ML20148C405
| ML20148C405 | |
| Person / Time | |
|---|---|
| Site: | Saint Lucie  |
| Issue date: | 10/21/1996 |
| From: | Kreh J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Ennis J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| Shared Package | |
| ML20141C820 | List: |
| References | |
| FOIA-96-485 NUDOCS 9705190200 | |
| Download: ML20148C405 (104) | |
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From: g7g To: James JDE1 - Kreh , #f) *' / i
- Date: 10/21/96 7:24am {
Subject:
Your St. Lucie AR -Reply Here's the report material. Sorry I didn't respond last week from St. Lucie, but I was l
" locked out" of the LAN after some snag associated with changing my password. l y
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1 9 Irformation in this record as deleted lg in t.ccordan:c with the freedom of informatiod Act, emrcticas _/s Fn'y_Q6-f][ "
9705190200 970512 PDR FOIA BINDER 96-485 PDR
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.i OCTOBER 9. 1996 CASE NO. Ril-96-A-WHAT IS THE REQUIREMENT / VIOLATION?
l-2. Hurricane response procedures; failure to take timely cortective action on identified weaknesses / problems (various unaddressed Condition Reports) 3-4. Requirements were not deligeated by alleger and are not known to the p eparer of this allegation Report. : ng l
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i OCTOBER 9. 1996 CASE NO. RII-96-A-l WHAT IS THE REQUIREMENT / VIOLATION?
l 1-2. Hurricane response procedures; failure to take timely corrective action on identified l weaknesses / problems (various unaddressed Condition Reports) '
.- - l 3-4. Requirements were not delineated by alleger and are not known to the preparer of this l Allegation Report. . .. l l
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UNITED STATES NUCLEAR REGULATORY i
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SEN'OR MANAGEMEE MEE'N3 ST. LUCIE NUCLEAR PLANT BRIE: LNG MATERIALS OCTOBER 24,1996 13 If E;f2230l'3L. /
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Pre-Decisional i Semiannual Plant Performance Assessment St. Lucie 1 and 2 Current SALP Assessment Period: 1/7/96 through 3/97 Last SALP Rating Previous SALP Rating 1/2/94 - 1/6/96 5/3/92 - 1/1/94 '
Operations 2 1 Maintenance 2 1 Engineering 1 1 Plant Support 1 1 INPO assessment July 1995 - Category 1 I. Performance Overview Since July 1995. there have been a series of events that led to cuestioning the plant's overall performance. An NRC root cause effort cetermined that, in addition to procedural adherence / adequacy weaknesses the licensee suffered from weaknesses in both interfaces across organizational lines and corrective actions. The SALP board concluded that performance ir the areas of Operations and Maintenance had declined to level 2. since the SALP board, additional examples of declined performance were noted. These have included:
e Significant operator inattentiveness which resulted in the i
' overdilution event on January 22, 1996, highlighted the recent large number of personnel errors and lack of command and control in the control room (SL3. CP).
e On February 22. 1996, a dropped CEA and an ensuing Unit 1 shutdown resulted in the declaration of an unusual event. During the shutdown, main feedwater regulating valve instabilities resulted in operators manually tripping the unit.
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e On February 24. a containment radiation monitor was rendered inoperable for two days due to an improper valve lineup following a grab sample. As a result, the unit was started up without this i TS-required component available. Several instances of failure to l follow procedures and operator inattention led to the extended o
period of inoperability (SL4).
e- On May 7. an inspection indicated that a significant number of shifts had been worked with fire brigade members which were not
. medically qualified. A breakdowr. in the tracking of this data i resulted from a key individual being laid off. ,
[ e On May 12. fuel movement was commenced on Unit I wit'- only 1 of l . 2 wide range NI channels available. Operators perfor n -
- surveillance test on the inoperable channel did not ; late l
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with the refueling center properly. Additionally, the fuel offload was commenced without incorporating requirements from the '
spent fuel pool heat load calculation into the appropriate operational procedures.
e On June 6. Unit 2 was manually tripped due to high generator gas temperature. Root cause was a screw which vibrated loose and resulted a temperature control valve feedback arm falling free of its connection. This failure mode had been encountered before.
e 0n June 16. an inspection identified that 56 individual violations i of overtime guidelines had occurred on the part of 4 individuals !
