ML18066A892
| ML18066A892 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 02/21/1997 |
| From: | PALMISANO T J CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9703030519 | |
| Download: ML18066A892 (13) | |
See also: IR 05000255/1996014
Text
consumers . Power*.*** . l'OWERIN&
llllClllliAWS
l'IUlliRESS
Palisades
Nuclear Plant: 27780 Blue Star Memorlal Highway, Covert, Ml 49043 February 21, 1997 U.S. Nuclear Regulatory
Commission
Document Control Desk Washington, DC 20555 DOCKET 50-255 -LICENSE PPR-20 -PALISADES
PLANT Thomas J. Palmisano
Plant General Manager . RESPONSE TO NOTICE OF VIOLATION
FOR TWO VIOLATIONS
IN NRC . INTEGRATED
INSPECTION
REPORT NO. 50-255/96014(DRP)
-. ---NRC Inspection
Report No. 50-255/96014(DRP)
dated January 22,_1997, identified
two Severity Level IV Violations
of NRC requirements.
The first violation
identified
two examples where the plant staff did not adhere to procedures
while performing
outage related activities.
The second violation
identified
an example where adequate installation
instructions
were not provided for a temporary
modification
to the containment
polar crane. response to these violations
is in Attachment 1 . . . . . Consumers
Power Company (CPCo) agrees to the violations
as stated. SUMMARY OF COMMITMENTS
This letter contains three new commitments
and no revisions
to existing commitments.
1. Periodic.activity, SPSOSO, will be revised to use the terminology
of operating
procedure, SOP 30, and to make the steps to align automatic
transfer switch, * YSO, an Operations
responsibility
with the appropriate
sign offs. . . . A review of all installed
modifications
will be conducted
to verify tha. t J . acceptable
standards
were used for installation. . * -r-/ 1 . .. . . __, 2. 9703030519
970221 PDR ADOCK 05000255 G PDR
Ml f HD /ID/ f MIJMI /ID A CMS ENERGY COMPANY
,. ' . 3. The Temporary
Modification
process will be reviewed to assure that adequate . guidance is provided to the design engineer for providing . . instructions, and for verifying
that the temporary
modification
was installed
as intended by the design. *
Thomas J. Palmisano
Plant General Manager CC * Administrator, Region Ill, USNRC Project Manager, NRR, USNRC NRC Resident.Inspector
-Palisades
- Attachment
- .. 2
. ATTACHMENT
1 CONSUMERS
POWER COMPANY . PALISADES
PLANT ** DOCKET 50-255 RESPONSE TO TWO VIOLATIONS
FROM NRC INSPECTION
-REPO_RT 50-255/96014 (DRP)
JANUARY 22, 1997 10 Pages
. * RESPONSE TO-NOTICE
OF VIOLATION
FROM NRC INSPECTION
REPORT NO. 5'?_,-255/96014(DRP)
NRG VIOLATION
1) 10 CFR 50, Appendix B, Criterion
V, "Instructions, Procedures, and Drawings, 11 requires that activities
affecting
quality shall be prescribed
by documented
instructions, procedures, or drawings, of a type appropriate
to the circumstances
and shall be accomplished
in accordance
with these instructions, procedures, or drawings.
- a. * Licensee procedure
CPAL-RFM-002, Revision 0, Section 9.2.11, "Uncouple
CROMs and Raise RackExtensions, 11 required in step C.4 that all CRDMs be mechanically'
locked prior to ins*erting
a reactor trip . into the
protection
system. . b. Work Order No. 24610226 and PPAC No. SPS050, "PM Auto Transfer Switch, 11 Step 11, required that operations
return the isolation
handle to . normal position prior to performing
step .12, which required that operations
return the bypass handle to automatic.
Contrary to the above, a.* On November 7, 1996, the operations
shift did not ensure that the . control rod drive mechanisms
were mechanically
locked prior to inserting
a reactor trip signal, resulting
in the CROM racks dropping into **the reactor vessel upper guide structure.*
b. 'On November 17, 1996, the operations
shift did not return the isolation
handle to the normal position prior to returning
the bypass handle to *: automatic
position *. resulting
in a loss of power to instrument
AC bus Y-01. This is a Severity Level IV violation (Supplement
/). 1
CONSUMERS
POWER COMPANY RESPONSE *Consumers-Power
Company (CPCo) agrees with the violation
as stated. ,REASON FOR VIOLATION
Event 1a. Several factors *Contributed
to this event. First, the "C" shift Control Room Supervisor
and the Control Operator were not fully knowledgeable
about the status of the control rod drive mechanisms.
