheopenpositionimmediately
following
thelossofRCSinventory
eventonAugust10,1995,whenControlRoomoperators
discovered
theclosedstatusofthevalves.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-153.CORRECTXVE
STEPSTOAVOXDFURTHERVXOLATXONS
A.AllOperations
NuclearPlantSupervisors
(NPS)heldmeetingswiththeircrewssubsequent
tothiseventtoreiterate
FPL'sgoalforerrorfreeperformance.
B.C.D.Theplanthasadoptedverbatimcompliance
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures."
Management
isconducting
adailyreviewofControlRoomchronological
logstoreinforce
theexpectation
fordetailandcompleteness.
IPlantadministrative
procedures
havebeenrevisedtoprovideforincreased
reviewsbyplantstaffofthelogscontrolling
valverepositioning.
Fullcompliance
wasachievedonAugust10,1995,withthecompletion
ofitem2above.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
D:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
inAppendixAofRegulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
1.dincludesadministrative
procedures
forprocedural
adherence.
Procedure
QI5-PR/PSL-1,
Rev.62,"Preparation,
Revision,
Review/Approval
ofProcedures,"
Section5'3.2,statesthatallprocedures
shallbestrictlyadheredto.OP1-0410022,
Rev22,"Shutdown
Cooling,"
step8.3.7,requiredthatV3652,theBShutdownCooling(SDC)hotlegsuctionisolation
valve,belockedopenwhileplacingtheBSDCloopinservice.Contrarytotheabove,onAugust29,acontrolroomoperatorfailedtoplaceV3652inalockedopencondition
whileplacingtheBSDCloopinservice.Asaresult,the1BLowPressureSafetyInjection
Pumpwasoperatedwithitssuctionlineisolated.
RESPONSED:REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofautilitylicensedoperatorwhofailedtoproperlyverifythealignment
oftheshutdowncooling(SDC)systemflowpathinaccordance
withtheapprovedplantprocedure,
priortostartingthe1BLowPressureSafetyInjection
(LPSI)Pump.Thisresultedinthefailuretoopenthe1BLPSIPumpsuctionisolation
valve.2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.TheControlRoomoperators
notedtheerrorinvalvealignment
andtheLPSIpumpwassecuredapproximately
5minutesafterbeingstarted.Asubsequent
inspection
determined
thatnodamagehadoccurredduringtheshortperiodofpumpoperation.
B.Thesystemwasrealigned
inaccordance
withtheapprovedprocedure
andtheLPSIpumpwasrestarted.
Subsequent
operation
oftheLPSIpumpwassatisfactory.
C.AnASMESectionXIcoderunwasperformed
satisfactorily
onthe1BLPSIPumpandasubsequent
Engineering
assessment
concluded
thatpumpoperability
hadnotbeenadversely
affected.
St.LucieUnits.1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-153.CORRECTIVE
STEPSTOAVOIDFURTHERVIOLATIONS
A.Thelicensedoperatorinvolvedinthiseventwasdisciplined
inaccordance
withplantpolicy.B.Operations
implemented
procedure
changeswhichrequiretheuseofadedicated
procedure
readertoassistintheimplementation
ofSDCrelatedevolutions.
C.AllOperations
NuclearPlantSupervisors
(NPS)heldmeetingswiththeircrewssubsequent
tothiseventtoreiterate
FPL'sgoalforerrorfreeperformance.
D.Theplanthasadoptedverbatimcompliance
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures."
E.Thiseventwillbeincludedintolicensedoperator,
requalification
training.
Thisactionwillbecompleted
byJanuary1,1996.4.Fullcompliance
wasachievedonAugust29,1995withthecompletion
ofitem2Aand2Babove.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
E:Technical
Specification
6.8.1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
inAppendixAofRegulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
1.dincludesadministrative
procedures
forprocedural
adherence.
Procedure
QI5-PR/PSL-1,
Rev.62,"Preparation,
Revision,
Review/Approval
ofProcedures,"
Section5.13.2,statesthatallprocedures
shallbestrictlyadheredto.QI16-PR/PSL-2,
Rev.1,"St.LucieActionReport(STAR)Program,"
requiredthatSTARsbeinitiated
forQualityAssurance
auditfindingsandindependent
technical
reviewrecommendations'ontrary
totheabove,aSTARwasnotgenerated
whenaQualityAssurance
reviewofaninadvertent
Unit1containment
spraydown,
documented
ininteroffice
correspondence
JQQ-95-143,
identified
thepracticeofprelubricating
FCV-07-1A,
Containment
SprayheaderAflowcontrolvalve,whenperforming
valvestroketimetesting.RESPONSEE:1.REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofutilityQualityAssurance
(QA)personnel.
