ML17261A969

Responds to Violations Noted in Insp Rept 50-244/89-16. Corrective Actions:Operations & Maint Personnel Received a Procedure Training That Highlights A-1408, Independent Verification, Requirements

ML17261A969
Person / Time
Site:	Ginna
Issue date:	02/23/1990
From:	Mecredy R ROCHESTER GAS & ELECTRIC CORP.
To:	Russell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
References
NUDOCS 9003020138
Download: ML17261A969 (18)

Text

AO;ELERATED DISHUBUTION DEMONSHWTION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)ESSION NBR:9003020138 DOC.DATE: 90/02/23 NOTARIZED:

NO DOCKET ACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH.NAME.AUTHOR AFFILIATION MECREDY,R.C.

Rochester Gas&Electric Corp.RECIP.NAME RECIPIENT AFFILIATION RUSSELL,W.T.

Region 1, Ofc of the Director

SUBJECT:

Responds to violations noted in Insp Rept 50-244/89-16.

DISTRIBUTION CODE IE01D COPIES RECEIVED:LTR ENCL SIZE: TITLE: General (50 Dkt)-Insp Rept/Notice of VqoIation Response NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72).

E'05000244'/RECIPIENT ID CODE/NAME PD1-3 PD INTERNAL: AEOD AEOD/TPAD NRR SHANKMAN, S NRR/DOEA DIR 11 NRR/DREP/PRPB11 NRR/DST/DIR 8E2 NUDOCS-ABSTRACT OGC/HDS2 RES MORISSEAU,D RNAL: LPDR NSIC COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 2.2 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME JOHNSON,A AEOD/DEIIB DEDRO NRR/DLPQ/LPEB10 NRR/DREP/PEPB9 D NRR/DRIS/DIR NRR/PMAS/ILRB12 0 N,J RGN1 FILE 01 NRC PDR COPIES LTTR ENCL 1 1 D 1 1 1 1, D 1 1 1 1 S 1 1 1 1 1 1 1 1 1 1 1 1 R-D A NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTETH CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO ELMINATE YOUR NAME FROM DISTRIBUTION LISIS FOR DOCUMENTS YOU DON'T NEEDl TAL NUMBER OF COPIES REQUIRED: LTTR 24 ENCL 24 D

I!I",<Ilail!~II,".Ilf

/I/gpiK;',"l ROCHESTER GAS AND ELECTRIC CORPORATION

~89 EAST AVENUE, P 5cwp.~0\1~*K I ,%0%l5 55A55 ROCHESTER, N.Y.14649-0001 February 23, 1990 T C 5.E P H O N C A@CA CODE VI55 546-2700 Mr.William T.Russell Regional Administrator U.S.Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406

Subject:

Response to Inspection Report 50-244/89-16 Notice of Violation R.E.Ginna Nuclear Power Plant Docket No.50-244

Dear Mr.Russell:

The enclosed response to the Notice of Violation contains our response to Violation 89-16-01 from the inspection at the R.E.Ginna Nuclear Power Plant from November 7 through December 11, 1989.The attached response includes Human Performance Evaluation System (HPES)investigation information and our corrective actions.Our long-term corrective actions have been determined to address the repetitive nature of these concerns, and the need for increased management attention.

Very truly yours, Robert C.Mecredy Division Manager Nuclear Production xc: U.S.Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Ginna NRC Senior Resident Inspector 5'003020'q PDR A'i'OC.I;0.000:44 C~PDC (original)

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RESPONSE TO NRC INSPECTION REPORT 50-244/89-16 Routine Inspection Report 50-244/89-16, Appendix A, stated in part: " During an inspection at the R.E.Ginna Nuclear Power Plant from November 7 through December 11, 1989, the following violation was identified in accordance with the NRC Enforcement Policy (10 CFR 2, Appendix C).Technical Specification 6.8.1 requires in part that written procedures shall be'established, implemented, and-maintained

.covering activities referenced in Appendix A of Regulatory Guide 1.33, November 1972.Activities referenced'n Appendix A include maintenance and equipment control.Calibration Procedure (CP)-410A, Calibration and/or Main-'tenance of Saturation Temperature Monitor System"B" Loop, requires restoration of the test switch to the original position.In addition, Administrative Procedure (A)-1408,.

Independent Verification, and Procedure A-52.4, Control of Limiting Conditions For Operating Equipment, require in-dependent verification, by observation of proper indication or response, following alignment and restoration of equipment required by technical specifications.

Contrary to the above, on November 17, 1989, following maintenance on the'B'oop saturation temperature monitor required by TS 3.5.3 using CP-410A, the test switch was not restored.to the original position and did not receive independent verification of instrument response or switch position." Rochester Gas and Electric concurs with the above violation as described.