Second, the shift turnover between "B" shift and "C" shift was inadequate
in that it failed to identify the controlling
procedure
and it failed to discuss. the need to contact Refueling
Services after Electrical
maintenance
was completed
with -CRD #33. Third, the Control Room Supervisor
and the Control Operator failed.to
question the need for a-procedure
and determine
which procedure
was governing
the evolution.
- Piscussion
On November 7, 1996, preparations
were being made to remove thereactor
vessel* head. These preparations
require. * 1) The uncoupling
of the control rods from their drive mechanisms.
2) Raising the control rod drive racks 3) Mechanically
locking .the control rod drive racks . 4) De.-energizing
the control rod drive motors, clutches, and brakes by placing the reactor protection
system in the "reactor.
trip" mode. On "A" shift, the Refueling
Services personnel
began to uncouple the control rod drives. About 1300 on "B" shift, the Refueling
Ser-Vices
Supervisor
called the Control -Room to let the Control Room know the uncoupling
was completed
and Operations
was requested
to raise the control rod drive racks. At this time, Operations
discussed
the status of the uncoupling
with Refueling
Services and understood
that the Refueling
Services procedure
was controlling.
Operations
then withdrew forty-four
of the five control rod drive racks, but problems were*encountered
with CRD #33 rack. Electrical
maintenance
personnel
assistance
was requested.
While the plant electricians
were repairing
CRD #33, Operations
turnover between "B" and '!C" shifts occurred.
During this turnover, general information
concerning
the control rods was . exchanged, but it was not established.that
the Refueling
Services procedure
was controlling. "C"*shift
Operations
personnel
did not understand
that the Refueling
- Services procedure
was controlling
the evolution
and that Refueling
Services required notification
to lock the control rod drive racks after CRD#33 rack was withdrawn
.. 2
. '. * On "C" shift the electricians
finished repairing
CRD #33, withdrew the control rod drive rack and mechanically
locked itin place. The Shift Supervisor, upon being notified that CRD #33 problem had been resolved and the control rod drive rack was mechanically
locked, thought the next sequential
step to be performed
was to place the reactor protective
system in the "reactor trip" mode. The Shift Supervisor
did not verify the status of the control rod drive racks nor did he determine
which procedure
was controlling
the evolution
and verify that the prerequisites
were met. The Shift Supervisor
directed Control Room personnel
to place the reactor protection
system in the "reactor trip" mode. Control Room personnel
observed all control rod drive racks, except CRD #33 rack, reinserting
into the reactor vessel upon the reactor protection
system trip initiation.
Subsequently, it was recognized
that the control rod racks had not been mechanically
locked when control rod #33 rack problem was encountered.
The Refueling
Services procedure
allowed the control rod drive racks to be l.ocked after all the racks were withdrawn.
Event 1b. The reasons for this event included inadequate
understanding
of the work scope, inadequate
communications, inadequate
work control documents
and improper equipment
operation.
- Discussion
- On November 17, 1996, the plant was in refueling
shutdown conditions
with shutdown cooling system in operation.
The instrument
AC Bus, Y01, was being supplied from Motor Control Center 1. Y01 is critical to the operation
of the shutdown cooling system as it affects shutdown cooling heat exchanger
bypass and: discharge
valves (CV-3006 . and CV-3025).
Earlier in the day these valves were placed on their manual hand jacks to maintain their position as instrument
air was isolated and tagged for another maintenance
activity.
An electrical
preventative
maintenance
activity (PPAC) was schedul_ed
for the Y01 automatic
transfer switch, YSO. This required the YSO switch to be removed .from _ service so electrical
maintenance
personnel
could remove the switch from the cabinet and take it to the electrical
shop to perform the preventative
maintenance.
Control Room personnel
reviewed the activity but focused on the impact of this activity on the operation
of the shutdown cooling system. They determined
that the shutdown cooling heat exchanger
bypass and discharge
valves would not be affected as they were manually peing operated by the valves' hand jacks. The outage schedule stated that Operations
was to "Manually
align Y01 to'its normal supply". However, because all *the PPAC steps were assigned to Electrical
Maintenance
for completion, Operations
3
- * did not obtain a copy of the procedure
to review, and failed to establish
the full electrical
maintenance
work scope ... Subsequently, Operations
decided to implement
a portion of SOP 30 that configured
the YSO switch from automatic
to normal, but did not recognize
the need to place the isolation
handle to "open" (see attached sketch). This configuration
fulfilled
only one of two alignment
steps specified
in the PPAC. The Control Room Supervisor (CRS) directed an Auxiliary
Operator (AO) to configure
Y01 onto its normal supply using SOP 30. The AO accompanied
by the System Engineering
Test Coordinator (SETC) performed
the alignment.