QApersonnel
wereintheprocessofconducting
anindependent
reviewfocusingonthecontributing
factorsassociated
withaUnit1containment
spraydownevent.Thepracticeofpre-lubricating
Containment
SprayheaderflowcontrolvalveFCV-07-lApriortosurveillance
testingwasidentified
duringthis.review,butwasnotdetermined
tobeacontributing
factortothisevent.Recommendations
tocorrectthisdeficiency
weretherefore
notcontained
intheresulting
QAreport,norwasaSt.LucieActionRequest(STAR)generated
inatimelymanner.2.=CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.ASt.LucieActionRequest(STAR951048)wasgenerated
onSeptember
7,1995todocumentthedeficient
practiceofpre-lubricating
Unit1andUnit2containment
sprayflowcontrolvalvespriortosurveillance
stroketimetesting.B.Temporary
changeswereissuedtoplantsurveillance
procedures
onSeptember
2,1995toremovethepracticeof'pre-lubricating
valvespriortosurveillance
testing.10
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-153.CORRECTIVE
STEPSTOAVOIDFURTHERVIOLATIONS
A.B.C.AmeetingwasheldonSeptember
13,1995betweentheVicePresident
ofNuclearAssurance
andallSt.LucieQualityAssurance
andQualityControlpersonnel.
Duringthismeeting,clearexpectations
wereprovidedregarding
thethreshold
foridentification
anddocumentation
ofdeficiencies
byQualitypersonnel.
EOnOctober25,1995,asecondmeetingwasheldbetweenthesiteQualityManagerandSt.LucieQApersonnel.
Duringthismeeting,therequirements
oftheQualityInstruction
QI16-PR/PSL-2,
"St.LucieActionReport(STAR)Program"werereviewed.
Theresponsibility
ofQApersonnel
fortimelyidentification
anddocumentation
ofdeficiencies
inaccordance
withthisprocedure
wasreinforced.
Permanent
changeswillbemadetoplantsurveillance
procedures
todiscontinue
thepracticeofpre-testlubrication
ofthevalvespriortosurveillance
testing.Thisactionwillbecompleted
byDecember1,1995.4.Fullcompliance
wasachievedonSeptember
7,1995withthecompletion
ofitem2Aabove.
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
F:Technical
Specification
6.8~1.arequiresthatwrittenprocedures
beestablished,
implemented,
andmaintained
coveringtheactivities
recommended
inAppendixAofRegulatory
Guide1.33,Rev.2,February1978.AppendixA,paragraph
1.dincludesadministrative
procedures
forprocedural
adherence.
Procedure
QI5-PR/PSL-1,
Rev.62,"Preparation,
Revision,
Review/Approval
ofProcedures,"
Section5.13.2,statesthatallprocedures
shallbestrictlyadheredto.ADM-08.02,
Rev7,"ConductofMaintenance,"
Appendix5,step5,requiredthatprocedures
bepresentduringworkandthatindividual
stepsbeinitialed
onceperformed.
Contrarytotheabove,inspection
ofworkinprogressrevealedthatindividual
stepswerenotinitialed
onceperformed
uponcompletion
forworkconducted
inaccordance
withPlantChange/Modification
11-195.RESPONSEF:1.REASONFORVIOLATION
Therootcauseofthisviolation
wascognitive
personnel
erroronthepartofanElectrical
Department
journeyman
whofailedtoproperlydocumentthecompletion
ofstepswhileperforming
workactivities
associated
withthetripsolenoids
onthe1BEmergency
DieselGenerator
(EDG).Thestepswerenotinitialed
astheywerebeingperformed,
inaccordance
withapprovedplantprocedure.
2.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.Thestepsofthemaintenance
procedure
beingworkedweresignedoffbythejourneyman
immediately
following
thecompletion
oftheworkonAugust31,1995,andthecompleted
procedure
wasreviewedbythechiefelectrician
andElectrical
supervisor.
B.TheEDGcircuitry
wassubsequently
testedfollowing
completion
oftheworkonAugust31,1995,andperformed
satisfactorily.
12
0
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-153.CORRECTIVE
STEPSTOAVOIDFURTHERVIOLATIONS
A.Meetingswereheldfollowing
thiseventwithElectrical
Maintenance
employees
toreviewthisincidentandemphasize
management
expectations
regarding
thedocumentation
ofw'orkactivities.
B.Supervisors
fromeachMaintenance
discipline
haveconducted
meetingswiththeiremployees
toreinforce
theneedforstrictadherence
totheadministrative
requirements
relatedtoprocedure
use.C.Theplanthasadoptedverbatimcompliance
astheonlyacceptable
meansofprocedure
compliance.
Thisrequirement
hasbeenincorporated
intoplantQualityInstruction
QI5-PR/PSL-1,
"Preparation,
Revision,
Review/Approval
ofProcedures."
4.Fullcompliance
wasachievedonAugust31,1995withthecompletion
ofitem2Aand2Babove.13
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15VIOLATION
G:10CFR50AppendixB,Criterion
V,"Instructions,
Procedures,
andDrawings,"
requires,
inpart,thatactivities
affecting
qualityshallbeprescribed
bydocumented
procedures
ofatypeappropriate
tothecircumstances.
