ML17228B369
| ML17228B369 | |
| Person / Time | |
|---|---|
| Site: | Saint Lucie  |
| Issue date: | 12/15/1995 |
| From: | Goldberg J FLORIDA POWER & LIGHT CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| L-95-336, NUDOCS 9512270114 | |
| Download: ML17228B369 (13) | |
See also: IR 05000335/1995018
Text
MA~MJ.j.7!ACCELERATED
RIDS PROCESSli REGULATORY
INFORMATION
DISTRIBUTION
SYSTEM (RIDS)CCESSION NBR:9512270114
DOC.DATE: 95/12/15 NOTARIZED:
NO FACIL:50-335
St.Lucie Plant, Unit 1, Florida Power&Light Co.50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION
GOLDBERG,J.H.
Florida Power&Light Co.RECIP.NAME
RECIPIENT AFFILIATION
Document Control Branch (Document Control Desk)SUBJECT: Responds to violations
note'd in insp repts 50-335/95-18
&50-389/95-18.Corrective
actions:location
of key 21 was verified&valve/switch
deviation log entry for AFAS bypass switch closed out on 951004.DISTRIBUTION
CODE: IE01D COPIES RECEIVED:LTR
ENCL SIZE-TITLE: General (50 Dkt)-Insp Rept/Notice
of Vio ation Response NOTES DOCKET FT 05000335 05000389 RECIPIENT ID CODE/NAME PD2-1 PD INTERNAL: ACRS AEOD/SPD/RAB
DEDRO NRR/DISP/PIPB
NRR/DRPM/PECB
NUDOCS-ABSTRACT
OGC/HDS3 EXTERNAL LI TCO BRYCE I J H NRC PDR COPIES LTTR ENCL 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME NORRIS,J AEOD/DEIB AEOD/TQC PI'hE CENTE~R NRR/DRCH/HHFB
NRR/DRPM/PERB
OE DIR RGN2 FILE 01 NOAC COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 NOTE TO ALL"RIDS" RECIPIENTS;
PLEASE HELP US TO REDUCE iiVASTE!CONTACI THE DOCL'CLIENT
CONTROL DESK.ROOM PI-37 (EXT.504-2083)TO E LI XII.'CATE YOUR.CAME PROD!DISTRIBUTIOi
J LISTS I'OR DOCl MEN'I'S YOU DON"I'EED!
OTAL NUMBER OF COPIES REQUIRED: LTTR 20 ENCL 20
Florida Power 8>>Light Company, P.O.Box 128, Fort Pierce, FL 34954.0128
December 15, 1995 L-95-336 10 CFR 2.201 U.S.Nuclear Regulatory
Commission
Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie UnitS 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 Florida Power and Light Company has reviewed the subject inspection
report and pursuant to 10 CFR 2.201 the response to the notice of violation is attached.Very truly yours, J.H.Goldberg President-Nuclear Division JHG/FPS Attachment
cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St.Lucie Plant'r>>512270114
'751215 PDR ADOCK 05000335 9 PDR an FPL Group company
Re: St.Lucie Un s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 Violation A Technical Specification 6.8.1.a required that written procedures
be established, implemented, and maintained
covering the activities
recommended
in Appendix A of Regulatory
Guide 1~33, Rev 2, February 1978.Appendix A, paragraph 1.d includes administrative
procedures
for procedural
adherence.
