ML20136G491

Requests Plans & Programs to Resolve Concerns Identified Re Investigation of 850609 event,plant-specific Findings, Programmatic & Mgt Issues Contributing to Event & Recent Performance of Facility.List of Areas of Concern Encl

ML20136G491
Person / Time
Site:	Davis Besse
Issue date:	08/14/1985
From:	Harold Denton Office of Nuclear Reactor Regulation
To:	Williams J TOLEDO EDISON CO.
References
TAC-59702, NUDOCS 8508190483
Download: ML20136G491 (12)

Text

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li; ;y NUCLEAR REGULATORY COMMISSION WASHINGTON D. C. 20555 l

l l Mi4 m Docket No. 50-346 Toledo Edison Company ATTN: Mr. Joe Williams, Jr.

Senior Vice President, Nuclear Edison Plaza

! 300 Madison Avenue Toledo, Ohio 43652

Dear Mr. Williams:

On June 9, 1985, Toledo Edison Company's Davis-Besse Nuclear Power Plant was operating at 90% power when it experienced an event that involved the loss of all feedwater. After the complete loss of main feedwater, an operator error, malfunctions of two containment isolation valves in the safety-related auxiliary feedwater system, and overspeed trips of both steam turbine-driven auxiliary feedwater pumps resulted in the loss of all sources of feedwater to the steam generators. Recovery from this event involved operator actions outside the control room, the addition of feedwater from the (non-safety related) startup feedwater pump, and restoration of feedwater from the two steam turbine-driven auxiliary feedwater pumps.

The NRC subsequently investigated the circumstances of this event and documented its conclusions in NUREG-1154 (Loss of Main and Auxiliary Feedwater Event at the Davis Besse Plant on June 9, 1985). An advanced copy of that report was sent to you on July 26, 1985. The investigation concluded that the underlying causes of this event were: (1) the lack of attention to detail in the care of plant equipment; (2) a history of performing troubleshooting, maintenance and testing of equipment, and of evaluating operating experience relating to equipment in a superficial manner and, as a result, the root causes of problems were not always found and corrected; (3) the engineering design and analysis effort to address equipment problems was frequently either not utilized or was not effective; and (4) that equipment problems were not aggressively addressed and resolved.

These underlying causes are indicative of significant programmatic and manage-ment deficiencies. Accordingly, we have identified the following general areas of concern which must be addressed in your response to this event:

1. Completion of the investigation of the June 9, 1985 event, including analysis of the equipment failures, determination of the root causes, determination of the implications for other equipment, and completion of corrective actions.

2. The plant-specific findings regarding this event.

3. The programmatic and management issues that have contributed to this event and more generally to the recent perfonnance of Davis-Besse.

8508190483 850814 PDR ADOCK 05000346 s PDR

Mr. Joe Williams, Jr. Additional information on these general areas of concern are identified in the enclosure to this letter.

Pursuant to 10 CFR 50.54(f), you are requested to furnish, under oath or affirmation, no later than 30 days from the date of this letter, your plans and programs to resolve the concerns identified above and in the enclosure.

The plans and programs should specify those actions to be completed prior to restart of Davis-Besse and include a schedule for any longer term actions.

We are prepared to meet with you in our office in Bethesda, Maryland to discuss your plans and program prior to the submittal of your written response and as soon as your program is sufficiently well-defined to make such a meeting useful.

Over the past few years we have identified deficiencies through enforcement actions, Performance Appraisal Team (PAT) inspections, and Systematic Appraisal of 1,1censee Performance (SALP) evaluations, as well as through more routine inspection and licensing contacts. In late 1983 Toledo Edison initiated a Performance Enhancement Program (PEP) to improve regulatory performance at Davis-Besse. Modifications to this program were made in response to the most recent Systematic Assessment of Licensee Performance (SALP) and, more recently, Toledo Edison made management changes to strengthen performance. Prior to the availability of NUREG-115a, you outlined in a July 18, 1985 letter, an initial program to identify and implement those measures necessary to return Davis-Besse to safe operation. While these programs for responding to the June 9, 1985 event and for improving your performance may have considered some of the concerns in NUREG-1154, they should be reexamined in accordance with the above request.