J 1.Reason for Violation A Human Performance Evaluation System (HPES)investigation was conducted on this event.A Causal Factors Chart has been prepared and is attached.The concept of barriers and defense in'depth to ensure safe operation and maintenance of the plant was challenged by this event.The HPES investigation identified numerous Specific Barriers that were meant to ensure correct performance of CP-410A, but in varying degrees were ineffective in preventing this event..Our analysis of this and other similar events points to three Primary Root Causes.iI Inadequate procedural direction Ineffective statement of station policies, mmunication, and follow-up of these policies Lapse.in the"good work practices" of individuals co-some 2 0 Corrective Actions Taken and Results Achieved A.While performing Main Control Room channel checks, the operators discovered the 1B subcooling monitor indicator pegged high.Instrument and Control Technicians were called in for troubleshooting and found the test switch not in the recpxired position.The test switch was repositioned, the monitor's restoration and indication was verified and the monitor was returned to service.B.Operations and Maintenance personnel have received"A" procedure training that highlights A-1408,"Independent Verification" requirements and A-503,"Procedure Ad-herence".C.Meetings were held with each operating shift, selected discipline and Administrative groups.The HPES in-vestigation was discussed with each group in detail, using the Causal Factor Chart as a presentation aid.These discussions focused on:*Barriers and defense in depth*Work group interfaces

• Management communication of policies, and follow-up for effective implementation

• Importance of the independent verification Process in daily plant operation*Corrective-Action Plan and specific roles for each work group

Management conducted a group meeting with the three Operators and the three I&C Technicians that were involved in this event.This meeting addressed What, Why, and Under What Conditions events occurred from the perspective of each participant.

The focus was on understanding the event and establishing' basis for Corrective Action to prevent recurrence.

A memo to all Maintenenance personnel, dated February 06,1990, provides instructions to ensure that the latest revision of the implementing procedure is in the work package and that.the procedure has been marked up for independent verification of restoration steps as applic-able.A read and acknowledgement sheet was included with the memo, to en'sure the.memo was understood.

Good work practices have been re-emphasized in Section, Foreman, planning, and Shift Supervisor meetings.Also, as noted in the RGGE response to Inspection Report 89-15, directions have been provided to Operations personnel concerning improved on-shift attention to detail, improved in-depth communications and acknowledg-ement of responsibilities for return of equipment to service.CP-410A and CP-409A have been deleted to prevent use of these deficient procedures.

The new Procedure Upgrade Program (PUP)procedures for calibration of the Saturation Temperature Monitor System are in draft form, ready for review, and will be available prior to next scheduled use.This upgrade corrects multiple action steps, lack of independent verification, inadequate technical content, lack of proper warnings, cautions, and notes and improves on overall procedure format and performance.

Label requests were initiated and completed for test switches TS-410A-1 and TS-409A-l.,Also, a Drawing Change Request was initiated to revise Foxboro's drawings CD-11 and CD-21 to clearly identify the test switches.Other protective system rack drawings were reviewed for test switch installations similar to TS-409A-1 and TS-410A-1 and none were found.

Corrective Ste s Which Will Be Taken To Avoid Future Violations A.The Procedure Upgrade Program (PUP), for calibration procedures is ,in progress and on schedule for a 1990 completion.

The remaining maintenance procedures to be upgraded are scheduled to be completed in 1992.This upgrade program address industry recognized procedure good practices in terms of'content, format, and process.C.-A Task Force will be formed to focus on problems as-sociated with procedure adherence,=

system alignments, independent verificaton, and their repetitive nature.The Task Force goal will be to eliminate these conditions.

This task force will report to the Plant Manager.A request for a Training Effectiveness Evaluation on"A" Procedure training was generated by the Plant Superinten-dents.This evaluation iscurrently being performed by the Training Evaluation Group, and will be completed by March 02, 1990.The Request focused on the following areas: 2 How effective were the Station personnel in communicating plant needs to the training groups?How effective is the training process as it was applied to training on"A" procedures?

This evaluation will assist the Task Force'in assessing the effectiveness of Plant and.Training Organization interfaces.

This will provide information for potential changes in the training process and the training programs that address procedure adherence and independent verific-ation.D.A Training Change Request (TCR)was submitted requesting training for I&C personnel concerning the Saturation Temperature Monitor System interrelationships.

E.As noted in the RG&E Response to Inspection Report 89-15"Administative Procedure A-52.4"Control of Limiting Conditions for Operation" has been changed to further delineate expected actions of personnel for return to service of previously inoperable equipment.

Specific examples are utilized within the body of the procedure to reinforce these requirements." This procedure change is currently awaiting PORC approval following comment resolution.

This approval will be completed by March 09, 1990.

'i' F.Utilize the Quality Performance Organization to aid management by providing a special assessment as feedback on the effectiveness of procedure adherence and indepen-dent verification procedures and activities.