Procedure QI 5-PR/PSL-1, Rev 62,"Preparation, Revision, Review/Approval
of Procedures," Section 5.13.2, stated that all procedures
shall be strictly adhered to.Contrary to the above, procedures
were not adhered to strictly in the following examples: AP 1-0010123, Rev 99,"Administrative
Controls of Valves, Locks, and Switches," required: that"All valve or switch position deviations
or lock openings shall be documented
in Appendix C Valve Switch Deviation Log...".[step 8.1.6];that"The NPS/ANPS/NWE
shall ensure that the verification
of the status of all valves, locks and switches under Administrative
Control is performed at the required intervals specified in AP 1-0010125...[step
8.3.1]which"Verifies that log entries are current and valid".[step 8.3.2.3];and that"A log of keys issued shall be maintained
by the ANPS for the Controlled
Key Locker...Appendix
B, Rack Key Log"...[step 8.2.2].On September 30, 1995, during a Steam Generator draining evolution on St.Lucie Unit 1, operators failed to make an Appendix B log entry when the AFAS AB BYPASS SWITCH (Key N21)was issued and returned.Further, the NPS/ANPS/NWE
verification
of the status of the AFAS AB BYPASS SWITCH Appendix C log entry performed on the midnight shifts of October 1 through October 3, 1995, failed to verify that the log entry was current or valid.2.AP 2-0010123, Rev 68,"Administrative
Controls of Valves, Locks, and Switches," required: that"All valve or switch position deviations
or lock openings shall be documented
in Appendix C Valve Switch Deviation Log...".[step 8.1.6];and that"The NPS/ANPS/NWE
shall ensure that the verification
of the status of all valves, locks and switches under Administrative
Control is performed at the required intervals specified in AP 1-0010125...[step
8.3.1]which"Verifies that log entries are current and valid"...[step
8.3.2.3].OP 2-0400050, Rev 16,"Periodic Test of the Engineered
Safety Features," required that"The following logs will be reviewed prior to the performance
of applicable
test sections...The
Valve Switch Deviation Log."[step 5.3.1]
Re: St.Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 Contrary to the above, on October 7, 1995, during troubleshooting
of AFAS Channel D on St.Lucie Unit 2, operators failed to make the appropriate
Appendix C log entries when the AFAS CABINET DOOR (Key 5202)was restored at 2:00 PM.or when the AFAS CABINET DOOR was reopened and restored at 2:35 PM and 4:10 PM, respectively.
Further, the NPS/ANPS/NWE
verification
of the status of the AFAS CABINET DOOR performed on the midnight shifts of October 8 through October 10, 1995, failed to verify that the Appendix C log entry for the AFAS CABINET DOOR was current or valid.This is a Severity Level IV violation (Supplement
I).FPL Res onse 1.CONCURRENCE
AND REASON FOR THE VIOLATION FPL concurs with the violation.
The root cause of this event was as follows: (1)failure to follow procedures
in that the shift operators failed to adequately
maintain the Rack Key Log and, (2)failure to follow procedures
in that the operators did not adequately
maintain the Valve/Switch
Deviation Log.A contributing
factor was that the procedure/check
sheet used for maintaining
status control of the Valve/Switch
Deviation Log did not provide instructions
with respect to ensuring that the Valve/Switch
Deviation Log entries were current and.valid.As stated above, the operators are required by Administrative
Procedure AP 1-0010123,"Administrative
Controls of Valves, Locks, and Switches," to maintain a log of keys issued from the Controlled
Key Locker.The log is described in Appendix B, Rack Key Log.On September 30, 1995, shift operators failed to make an Appendix B log entry when the AFAS AB Bypass Switch key was issued from (and subsequently
returned to)the Controlled
Key Locker to allow for the AFAS Switch to be placed in the Bypass position for work associated
with steam generator cooling and wet layup.The requirement
for maintenance
of this log is clearly defined in the subject procedure.
A lack of attention to detail on the part of the operators resulted in a failure to meet the procedural
requirements.
AP 1-0010123 also requires that valve and switch position deviations
be documented
in Appendix C, Valve/Switch
Deviation Log.This AP also requires that a verification
of the status (e.g., position)of all valves, switches, and locks under administrative
control be performed at intervals (specified
in AP 1-0010125)
to be each midnight shift while in Modes 1-6.
Re: St.Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 On October 7, 1995, shift operators failed to make the appropriate
Appendix C entries when the AFAS Cabinet door (Key g202)was restored, reopened, and restored again.This failure was the result of a lack of attention to detail on the part of the operators.
In addition, the operators'eview
of the Valve/Switch
Deviation Log, performed on the midnight shifts of October 8-10, 1995, failed to verify that the Appendix C log entries for the AFAS Cabinet door were current and valid.However, the checklist for the implementing
for the midnight shift verification
only required that the operators review the Valve/Switch
Deviation Log to ensure that no valves or switches were in an alignment which could cause a Tech Spec LCO to be exceeded.No direction was given in this AP to verify that the log entries were current and valid.A contributing
factor to the failure to adequately
verify the status of the log entries was a procedural
deficiency
in Check Sheet 2 of AP 1-0010125.