L over a 30 day period. ' Evidence also existed that employees were i regularly working longer hours than those reported on their timesheets e On July 20. Unit 1 experienced a loss of charging flow when, due to a mispositioned board selector switch, both operating pumps 3 i stopped on a faulty indication of high pressurizer level, caused l l- by I&C errors.
e A number of engineering-related problems have been identified. to include-i I l e A number of annunciator response procedures which were l inaccurate due to a failure to update them when design j modifications took place.
i e Four similarly miswired nuclear instrumentation channels due to errors in control wiring diagrams implemented during a modification. The condition was identified at full power and resulted in an entry into TS 3.6.3.
e Nonconservative errors were identified in auxiliary I feedwater actuation system setpoints due to a failure to ;
incorporate as-built data in instrument calibration l
, calculations. !
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' e Maintenance overtime usage was found excessive in that four i individuals were responsible for 56 examples of. non-approved l exceedences of Technical Specification overtime guidelines. '
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l e On August 14. glue was found in key lock switches on both units' l L hot shutdown panels. rendering the switches inoperable. The 1 l- tampering instances appeared to be additional examples of padlocks ;
i and door locks which were identified in July. -
! In addition to the inspection findings above. the ins)ectors have noted i a general low state of morale. A great number of bot 1 management and i non-management employees have expressed concern with regard to the l l company's ongoing downsizing effort. The general feeling is that, unlike Turkey Point, which was afforded the budget and time to improve !
prio* to downsizing, St. Lucie is expected to improve AND downsize !
,i simultaneously.
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t i II. Functional Area Assessment - Ooerations A. Assessment Performance in Operations appears to have leveled.
At the time of )
the last PPR operator errors and operational events were on the i increase. In the past six months. examples of improved operator '
attention to detail and conservative decision-making have been ;
l identi fied. Strong performance was identified in the area of J reduced inventory operation. Weaknesses were identified in the 1
- l. areas of procedural quality and operability maintenance and i t
decision-making. Improvements in control room environment. 1 formality, and communications have been noted. The licenne has l appeared to make inroads in the areas of operator self-assessment '
and documentation of adverse conditions.
B. Basis
- 1. Attention to Detail and Conservative Decision-Making
- e Non-licensed operators were successful in identifying
- two cases of inadvertent containment radiation monitor
, inoperability and a breach in a fire-rated assembly.
l e After a non-conservative decision which resulted in a j late declaration of an NOUE for CVCS system leakage. !
l operators have declared three NOUEs for similar circumstances (CVCS leakage outside containment which .
could not be quickly quantified). Management has been l effective in encouraging conservative decision-making.
l e Entry into a shutdown action statement when 4 Unit 2 ;
control rods would not respond electrically. ;
1 o Five entries into reduced inventory during the period I l without err 6r. ;
e Timely trip of Unit I due to apparent gas buildup in the IB transformer.
e Terminating a Unit 1 startup due to predictions that i xenon decay would invalidate the estimation of critical conditions. ,
- 2. Weaknesses in Procedures and Maintenance of Operability l
- Numerous errors identified in annunciator response procedures.
i e Full core offload began on Unit I without j incorporating requirements from the fuel pool heat j load calculation into operational procedures.
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l l e Operator aids found in the field did not agree with I
procedural requirements for the tasks they described.
e Unit 1 fuel movement began without the required 2 operable channels of wide range nuclear instruments due to the performance of a surveillance test. ;
e Clearance hung during the Unit 1 outage resulted in inoperability of audible count rate in containment.