The SETC explained
to the AO that not only would Y01 have to be placed on its normal power supply but, also, YSO must be isolated by moving the isolation
handle to the "open" position.
At this point the AO should have contacted
the.CRS for direction
and permission
to perform the isolation.
However, the AO did the isolation
and then communicated
the completion
of the activity and the additional
step taken to the Nuclear Control Operator (NCO). The NCO understood
this message to mean that the activity was completed
as directed by the CRS. Therefore, the CRS was not informed that YSO was isolated.
After the electrical
mainter:iance
activity was completed, the Electrician
informed the Work Control Center Lead SRO that maintenance
was completed
and that the Electrician*
needed to be present when Operations
restored the switch in order to sign. the work order steps. Also, the SETC contacted
the Work Control Center and * . reque$ted
that he be notified prior to the restoration
activity;
however, neither were contacted.
If either the Eiectrician
or the SETC had been at the work site.during
restoration, or if the work activity been written to have Operations
sign off for . . restoration, Operations
would have understood
the desired position of YSO. \ . . . Work Control Center notified the Shift Lead SRO that YSO could be restored.
with the CRS on restoring
YSO, and they decided to proceed. The CRS assigned a different
AO to restore YSO, informed the AO and Shift Lead SRO of the. steps he had directed the previous AO to perform, and identified
the steps of SOP 30
to restore YSO.. * * * * * * * The Shift Lead SRO and the AO went to perform the alignment
of YSO. They observed the isolation
handle, the source light indication
and the switch's physical position, but they did not recognize
their indications
were different
than expected.
The AO placed the YSO bypass handle from normal to automatic.
Because the isolation
handle had not been restored to the "close" position, YSO failed to transfer and Y01 was de-energized.
' l 4
,. CORRECTIVE
ACTIONS TAKEN AND RESULTS ACHIEVED The following
actions were taken. _ Event 1a. 1. Refueling
and Maintenance
outage activities
were temporarily
suspended
on November 18, 1996 to review and reinforce
nuclear, radiation, and industrial/personnel
safety concerns with all work groups on site. This event and several other events from the first two weeks of the outage were reviewed with all crews. A common theme running among the identified
issues is the lack communications
between work groups and alignment
among workers. * * 2. Three specific responsibilities
were reinforced
at the Operations
Department
stand down meetings.
These were: . " Shift Supervisors, are to identify Operations
activities
from the outage schedule with an understanding
of the relationship
between these . and others. It is intended that this understanding
will contribute
to well-informed decision making
the Operations
organization.
- . Work Control Center Senior Reactor Operators
are to direct work activities
- having Operations
involvement
to Control Room personnel
for authorization . . * This is to provide interfacing
work documents
physically
to the individual.s . who will be performing
the activity, better communications
between Operations
and other. work discipline*
personnel, and improve the information
flow to those individuals
who will be directing
the activity>
- Control. Room personnel
are to assure they have a complete understanding
- of activities
requested
of them and that proper alignments
have been made. . . 3. . . The control rod drive blades and racks were inspected
for damage due the trip occurring
with a reduced water level. No damage was observed on any of the control rod drive blades or racks. * * Event 1b. In addition to actions 1 and 2 from above, the following
actions were taken. 1. Shift Supervisor, CRS, Lead SRO, AO and other Operations
personnel
involved discussed
this event and the barriers that could have prevented
it. The 5
.. . . -discussion
included responsibilities
for proper communications, pre-job briefings, equipment
operation, self checking and other aspects of operator ccmduct. 2. Shift Operations
Supervisor
has briefed the Shift Supervisors
and SROs on the need to identify and conduct pre-job briefings.
The expectation
to conduct . . --. job briefings
whenever coordination
between two or more work groups is required has been re-established.
- 3. * Maintenance
and Construction
Manager reinforced
pre-job briefing expectations
with maintenance
and construction
supervision
personnel
using this event as an example where a collective
pre-job briefing may have prevented
the event. CORRECTIVE
ACTIONS REMAINING
TO BE TAKEN TO AVOID FURTHER VIOLATIONS . Periodic activity, SPS050, will be revised to use the terminology
of operating , * procedure, SOP 30, and to make the steps to align automatic
transfer switch, YSO, an Operations
responsibility
with the appropriate
sign offs. DATE WHEN FULL COMPLIANCE
WILL BE ACHIEVED * CPCo is now in full compliance.