2~CORRECTIVE
STEPS TAKEN AND RESULTS ACHIEVED A.The location of Key 521 was verified and the Valve/Switch
Deviation Log entry for the AFAS Bypass Switch was closed out on October 4, 1995.B.The location of Key 5202 was verified and the Valve/Switch
Deviation Log entry for the AFAS Cabinet Doors was closed out on October 11, 1995.3.CORRECTIVE
STEPS TO BE TAKEN TO AVOID FURTHER VIOLATIONS
A Night Order was issued on November 10, 1995 that required the ANPS to review the Valve/Switch
Deviation Log each shift to ensure that the verification
of the status of all valves, locks, and switches under Administrative
Control is performed at specified intervals and that the log entries are current and valid.B.A Temporary Procedure Change to AP-0010125
has been implemented
to incorporate
the following changes: 1.The NPS will review the Valve/Switch
Deviation Log each shift.2.The ANPS will review the Key Rack Log each midnight shift., 3.The STA will review the Valve/Switch
Deviation Log once per week.C.A Procedure Change Request has been submitted to permanently
incorporate
the changes listed in (3B)above.
Re: St.Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 4.DATE OF FULL COMPLIANCE
Full Compliance
was achieved on October 11, 1995.VIOLATION B Technical Specification 6.8.1.a required that written procedures
be established, implemented, and maintained
covering the activities
recommended
in Appendix A of Regulatory
Guide 1.33, Rev 2, February 1978.Appendix A, paragraph 1.c includes administrative
procedures
for equipment control.Procedure QI 14-PR/PSL-1, Rev 25,"Inspection's, Test and Operating Status," Section 5.5, stated that equipment clearance tags be attached to the isolating switch fuse or valve according to OP 0010122, Rev 59,"In-Plant Equipment Clearance Orders." Step 4.1 requires that a clearance shall be required when operation of equipment could create a hazard to personnel or equipment.
Contrary to the above on September 15, 1995, during the cleaning of Unit 2 condenser water boxes, the 2B2 waterbox manway was removed to replace a leaking gasket without implementing
a clearance.
When the maintenance
foreman and mechanic attempted to remove the manway cover, the negative pressure that existed across the manway sucked the cover back on the waterbox and severed a portion of the mechanics finger.This is a Severity Level IV violation (Supplement
I).FPL Res onse CONCURRENCE
AND REASON FOR THE VIOLATION FPL concurs with the violation.
The root cause of the event was a failure to follow procedures
in that the parties involved failed to obtain the proper work clearances
in accordance
with OP 0010122,"In-Plant Equipment Clearance Orders." On September 15, the Unit 2 2B2 waterbox manway was observed to be leaking following the start of 2B2 circulating
water pump after waterbox cleaning.A decision was made to replace the manway gasket.The Mechanical
Maintenance
foreman working this job informed the ANPS that the gasket replacement
would be a short duration task.The ANPS and maintenance
foreman decided that a clearance would not be required as long as operators were stationed at both the local circulating
water pump pushbutton
station and at the control switch on RTGB 202, to prevent inadvertent
pump start.
Re: St.Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 At ll:41 p.m., the 2B2 CWP was stopped.OP 2-0620020, Rev 26,"Circulating
Water Normal Operating Procedure," Step 4.14, stated that, if CW pumps were being shutdown one at a time for waterbox cleaning, section 8.8 of the above procedure was to be used.Step 8.8.4 stated that a green flag on the CW pump control switch in the control room indicated that the waterbox vacuum breaker would open and the steam supply valve to the waterbox primer would close.Based on the above guidance, the CWP control switch was green flagged and permission
was granted by operations
to mechanical
maintenance
to begin manway gasket replacement.
The manway cover bolts were removed and the mechanical
maintenance
foreman and a mechanic attempted to remove the manway cover.When the pressure seal was broken, the mechanic allowed his right index finger to come between the cover and the waterbox.A negative pressure developed and sucked the cover back onto its flange and severed part of the mechanics finger.A subsequent
review of the control wiring diagrams for the vacuum breaker found that the CWP breaker'control
fuses had to be removed to open the vacuum breakers.A review of the event found that:~Neither the maintenance
workers nor the ANPS anticipated
that a vacuum would exist once the CWP was secured.~The steps in the procedure for CWP operation indicated that when the CWP control switch was green flagged, no other precautions
were required.~The maintenance
workers, after discussions
with the ANPS, did not verify that the system was de-energized
prior to starting work.2.CORRECTIVE
STEPS TAKEN AND RESULTS ACHIEVED 3~A.The injured employee was transported
to the hospital.B.Work was completed and the system restored to service.CORRECTIVE
STEPS TO BE TAKEN TO AVOID FURTHER VIOLATIONS
A.Disciplinary
action was'taken against the Operations
and Maintenance
supervision
involved in the decision to work without proper clearances.