- 3. Other Observations e Good performance was noted during a Unit 2 downpower due to low turbine auto-stop oil pressure. a Unit 2 trip due to a failed turbine cooling water valve, several startups.'and fuel movements in Unit 1 containment.
i e Poor performance was noted in the use of a single I
o)erator for fuel movement in the spent fuel pool in tie control of keys for PORV operation outside of the control room. in the control of backup charging pump selector switch posn ,on and in performing a test of a turbine-driven AFP which resulted in a pump trip e Equipment failures continue to challenge operators, with the occurrence of two manual trips per unit-this calendar year due to equipment failures.
C. Future Inspections
! The high number of allegations and an increase in resident involvement with engineering activities has reduced the available time for core Operations inspections. The site has been brought to an N+1 staffing level: however, qualification of the new resident is not anticipated until February. 1997. Additionally, both assigned Resident Inspectors will be attending CE training at TTC for three weeks in October / November. An acting resident has been arranged for the period; however, inspection at the N+1 level will not be possible until the end of the current SALP cycle (March 1997). Consequently. Senior Resident and Resident l Inspectors objectivity visits. involving control room j observations, are planned. Additionally. DRS inspections of the l licensee's procedure development and approval process, which has i recently changed in an effort to improve procedure quality, are l planned.
i j III. Functional Area Assessment - Maintenance f
A Assessment: An increase in personnel errors and equipment problems i was noted. The majority of the equipment problems are BOP
- related. For the most part the licensee considered safety in
- establishment of geals and for monitoring of systems and 4
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l comporients in the mairitenance rule. The maintenance program is adequate.
B. Basis:
l The maintenance area was rated good overall the last SALP period. !
1 The last. PPR indicated a problem with EDGs and procedure problems. j The plant matrix indicates 12 equipment failures.12 personnel errors and 3 procedure problems during the last 6 months.
Examples of personnel errors were:
, - 8/31/96 Improper use of M&TE for meggering NI cables
- 8/3/96 Free 7.e seal left unattended i
! - 7/30/96 3 of 4 linear NI channels found miswired )
l - 7/20/96 2 charging pumps tripped due to erroneous level signal L Power Reduction caused by Equipment Failures in the last 6 months:
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- 4/20/96: Unit 2 - Turbine Stop Oil orifice blockage.
- 4/09/96: Unit 2 - Downpower due to Circ Water Piping leakage.
- 5/24/96: Unit 2 Downpower due to CEDM problems.
l - 5/31/96: Unit 2 - Downpower due to MSR TCV closure due to blown ,
i fuse. !
! - 6/06/96: Unit 2 - Reactor trip resulting from high generator H2 l temp due to failed TCV.
- 6/22/96: Unit 2 - Downpower due to 2B FRV Controller problems.
- 7/23/96: Unit 1 - Manual trip due to turbine maintenance.
l Maintenance Backlog:
- Non-outage corrective maintenance backlog: 1101 items, no significant changes since beginning of year.
- Overdue Preventive Maintenance Backlog: 30 Maintenance PMs were late
- Maintenance Rule A(1) systems: 6 systems l - EDG governors. EDGs. 4.16 KV AC safety related breakers. PORVs.
C Future Inspections:
- Maintenance Rule follow-up: 62703 (RI)'- 1 week
- ISI inspection: 73753 (core) - 1 week
- Integrated S/G Replacement Inspection: 73753 (RI) - 3 weeks i l
i IV. Functional Area Assessment - Enaineerina A .- Assessment j i St. Lucie received a SALP 1 rating during the SALP period that ,
ended January 6. 1996. The licensee has declined in performance ,
[ during this PPR period (March-September 1996) due to problems with j
. configuration mana9ement/ design control and a failure to identify '
,i 'an US0.
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l B. Basis PIM TRENDS / ISSUES: The trend indicated was for configuration ,
l management as described in design control issues below and an i issue for failure to identify an US0 for a 50.59 evaluation '
-(September 19. 1996).