6
Y-50 AUTOMATIC
TRANSFER SWITCH I I I ! i _! -i ' I I I I I i i I . * EMERGENCY
BYPASS HANDLE. CE ... AUTOMATIC
- * . OfEN . *NORMAL T a.£ROENCY
TCJL..IU:XX
NORMAL m FAm SWITOf SOURa (KM!Nl'ARY)
SOURCE * AVAJl...&BIE
...... AVAILABIP
- .. 0 11tANSFER . TE$t' LOAD (])NNECJE)
TO NORMAL * . 1t1SI' .. NORMAL
.* *1MCC#2! l , RESET ro* MCC # 1 I* I NORMAL 1*
7 . . .
- . * NRC VIOLATION
.2.) 10 CFR 50, Appendix B, Criterion
Ill, Design Control, requires, in part," that . design control measures " ... shall include provisions
to assure that appropriate
quality standards
are specified
and included in design documents
... ," and that " ... design control measures shall provide for verifying
or checking the adequacy of design, such as by the performance
of .. design reviews. Design changes, including
field changes, shall be subject to design control measures commensurate
with those applied to the original design ... " Palisades
Administrative
Procedure
9.31, "Temporary
Modification
Control," Revision *12, Paragraph
7.1.8, required that a technical
review be conducted
to verify that instructions
for installation
were correct .. Contrary to the
On November 6, 1996, Temporary
Modification (TM)96-050 to the containment
polar came did not contain correct installation
instructions
for replacement
of a single solenoid with two solenoids.
The original solenoid was*hard mounted and was provided with adequate ventilation
to prevent premature
failure. As the result of inadequate
preparation
and review, TM 96-050 did not provide instructions
for mounting the second of the two replacement
solenoids.
The* second solenoid was installed
utilizing
duct tape and "tie-wtaps" in a manner which resulted in overheating
and failure of the solenoid coil, and a subsequent . * electrical
fire .. This is a Severity
IV violation (Supplement
1 ). CONSUMERS
POWER COMPANY RESPONSE Consumers
Power Company (CPCo) agrees with the violation
as stated. REASON FOR THE VIOLATION . Based on the inspection
data from the failed coils, the most likely cause of the failure on the trolley crane brake coils is the manner which the coils were mounted. This *inadequate
mounting design was caused by the failure of design personnel
to.identify
soler:ioid
heat dissipation
as critical characteristic
during the design process . 8 . -
- Discussion . A temporary
modification
was required to the containment
Polar Crane due to a failure of the existing 460VAC solenoid on the trolley brake actuator.
No replacement
460VAC solenoid was available.
When this solenoid is energized, the actuator releases the braking mechanism
on the crane trolley motor. ) The modification
involved the replacement
of the original 460VAC coil with 230VAC coils. One of the 230V coils would be installed
in the position of the original coil and the second would be used as a dummy load to provide a voltage drop across it. This would result in a voltage dividing circuit which would divide the 460 volts from the circuit supply in half thus applying 230 volts across each coil. To ensure that the impedance
w<ifs matched a spare plunger was inserted into the dummy coil and fixed in the inserted position using duct tape. The dummy coil was then tye-wrapped
to a . support bar and additional
tape was wrapped around it. The temporary
modification
to substitute
the 230VAC coils for the 460VAC was an acceptable
design. However, the dummy coil mounting design was focused on making sure the coil did not come loose and fall into the debris free zone inside containment.
- . Potential
overheating
of the dummy coil was not considered
in the design. The Polar Crane was in service with the temporary
modification
in place for approximately
60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> before failure occurred.
With high usage of the Polar Crane. and repeated starts and stops on the trolley crane motor, the additional
layers of tape on the dummy coil caused chronic overheating
of the dummy coil. The epoxy insulating
material became hot enough to melt and the dummy coil wires shorted togetheL This allowed the full 460 volts to be applied across the 230VAC working coil, causing its failure. The smoke and. arcing observed was the result of the dummy coil overheating, causing the duct tape to catch fire and burn. No evidence of arcing to the support structure
was found around either coil. CORRECTIVE
ACTIONS TAKEN AND RESULTS ACHIEVED 1. * The two 230 volt coils were replaced with a new. 460 volt coil. It has been in use *without incident since it was installed
.. 2. This event was reviewed as a lessons learned with all Design Engineering
at a department
stand down meeting. Discussions
covered conditions
leading to the event, and the need for Design Engineering
to consider all operating
characteristics
in design . 9
CORRECTIVE
ACTIONS REMAINING
TO BE TAKEN TO AVOID FURTHER VIOLATIONS
1. A review of all installed
temporary
modifications
will be conducted
to verify that acceptable
standards
were used for installation.
2.* The Temporary
Modification
process will be reviewed to assure that adequate guidance is provided to the design engineer
for providing
installation
instructions, arid for verifying
that the temporary
modification
was installed
as intended by the design. DATE WHEN FULL COMPLIANCE
WILL BE ACHIEVED CPCo is in full compliance. . * 10