4.The Date When Full Com liance Will Be Achieved Full compliance was achieved November 17, 1989, when the test switch was repositioned, the monitor's restoration and indication was verified, and the monitor was returned to service.RGEE recognizes the need for increased management attention, due to the repetitive nature of problems associated with procedure adherence, system alignments and independent verification.

Our goals are to eliminate incorrect system alignments, and assure independent verification whenever specified.

We have made progress toward achieving this goal, and are continuing to reinforce our corrective actions on an urgent basis.Any future inadequacies in procedure adherence, system alignments, or independent verifications will be dealt with on a case-by-case basis and will be thoroughly investigated.

Any necessary follow up actions including procedure corrections, policy clarifications, or individual counseling will be taken.

Training on A-lant Procedure Adhcreacc Requirements" snd work group discussion of 6/29/89 memo referring to ncw requirement on double signoff was not effective.

Training on A-1408"Indcpcndent Vcrilication" was not cffectivc.(Note: 12/15/80letter to NRCcommincd RG&E to perform vnilication of correct performance.

Maasttancnt communication and follow-up on A-303 and A-1408 did not occur.Maintcnancc memo of 6/29/89 follow.up mcaiags with shops aot held.Double signroff steps should have been identilied in planning, but werc not.HPES 90-01"CP-410A Test Smite Returned" CAR 1990 NRC Inspection Report 60-244/89-16 Violation 01 Proccdurc dcsignt Test switch is not called out.Ia step 5.6.7, thrcc actions arc uircdi~isconncct equipment~Rcstorc module to operation~Restore test switch 5.6.7 is on the bottom of a page.Turn thc page for 5.6.8, which may bc out of sequence-or not rcquircd?The same function pnformcd in second"and" of$.6.7.g.Tech 1 cominues step 5.6.7 2.ThC 2 add Tech 2 had a 4.Calibratioa steps corn letcd I i.JOB START 5.Tech I begins step 5.6.7 which contains three'steps nncctcd by two"ands": fT, I2, Tech IandTech2tookout

-52.4,"Control of Limiti~~dIustments not required P L'~.Cs ibration ok..ccdhdioaadat t problem understanding step 5.6.Unclear directions for tep 5.6.3'f ihc procedure.

topped and discussed.

ng't>i.m~dCT'~~ro Condrtrons for Opcraung I2t~drcstore module to normal': operation aad rcstorc." Rcconnccts leads thea indcpendenily verify tightness of!.all tcrminah.-

Disconnca all calibration uipmcnt and rcstorc." cvicwcd logic snd agreed to tdq g rocecd ast5.6.3.'2"w"~rr'~~~

'cch I dtseoaneas test ul meat.i tep 5.6$is rcdundart of middle J rtion of ste 5.6.7 (above).i(Friday, November 17, 1989 air~0"f>CP, adtddWTT drdxl$w i Q9 pp hours>ah~a.'.=g.

IQ 17 hour1.967593e-4 days <br />0.00472 hours <br />2.810847e-5 weeks <br />6.4685e-6 months <br />s-atp~~@IIcqhtac fha ihi After Iulleh":-*': "",~id~%$'k<R~e55'iN~hrv~M!Nw~:s fa I'<<Pare"+I 0@v r I O"'P 409A and CP 410A arc done only once a year.CP 410A was originally schcdulcd for Tcehs A&B, but they werc called away on another job.Tech I and Tech 2 took over thc cart at approx.09:00 hrs.For steps 5.6.0-5.6 6, Tech I was in Relay Room and Tech 2 in the Control Room?During thc course of thc day'work, Tech 2split his time bctwcen tbc Relay Room and thc Control Room.Tech I spent thc entire day in thc Relay Room.To"restore module" r cans to rcconnca leads.Takes 3-I min.Checks tightncss of taminals.Moves on to step 5.6.8-top of a new page.5.6.8 stata"Connea leads to pair terminals from which they werc remcved.Check tightncss of all terminals." Ncithcr Tech I nor Tech 2 had done CPr4IOA before.g'ceh 2had done CPr409A ss part of 1989 Outage.)Tcchs and plannns wnc trained on Foxboro Spec 200 rnodulcs by thc vendor.The l&C Planner was not in that dsy.A backup planner handled thc p!arming.t t No"tsilgstcscssion" (discussion bctwcen pbnncr snd crew)wss held.a'.6.3"Hold thc voltage constant across pair terminal rrl (approx.4.5 VDC)snd incrcssc the voltage across pair terminal//3 until thc alarm actuates.Thc abrm is d low differential temp.alarm snd actuates when thc difference betwccn thc 2 voltages is Td 1.0 volt=.I volt." Brokea barrier Intact barrier Wonders: Is 5.6.8 pate of"rcsiorc module to normal opemtion.It is possible to rcconrc.".

and test tiahtness of leads, sad skip ihe third"and" of 5.6.7.