1 ENFORCEMENT: Letter of violation issued September 19, 1996. One )
level III and two level IVs in the area of US0 and configuration '
management.
i DESIGN CONTROL ISSUES: In enforcement identified two problems, one which failed to coordinate design changes to operating procedures with three exam)les: 1) Set point change to low level l alarm in the Hydrazine tan (. 2) removal or ICW lube water piping l and did not change abnormal procedure which affects operator l actions,. and 3) disabled a steam dump valve annunciator without I changing the annunicator response procedure. The second problem !
i identified the failure to change ICW drawings after a modification. 1 L (All three examples beptember 19. 1996). I l
l OPERATING FOCUS: The licensee took steps to prevent tube failure )
! of its steam generators on Unit 1 by plugging approximately 2300 l l tubes. These steam generate s will be replaced in fall 1997 ;
l outage.
MAJOR INITIATIVES: Unit 2 outage 4/15/97 97. Unit 1 S/G -I '
replacement outage fall '97 FSAR INITIATIVES: A review has been conducted of approximately l one-third of the FSAR (July 1996 inspection). This review was L performed mostly on Unit 1 and was performed on text material and not for curves and tables. No US0 or operability problems were .
found. Approval pending for reviewing remaining part of FSAR.
DBD/R: A Design Basis Documentation was performed for 20 design ,
basis documents. The program was completed near the end of 1995.
C. Future Inspections Engineering-9 weeks. basis: Evaluate new engineering Organization. FSAR project. configuration management and followup on design control issues.
V. Functional Area Assessments - Plant Sucoort i
A. Assessment l
The last SALP cycle ended 1/6/96. Plant Support was Category 1.
2 The licensee continues to maintain a satisfactory level of aerformance in the area of Plant Support. Some decline in Radiation Protection has been noted due to the loss of control of j contaminated tools and "xceeding dose goals. Emergency _
Preparedness ongoing inspection indicates a decline in j
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! performance. Hurricane preparations for hurricane Bertha were l conservative. Overall, site security has been adeclu6te.
- Training and qualification noted as a strength and management l observed to be aggressive in pursuing issues, but not aggressive in doing indepth review of events. Implementation of the fire protection program continued to be satisfactory.
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B. Basis I Radiation Protection NCV for' failure to control contaminated tools used in RCA (96-04.
! p 45) l Violation (repeat of above NCV) for numerous examples of failure to control contaminated tools. (96-09 p 25)
Internal and external exposures below 10 CFR Part 20 limits. (96-04, p 45 and 96-04, p 23) (1996 dose levels?).
1995 dose was 412 person-rem. Unplanned maintenance and rework caused 1995 dose goal of 283 person-rem to be exceeded by 129 person-rem. (96-04, p 50) !
l l Rad Techs decreased from 32 to 30 and 2 supervisors lost (96-04, p l 48)
Decon staff reduced from 22 to 12 persons. Levels of contaminated I equipment and materials increasing. (96-04, p 46) l Good radiological housekeeping and controls. (96-09. p 28) l The total area contaminated was at 250 ft2. (96-04, p 47) i Licensee accreditation of the FP&L DADS a good example of Radiation Protection staff's technical capabilities. (96-04, p ,
- 44) l Emeraency Preoaredness Conservative actions taken to prepare for Hurricane Bertha.(96-11.
p 3)
. Security Failure to report a confirmed tampering event within one hour, which resulted in a violation.
! Two events in prior to the above tampering event were documented 4 as tampered or unauthorized work, but management failed to notify
- security of these events. ]
l Numerous problems discovered by a 0A audit determined the FFD d
program to be weak.
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l Fire Protection A backup fire pump was installed to replace an out of service fire pump.