As you are aware, on June 10, 1985, the NRC Region III Office issued a Confinnatory Action Letter documenting actions you have taken or will take regarding this event. This letter supersedes that letter, as lead responsibility for NPC staff actions relating to facility restart has been assigned by the Executive Director of Operations to NRR. Consistent with your discussion with Region III on June 10, 1985, it remains our understanding that you will not restart the Davis-Besse facility without NRC approval.

Sincerely, l  %

Harold R. Denton, Director Office of Nuclear Reactor Regulation

Enclosure:

Areas of Concern Relating to the June 9, 1985 Loss of Feedwater Event cc w/ enclosure:

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\ Harold R. Denton, Director Office of Nuclear Reactor Regulation

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' Mr. Joe Williams, Jr. We are prepared to meet with you in our office in Bethesda, Maryland to discuss your plans and program when they have been sufficiently well-defined to make such a meeting useful. This meeting will provide an opportunity to ask questions regarding these concerns prior to finalizing your program plan. Additional meetings may be appropriate as your program plan is finalized.

Sincerely, Harold R. Denton, Director

\ Office of Nuclear Reactor Regulation

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i Mr. J. Williams Davis-Besse Nuclear Power Station Toledo Edison Company Unit No. 1 cc:

Donald H. Hauser, Esq. Ohio Department of Health The Cleveland Electric ATTN: Radiological Health Illuminating Company Program Director P. O. Box 5000 P. O. Box 118 Cleveland, Ohio 44101 Columbus, Ohio 43216 Mr. Robert F. Peters Attorney General Manager, Nuclear Licensing Department of Attorney Toledo Edison Company General Edison Plaza 30 East Broad Street 300 Madison Avenue Columbus, Ohio 43215 Toledo, Ohio 43652 Mr. Janes W. Harris, Director Gerald Charnoff, Esq. Division of Power Generation Shaw, Pittman, Potts Ohio Department of Industrial Relations and Trowbridge 2323 West 5th Avenue 1800 M Street, N.W. P. O. Box 825 Washington, D.C. 20036 Columbus, Ohio 43216 Paul M. Smart, Esq. Mr. Harold Kohn, Staff Scientist Fuller & Henry Power Siting Commission 300 Madison Avenue 361 East Broad Street P. O. Box 2088 Columbus, Ohio 43216 Toledo, Ohio 43603 Mr. Robert B. Borsum President, Board of Babcock & Wilcox Ottawa County Nuclear Power Generation Port Clinton, Ohio 43452 Division Suite 200, 7910 Woodnont Avenue Bethesda, Maryland 20814 Resident Inspector U.S. Nuclear Regulatory Commission 5503 N. State Route 2 Oak Harbor, Ohio 43449 Regional Administrator, Region III U.S. Nuclear Regulatory Commission 799 Roosevelt Road Glen Ellyn, Illinois 60137

2 ENCLOSURE AREAS OF CONCERN RELATING TO THE JUNE 9,1985 LOSS OF FEEDWATER EVENT I. Completion of the Event Investigation A. Completion of the investigation of the equipment malfunctions and operator errors that occurred during the June 9, 1985 event.

B. Determination of the root causes of the malfunctions and errors that occurred during the event and the implications to the rest of the plant.

C. Corrective actions needed to assure the reliability of the systems which can mitigate loss of feedwater events.

II. Concerns Directly Related to the June 9, 1985 Event A. Concerns identified in NUREG-1154:

1. The adequacy of the analyses for loss of feedwater events, including time margins and consequences of alternative sequences.

2. The adequacy of the design and operation of the SFRCS, including spurious actuations, seal-in features for SFRCS-actuated equipment, and single failures.

3. The potential adverse effect of plant physical security and administrative features (locked doors, locked equipment, etc.) on the operator's ability to gain timely access to equipment to mitigate accidents.

4. The availability of and role for the Shift Technical Advisor assistance during complex operating events.

5. The reliability of the Auxiliary Feedwater (AFW) containment isolation valves and other safety-related valves.

6. The adequacy of Toledo Edison Company's procedures and training for reporting events to the NRC Operations -

Center.