Contrarytotheabove,onAugust18,1995,ventingoftheLowPressureSafetyInjection
(LPSI)Systemwasconducted
inaccordance
withaprocedure
whichwasinappropriate
tothecircumstances.
Specifically,
OP1-0420060,
Rev.0,"VentingoftheEmergency
CoreCoolingandContainment
SpraySystems,"
didnotrequireaverification
thattheportionsofthesystembeingventedwerehydraulically
isolatedfromadjacentsystemsandflowpaths.
Asaresultofthisfailuretoestablish
properinitialconditions,
waterdrivenbythe1ALPSIpumpwasinadvertently
directedtotheATrainContainment
Sprayheader,resulting
inaspraydown
oftheUnit1ReactorContainment
Building.
RESPONSEG:REASONFORVIOLATION
Therootcauseofthisviolation
wasprocedural
deficiency
inthattheECCSventingprocedure,
OP1-0420060,
didnotstatetheplantconditions
requiredtosuccessfully
venttheECCSbutreliedupontheRCSheatupprocedure
tosetplantconditions.
Specifically,
theventingprocedure
didnotrequireoperators
toverifythatthepropercontainment
sprayheaderisolation
valveswereclosedpriortorecirculating
thewaterintheSDCsystem.Acontributing
factortothiseventwasthattheoperations
personnel
performing
theECCSventingprocedure
didnotrecognize
thattheexistingplantconditions
wouldresultinflowtothe'A'ontainment
sprayheaderwhenflowwasalignedthroughtheShutdownCoolingHeatExchanger.
Asecondcontributing
factorofthiseventwasthatFCV-07-1A
wasplacedintheopenpositionbecausethisvalvehadfaileditsASMEstroketimetest.Plantmanagement
madethedecisiontodeferthevalverepairandpositionthisnormallyclosedvalvetoitsengineered
safeguards
openpositioninlieuofrepairing
thevalvepriortostartup.14
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-152.CORRECTIVE
STEPSTAKENANDTHERESULTSACHIEVEDA.Operators
securedthe1ALPSIPumpandisolated,
theflowpathtothecontainment
sprayheaderfromtheLPSIPump.TheReactorCavitysumpwasdrainedtotheWasteManagement
System.B~Following
theevent,allnonessential
workatthesitewasplacedonhold,andUnit1wasmaintained
stableinMode3whileseniorplantmanagement
conducted
meetingswithallavailable
sitepersonnel
tostresstheneedforworkervigilance
andattention
todetail.Theneedtoreduceequipment
deficiencies
thatimpactoperations
wasalsodiscussed.
C.Unit1wascooleddownanddepressurized
toMode,5andaninspection
anddecontamination
ofcontainment
wasthenconducted.
Theeventwasevaluated
underanEngineering
evaluation,
whichresultedinacomprehensive
inspection
ofcomponents
insidecontainment
toensurefuturecomponent
reliability.
D.Operating
procedure,
OP1-0420060,
"VentingoftheEmergency
CoreCoolingan'dContainment
SpraySystem",wasrevisedSeptember
1,1995toincludetheplantconditions
requiredtobepresentduringventing.3.CORRECTIVE
STEPSTOAVOIDFURTHERVIOLATIONS
A.Plantpolicy105,"PlantOperation
BeyondtheEnvelopeofApprovedPlantOperating
Procedures",
wasrevisedtorequireatechnical
reviewofprocedures
whicharebeingimplemented
forthefirsttimeorforwhichplantconditions
aredifferent
fromthosedescribed
intheprocedure.
B.TheMaintenance
Department
established
ateamcomposedofplantstaffandengineering
personnel,
todetermine
therootcausefortheContainment
Sprayheaderisolation
valverepeatfailuresanddetermine
corrective
actionstoeliminate
thisoperatorworkaround.
FCV-07-1A
wasrepairedpriortoreturning
Unit1toservice.15
St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolation
InsectionReort95-15C.Existingplantdeficiencies
werereviewedbyseniorplantmanagement.
Additional
deficiencies
whichcouldimpactoperations
wereaddedtotheworkscopeoftheUnit1shutdown.
Thesedeficiencies
werecorrected
priortoreturning
theunittoservice.D.Administrative
procedure,
AP-0010147,
"Assessment
ofAbnormalPlantConfigurations
orSignificant
MaterialDeficient
'Conditions
onPlantOperation",
wasdeveloped
toenhanceoutagescopereviewandensurethatequipment
deficiencies
arerestoredinatimelymanner.E.St.Luciemanagement
instituted
aweeklyreviewofappropriate
performance
indicators
andworkbacklogstatus,including
theageofopenitemsandoperatorworkarounds.
F.AllOperations
NuclearPlantSupervisors
(NPS)heldmeetingswiththeircrewssubsequent
tothiseventtoreiterate
FPL'sgoalforerro'rfreeperformance.
G.Thiseventwillbeincorporated
intolicensedoperatorrequalification
training.
ThisactionwillbecompletebyJanuary1,1996.4.Fullcompliance
wasachievedonAugust18,1995withthecompletion
ofitems2A,2Cand2Dabove.16