C. Future Inspections InsDections Rationale L Health Physics (SALP 1 decline - maintain: watch)
Operational HP(83750) 2-Inspections with focus on procedure compliance: rework doses Effl/RadWast(84/86750) 3-inspections with focus on l accident / process monitor j installation & maintenance TI 133 Rad Waste Combine with 86750 Emergency Preparedness 1-Inspection with focus on Self-l Prog. (82701) Assessment results
! Regional Initiative inspection on l allegation followup (3 weeks. 2 l inspectors)
Security Prog (81700) Core Insp. to review security audits. corrective actions, management support and effectiveness, and review protected area detection eqitipment Sec. Prg/FFD (81700/81502) One regional initiative to followup on tampering and FFD issues Fire Protection None a
VI. Attachments
- 1. Power Profile l 2. Plant Issues Matrix
- 3. Current NRC Performance Indicators
- 4. Licensee. Organization Charts
- 5. Allegation Status L 6. Enforcement History l
- 7. Major Assessments Recent Generic Issues Status List 8
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ST. LUCIE - INSPECTION PLAN j 1
NUMBER OF PLANNED INSPECTION TITLE / PROGRAM AREA . INSPECTORS INSPECTION TYPE OF INSPECTION -
PROCEDURE /
DATES COMMENTS TEMPORARY INSTRUCTION 37550 NUCLEAR INSTRUMENTATION 2 10/7-18/96 REGIONAL INITIATIVE INSPECTION
- OPERATIONAL STATUS OF THE EP 2 10/7-18/96 REGIONAL INITIATIVE 82701
- PROGRAM 10/28-11/1/96 81502 FITNESS FOR DUTY 1 10/21-25/96 FOLLOWUP FFD/ TAMPERING S
40500 EFFECTIVENESS OF LICENSEE 1 10/21-25/96 INSPECT STATUS OF PERFORMANCE IMPROVEMENT CONTROLS IN IDENTIFYING RESOLVING. AND PREVENTING 2 1/97 PROGRAM PROBLEMS: CORRECTIVE ACTION REVIEW 84750 RADI0 ACTIVE WASTE TREATMENT AND 1 11/4-8/96 REGIONAL INITIATIVE EFFLUENT AND ENVIRONMENTAL TI 133/86750 MONITORING: SOLID RADI0 ACTIVE 11/18-22/96 WASTE MANAGEMENT AND .
TRANSPORTATION OF RADIOACTIVE MATERIAL 83750 DCCUPATIONAL RADIATION EXPOSURE 1 12/2-6/96 REGIONAL INITIATIVE 71001 LICENSED OPERATOR REQUALIFICATION 1 12/2/96 REQUALIFICATION PROGRAM PROGRAM EVALUATION INSPECTION l
62703 FOLLOWUP MAINTENANCE RULE TEAM 1 1/27 -31/97 REGIONAL INITIATIVE INSPECTION
2 INSPECTION NUMBER OF PLANNED PROCEDURE / TITLE / PROGRAM AREA INSPECTORS INSPECTION TYPE OF INSPECTION -
TEMPORARY DATES COMMENTS r
INSTRUCTION 73753 STEAM GENERATOR INTEGRATED 1 1/27-31/97 REGIONAL INITIATIVE INSPECTION 2/10-14/97 5/5-9/97 37550 ENGINEERING 1 2/3-7/97 CORE 50.59 FOCUS 92703 FOLLOWUP A/E EXPANDED SSFI TEAM 3 3/3-14/97 REGIONAL INITIATIVE INSPECTION OPEN ISSUES 73753 INSERVICE INSPECTION 1 4/28-5/2/97 CORE -MAINTENANCE PHYSICAL SECURITY PROGRAM FOR 1 TBD CORE SAFEGUARDS 81700 POWER REACTORS
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ST. LUC; UNIT 1 Op era tion al Period Feb ru a ry 1996 ,
through October 18, 1996 1 2 3 100 - =
3 On August 23,1996, 1 On February 24,1996, a manual trip was 80 -
x a manua trip was initiated initiated to perform y while going to a TS required . turbine maintenance. ,
shutdown
@ 60-s Z
w 4Q- 2 April 29, 1996, 4 The unit oper ated at o
a:: shutdow lfor 60% power du a to main
$ refueling transformer o oblems i 0 uiini :io .. . o uio n n o::iviiiviviiiivi m m m m r=n o n: :i o i n u ii n iiii . o ii F M A M J J A S O PERIOD OF OPERATION Graph does not include power reductions ;
for routine repairs, waterbox cleaning, or required repairs.