7. The reliability of the AFW system and turbine-driven

! pumps, including the need for a diverse pump.

l

8. The reliability of the PORV.

1 I _ _ _ _ _ _ _ _ _

6

9. The adequacy of control room instrumentation and controls.

10. The acceptability of the provisions which resulted in the inability to place the startup feedwater pump in service from the control room.

11. The resolution of those equipment deficiencies listed on Table 5.1 of NUREG-1154 and not addressed by other items, above.

12. The adequacy of plant operating procedures including verification that plant procedures involving " drastic" action are sufficiently precise and clear to ensure timely implementation.

13. The adequacy of safety system testing including verification that safety systems are tested in all configurations required by design basis analysis.

B. Additional NRC concerns:

1. Adequacy of procedures, equipment and training for quickly and efficiently starting or restarting equipment for loss of feedwater mitigation.

2. Adequacy of programs to minimize the likelihood of inadvertent isolation of AFW to both steam generators (including training of the plant operators and human factors aspects of the SFRCS control room equipment).

3. The plans and program for the installation of the new startup feedwater pump in accordance with the license condition of January 8,1985.

4. Adequacy of other engineered safety features, including design considerations, in light of the single failure vulnerabilities identified in the SFRCS and auxiliary feedwater system.

III. Management and Programmatic Concerns A. Adequacy of management practices including control of maintenance programs, use of operational experience, degree of engineering involvement, testing, root cause detemination of equipment misoperation, licensed and non-licensed operator training, and post trip reviews.

.a 4

-3_

B. Adequacy of the maintenance program, including maintenance backlog, maintenance procedures and training, vendor interface and correction of identified deficiencies.

C. Adequacy of the implementation of the Performance Enhancement Program (PEP) and any other ongoing corrective action programs.

D. Adequacy of the resources committed to the Davis-Besse facility for investigation of the event, resolution of the findings and conclusions prior to restart, and implementation of longer term measures to improve overall performance.

I

- l

• Docket No. 50-346 l Toledo Edison Company ATTN: Mr. Joe Williams, Jr.

Senior Vice President, Nuclear Edison Plaza 300 Madison Avenue Toledo, Ohio 43652

Dear Mr. Williams:

On June 9, 1985, Toledo Edison Company's Davis-Besse Nuclear Power Plant was operating at 90% power when it experienced an event that involved the loss of all feedwater. Subsequent to the complete loss of main feedwater, an operator error, malfunctions of two containment isolation valves in the safety-related auxiliary feedwater system, and overspeed trips of both steam turbine-driven auxiliary feedwater pumps resulted in the loss of all sources of feedwater to the steam generators. Recovery from this event involved operator actions outside the control room, the addition of feedwater from the (non-safety related) startup feedwater pump, and restoration of feedwater from the two steam turbine-driven auxiliary feedwater pumps.

Subsequent to the June 9,1985 event, the staff investigated the circumstances of this event and the probable causes. The staff conclusions are documented in NUREG-1154 (Loss of Main and Auxiliary Feedwater Event at the Davis Besse Plant on June 9, 1985). An advanced copy of that report was sent to you on July 26, 1985. In tems of their principal conclusion, the staff investigation concluded that the underlying causes of this event were: (1) the lack of attention to c'etail in the care of plant equipment; (2) a history of performing trouble-shooting, maintenance and testing of equipment, and of evaluating operating experience relating to equipment in a superficial manner and, as a result, the root causes of problems are not always found and corrected; (3) the engineering design and analysis effort to address equipment problems has frequently either not been utilized or has not been effective; and (4) that equipment problems were not aggressively addressed and resolved.

On July 18, 1985, in letter from Joe Williams, Jr. to Harold R. Denton and James G. Keppler, Toledo Edison set forth a program to address the event, to identify the causes of malfunctions which were experienced, to identify and implement those measures to return Davis-Besse to safe operation, and to plan for additional actions to be taken after restart. In this letter you stated your cormiitment to determine and correct not only those items identified as a result of the June 9,1985 event, but also to take those actions which will result in improving overall performance at the Davis-Besse Plant.

7 .-.

. Document Name:

, DAVIS-BESSE 8/7/85 Requestor's ID:

CARYN Author's Name:

RWessman Document Coments:}