Re: St.Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 B.A Safety Incident/Accident
Report was completed by the Local Joint Advisory Safety Committee.
This report evaluated the safe work practice requirements
for this type of maintenance.
Expectations
for safe work practices were disseminated
through the"Safety Alert" process.C.OP"1[2]-0620020,"Circulating
Water Normal Operating Procedure," was revised to clarify the requirements
associated
with opening the vacuum breakers.D.OP 0010122,"In-Plant Clearance Orders," was revised to provide more specificity
with respect to what maintenance
activities
can be performed without an , equipment clearance.
E.The maintenance
procedure for condenser waterbox cleaning and repair, M-0921, was revised to add a caution statement about the removal of manways.Also, the standard Nuclear Plant Work Order for waterbox cleaning has been revised to exercise caution when opening the condenser cooling system.F.The Site Training Department
will present this topic at a future In-House Events training class.4.DATE OF FULL COMPLIANCE
Full compliance
was achieved on September 16, 1995.VIOLATION 10 CFR 50 Appendix B Quality Assurance Criteria for Nuclear Power Plants and Fuel Processing
Plants required, in part: that"Measures shall be established
to assure that applicable
regulatory
requirements
and the design basis, as defined in 5 50.2 and as specified in the license application, for those systems, structures
and components
to which this appendix applies are correctly translated
into specifications, drawings, procedures, and instructions."..."The design control measures shall provide for verifying or checking the adequacy of design, such as by the performance
of design reviews, by the use of alternate or simplified
calculational
methods, or by the performance
of a suitable testing program."[III DESIGN CONTROL]
Re: St~Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 that"A test program shall be established
to assure that all testing required to demonstrate
that structures, systems, and components
will perform satisfactorily
in service is identified
and performed..."[XI TEST CONTROL]Contrary to the above, the licensee implemented
a Unit 2 Emergency Diesel Generator (EDG)control logic design that did not trip the EDG output breaker on receipt of a CSAS or CIAS signal when parallelled
with offsite power.This inadequate
design resulted in shifting the governor to the isochronous
mode, bypassing all protective
relays except overspeed and differential
current during integrated
safeguards
testing on October 12, 1995.This resulted in operating the EDG as a synchronous
motor for approximately
45 seconds until the CIAS signal was reset.Operation in the isochronous
mode while paralleled
with offsite power could expose the engine and generator to excessive mechanical
stress or electrical
overcurrent
conditions.
This is a Severity Level IV violation (Supplement
I).FPL Res onse CONCURRENCE
AND REASON FOR THE VIOLATION FPL concurs with the violation.
The root cause of the violation was a failure to identify a design deficiency
during initial design and testing and to adequately
review the revised Integrated
Safeguards
Test procedure prior to implementation
on Unit 2.The performance
of a revised Integrated
Safeguards
Test identified
an equipment concern in which an undesirable
logic response could occur from a spurious CIAS signal without its accompanying
SIAS signal.The original plant design of the Unit 2 EDG SIAS/CIAS/CSAS
logic was arranged such that during a surveillance
run with the EDG connected to the offsite power grid, the EDG could have been potentially
damaged upon receipt of a spurious CIAS signal.The revised Integrated
Safeguards
Test, which had been recently enhanced to more fully test discrete circuit logic paths, inadvertently
created this condition on the 2A EDG, resulting in a reverse power condition until the CIAS signal was reset after approximately
45 seconds.A subtle difference
between Unit 1 and Unit 2 was discovered
as a result of the reverse power incident and is considered
the main contributing
cause.The Unit 1 EDGs use the same
Re: St.Lucie U s 1 and 2 Docket No.50-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 frequency reference for both droop (follows grid frequency)
and isochronous (internal frequency reference)
modes;thus, switching from droop to isochronous
modes would not change the speed of the EDG.The Unit 2 EDGs use different frequency references
for droop and isochronous
modes;switching of the frequency reference is done using contacts from the same relay that provides the EDG start signal.The actual governor change from droop to isochronous
for both Unit 1 and 2 EDGs is controlled
by the 4160V bus feeder breaker position.In the case of a Unit 2 SIAS actuation, the EDG output breaker is opened,'f closed, and the EDG runs at the isochronous
speed.However, for a CIAS or CSAS without SIAS, the EDG output breaker would not open but the EDG speed would switch to the isochronous
speed.With a preset isochronous