ST. LU~ C I' UNIT 2 0 .erational Period February 1995 through October 18, 1996 1 2
=
100--
1 On April 20,1996 80- the unit was removed 0::
m from service during -
turbine testing 5 60 -
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Z N 40 -
U 2 On June 6,1996, the g
w unit was manually tripped w due to high generator 20 -
hydrogen gas temperature.
O nio nin o n in o n n o: :n nin n u net =n o n n o n o nin o n n o n n o n n o n o ni F M A M J J A S O PERIOD OF OPERATION Graph does not include power reductions for routine repairs, wa terb o x cleaning, or required repairs.
PLANT ISSUES MATRIX BY SALP AREA St. Lucie SECONDARY SOURCE SALP AREA 10 ITEM APPARENT CAUSE I COMMENTS DATE TYPE ENGINEERING _
Eithe, failure to install orifice dunng NCV 1R 96-06 M L Missing orifice plate identified in Unit 1 4/18/96 plant modification, or failure to reinstall ICW system during licensee field walkdowns. orifice following maintenance.
N Failure to promptly document a Engineering failed to initiate CR upon 4/29/96 NCV IR 96-06 discovery that approx. 35 S-R nonconformance.
instruments on each unit might have been calibrated at temperatures lower than those assumed in setpoint calcs.
L Initial temperature (and other) conditions Programmatic weakness in Plant 5/12/96 NCV IR 96-12. EA O rpecified in Unit 1 spent fuel pool heat Change / Modification process.96-236 load calculation (to support total core offload) was not factored into procedures.
CIRC water piping through-wall leaks Galvanic corrosion due to inadequate NEG S 4/9/96 cathodic protection following installation observed in two water boxes' outlets.
of stainless steelTapparogge components.
Unit 1 outage extended due to expansion New plugging criteria resulting from OTHER IR 96-08 O L 6/3/96 of SG MRPC tubeinspections. Tube discussions with NRR on defect characterization methodologies.
plugging approached 25% limit. PLAs submitted to NRR to allow plugging up to 30%.
Ongoing review by licensee of UFSAR Failure to update FSAR over time and OTHER 1R 96-08 L 6/8/96 failure to review FSAR properly when accuracy identified approximately 150 items, ranging from typographical errors to preparing procedures.
more substantive issues.
Page 1 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
SECONDARY SOURCE SALP AREA ID ITEM APPARENT CAUSE I COMMENTS DATE TYPE Unit 1 AFAS setpoints found Failure to employ as-built elevations of OTHER 1R 96-11 M L 7/18/96 condensate pots in the development of nonconservative during review of recalibration activities. calibration criteria.
3 of 4 Unit 1 linear NI channels found Drawing errors - discrepancy between 7/30/96 OTHER IR 96-11 O L miswired, with the detectors
- upper vendor technical manuals and control chambers feeding the lower NI drawer wiring diagrams generated for the inputs and vice-versa. Result was 3 installation of the new Unit 1 Ni drawers.
channels for which axial shape index was in error.
Engineering response to failure of HVS-4A Procurement engineering effective in 4/13/96 POS 1R 96-06 N motor considered good. locating and dedicating replacement motor and in identifying and resolving incorrect bearing rating calc for new motor. Minor problem existed in that new starting current profile was not adequately treated.
N CNRB activities surrounding PLA reviews 6/1/96 POS IR 96-08 in support of SG tube plugging issues were probing and competent.
N Unit 1 RWT liner inspection. Licensee satisfied committments to 6/8/96 POS IR 96-08 M inspect fiberglass liner in RWT. Results sat.
IR 96-14 N Engineering activities associated with leak 8/26/96 POS in class 3 line to containment fan cooler in '
accordance with GL 91-18 and GL 90-05 for non-code repair.
Examinations well-planned, performed STREN IR 96-08 M N ISI activities for SG and reactor vessel 6/8/96 and managed by very talented and eddy current examinations reviewed.
knowledgable personne!.