I 0 Switch func t called oui in training.I&C training stops at thc Spec 200 Icvcl.dNo training to address thc unique RG&E fcaturcs, such as the tnt switch,'or how thcsc modilications affect thc'plani operation.

Switch was installed in I9S5 as patt of a modification for thc R&T for monthly reactor uip breaker testing.Switch is called diffcrcnt names by different plant groups..Test switch is not fail-safe.

d>>4J a HPES 90-01: "CP-410A Test Switch Not Retu'-conducted herc NRC Inspection Report 50>>244/89-16 Violation Ol System training for I&C covering T SAT (temperature differential system)to include function of the test switch was not done.Test switch is not direaly labeled.Switch is a unique Ginna Station fcaturc.Test switch is located near thc bottom of the rack-aot near thc equipment being scrviccd Test switch is noi considcrcd part of thc Spec 200 module for I&C purposes.Of up to 20 modules in this rack, this is thc only loop with a test switch.Thcrc are only 3 switches of this type in thc entire plant.There are approximately 200 similar modules in the plant.THIS IS AN EXCEPTION.

I lf~Test switch Two tcchs arc rcquircd to sign off thc A-52.4.Procedure A-52;4 as written and as practiced may bc unclear and open to imcrprmauon

.Issues:~Who is rcsponsiblc?

~What is evcryonc rcsponsiblc for?.,7, last part of step 5.6.7:;>','" andrestoretestswitchto

,-g:.original position." j ga'OT PERFORhIED!

~9.Tech 1:>.'-.Oeans up job site.~@~.'Returns to shop..>>",>cGocs to Control Room to j~clear thc A-52.4"Contro 8, Continued proccdurc through S~tcp 5.95, a logical stopping 9:wg:po>>t.

~dr~>>Tech 2 leaves for doctor'aji iatmcnt.1 0, Tech I calls I&C ShoP.)>I I.A 52.4 also signed off by:~3~eg i>.I,-jTceh 3 takes call.Hc goes-,"v>" Head Control Operator i.-'.~a.'tothcControl Room and"-.'+Control Room Foreman ,";'+signs off thc A-52.4.'==~4 Shift Supervisor

,'.Tech I signs off thc A-52.4.i'~NZIeclarcd opcrablc at 15:00~~I';rCdd>>Ccc ccctccdcc.

Ncw shift docs proccdurc 0.6.13.Loop IB subcooling

Žindication pegged high.A.~>.I"Ginna Station Event Report" lilcd.lof Yi+?~~;-~y"~-+";LimiYing Conditions for" c KV>>>>~t~m~f'iM~::::-c:::->";:.".:;:.-.:."-c"(d>>cd'~L>>;:>>>>'::c':

'Ad.dc>>cd.<-14:45 hours~q=;-g~,'.:;

yu~d~.--.-.$~:..-Nr',.,>";...;~~",-'*.v.-"c

--.=.,-,~AY,.

p 15:00hours t;'..i g,.-.:p;Mgg, Possible intcrruptioa

-Tech 2 returns to Relay Room?Procedure CPA IOA, step 5.6.7"~nd rcstorc test switch to original position" was not pcrformcd.

Double vcriTication"with adouble check to bc performed by Ihc person(s)performing the proccdurc" was not done.Step 5.6.7 was not slashed in'he planning process per m<<mo to indicate that double sigaeff is ncccssary.

Tcchs werc not aware of this speciTic (double veri Iicatioa)suuation for step 5.6.7.Tech 2 had been in and out of thc Control Room during thc day.'ech I was ia thc Relay Room.Eatirc proccdme was not complctcd.

Tech 2 was in thc Control Room durino 5.7.4?Not sure.Howcvcr, hc de not check instrumentation relating to steps in 5.6.Tech 2did not do a walk@own inspection or check thc Coauol Room instrumentation prior to leaving for his doctor's appointment.

Good practices, (instrumentation check, walkdown, noting'as found'ad'as is'onditions) were not followed.Tech 2 gone to doctor and unavailablc to sign off the A-52.4.A-52.4, step 3.9 for verification of operabihty, was not pcrformcd correctly.

f (Procedure statesi"if operabihty of cquipmeat is not dcmonstratcd by performing a PT, an operator will veriEy thc valve l>>c up, switch and brcakcr position.)Good work practice not Eol!owed.I&C did not check instrumen-tation in thc Control Room.Good work practice not followed.Operations did not'check instru-mentation in thc Control Room.Friday afternoon 3:00 p m.Going into a wcckead.Coming up on a shift change.Broken barrier I Intact d barrier I&C Planner was contamcd at home.Hc knew about ihc test switch and surmised that it was the problem.

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