speed lower than the grid frequency, the Unit 2 EDG would try to slow down, resulting in a reverse power condition (as occurred during the test).If the preset isochronous
speed is higher than the grid frequency, the EDG would try to speed up and a generator overcurrent
condition would result.Either condition exposes the EDG to potential damage.While the original design satisfied the EDG design intent for the various Design Basis Accident scenarios, it failed to recognize the potential negative impact to an EDG should a spurious CIAS occur when running in parallel with offsite power.As a result of the St.Lucie Units 1 and 2 service water system operational
performance
inspection
audit performed in 1991, the Unit 1 Integrated
Safeguards
Test procedure was revised to address enhanced testing of the swing busses (C busses).The revised procedure was reviewed to ensure that all required Technical Specifications
had been included, that load shedding and sequencing
of A and B Train ESF components
were verified, that the swing bus components
were tested with the swing busses alternately
aligned to both A and B Train busses, and that all control logic pathways necessary for safeguards
equipment to perform their safety functions were adequately
tested.Section 8.6 performs manual CIAS, SIAS and CSAS actuation verification
with the EDGs synchronized
and fully loaded in parallel with offsite power.This section was changed in order to ensure that those components
which received multiple ESF signals are fully tested for each signal.Specifically, components
which change state for CIAS alone would need to be tested independent
a CIAS signal.The CIAS test was performed prior to the SIAS test;therefore, the EDG breaker remained closed until tripped by SIAS.The Unit 1 Integrated
Safeguards
Test was performed during the 1994 outage using the revised procedure.
No anomalies occurred regarding EDG operation while performing
Section 8.6 of the test procedure.
Re: I St.Lucie U s 1 and 2 Docket No.5-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 The Unit 2 Integrated
Safeguards
Test procedure was revised prior to the 1995 Unit 2 refueling outage.This revision essentially
duplicated
the Unit 1 test procedure, with changes as necessary for Unit 2 plant specific loads.The Unit 2 Integrated
Safeguards
Test procedure was given an extensive review similar to that done for the Unit 1 procedure.
In addition, a majority of the test procedure was modeled on the simulator, including the section leading to the reverse power condition, with no anomalies detected.Prior to this change, CIAS had not been actuated with the EDG running in parallel with offsite power;SIAS was actuated first, which tripped the EDG output breaker.However, in order to test components
which change state for CIAS alone, the Unit 1 methodology
to intitiate CIAS before SIAS was used.The Unit 2 Integrated
Safeguards
Test was performed on October 12, 1995, with the resulting EDG reverse power incident and termination
of the test.Although the Integrated
Safeguards
Test procedure review was very involved, the difference
between the Unit 1 and 2 EDG governor speed control circuitry was not identified.
Based on the numerous identical operating features between the Unit 1 and 2 safeguards
responses and the relative obscurity of the design differences
as shown on the control wiring diagrams and vendor drawings, the inappropriate
response to a CIAS signal was neither identified
nor expected.The revised Integrated
Safeguards
Test procedure, which was enhanced in anticipation
of the more stringent test requirements
discussed in the NRC Information Notice 95-15, discovered
this undesirable
condition.
2.CORRECTIVE
STEPS TAKEN AND RESULTS ACHIEVED A.Immediately
following the incident, EDG 2A was inspected and test run under load and found to be undamaged.
B.Unit 1 EDG start logic circuitry was reviewed to ensure that no similar failure modes existed on Unit 1.No similar failure modes were identified.
C.PCM 156-295,"Deletion of EDG Automatic Start on CIAS and CSAS," was implemented
on the Unit 2 EDGs.Post modification
and ESFAS testing was completed on December 6, 1995 with no anomalies occurring in EDG function.3.CORRECTIVE
STEPS TO BE TAKEN TO AVOID FURTHER VIOLATIONS
A.Design modifications
currently produced undergo rigorous multi-discipline
design review, verification, and post-modification
testing with the intent of detecting and eliminating
potential'esign flaws such as this.Therefore, any future design modifications
would be reviewed and tested under our present design control process to ensure that the affected component and plant responses are appropriate.
Re: St.Lucie U 1 and 2 Docket No.5-335 and 50-389 Reply to Notice of Violation Ins ection Re ort 95-18 B.Engineering
has determined
that future test procedure revisions which change the order of initiating
signals must be reviewed for the potential to adversely impact design functions.
The methodology
for ensuring that initiating
signal order changes receive increased review will be completed by March 15, 1996.4, DATE OF FULL COMPLIANCE
Full compliance
was achieved on December 6, 1995.10