21-Oct-96 Page 2 of 26 FROM: 10/18/35 TO: 10/13/
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 6/6/96 VIO IR 96-12, EA- N USQ, involving taking a normally open Licensee determined that small increase 96-249 EDG fuel oil line isolation valve to the in the probability of failure could be closed position and the use of operator overcome by admin processes.
action to open the valve on EDG start, cited at SL lit 7/12/96 VIO IR 96-12, EA N Two SL IV violations cited for Lack of appropriate pre and post-96-236 configuration management control installation review.
problems involving inaccuracies in procedures and drawings due to design changes.
8/3/96 VIO IR 96-11 M N Prelubrication of valves prior to Procedure which required prelube had surveillance testing in 1995 resolved as not been considered for potential effects being a violation of 10CFR50 Appendix B on stroke time.
criterion XI.
VIO IR 96-17 L Failure to satisfy QA plan requirements in Failure to perform independent 10/18/96 the development of design modifications verifications of design outputs to the Unit 1 Nuclear Instrumentation (drawings). Multiple examples. Also, system. failure to perform adequate validation and verification of software for incore monitoring.
6/3/96 WEAK lR 96-12. EA M S High temperature condition in Unit 2 rod Failure of an air conditioner. Further 96-236 control cabinet room due to failure of an review by licensee /NRC showed air air conditioner led to indications of rod conditioner was temporary equipment control problems. Indications later shown installed without design controls during to be false. Also, high temp condition led pre-op test phase.
to tailure of a diverse turbine trip relay.
7/12/96 WEAK IR 96-12 L Licensee veritcal slice inspection of EDG, Lack of proper configuration control over HPSI, and CCW systems revealed time.
numerous deficiencies in procedure, design document and FSAR accuracy.
FROM: 10/18/95 TO: 10/18/ Page 3 of 26 21-Oct-96
a SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE1 COMMENTS 10!12/96 WEAK IR 96-15 PS N No evidence could be found that Lack of design basis documentation.
containment leakage detection systems satisfied leak-before-break assumptions for detectability or seismicity.
MAINTENANCE 11/1[95 NCV lR 95 S ICI wiring error during RX head inctallation Personnel Error NCV 95-18-05 last RFO.
2/17/96 NCV IR 96-01, IR PS N Work on 1 A ECCS suction header through- Personnel work practices (workers 96-04 wallleak revealed strong FME, but poor ignored RWP requirements)
HP work practices observed regarding contamination control resulted in NCV.
5/8/96 NCV IR 96-06 , N Lack of verified (controlled) copy of Failure of Maintenance workers to procedure identified at CCW heat properly verify prucedures prior to exchanger jobsite. beginning work.
5/17/96 NCV IR 96-08 N Failure to verify the currency of procedure Cognitive personnel error in use at jobsite 5/17/96 NCV IR 96-08 N Failure to satisfy requirements for Cognitive error.
independence" on the part of independent verifier.
8/3/96 NCV II. 96-11 N Review of outage freeze seals indicated Stop work order by management for that one freeze seal had been left cleanup of the Unit 1 pipe tunnel unattended for approximately one hour. resulted in directing freeze seal watch to another area to make room for trash being hauled out of area.
FROM: 10/18/95 TO: 10/18/ Page 4 of 26 21-Oct-96
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SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 10/12/96 NCV IR 96-15 N QA identified 3 Greas of noncompliance M&TE storage area had been relegated with M&TE controls; one lack of a cat to a self-service facility, counter to OA sticker, lack of segregation of sat and plan requirements. indications are that unsat M&TE, lack of an individual a lack of personnel contributed.
controlling M&TE.
2/17/96 NEG IR96-01 N Freeze seal procedure lacked objective Procedural Weakness criteria defining when a freeze seal existed.
2/17/96 NEG IR 96-01 L Weakness identified in I&C calibration Procedural Inadequacy procedure - lack of detail provided for safety related calibrations.
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3/30/96 NEG IR n6-04 N Control of maintenance procedures was Programmatic vunerability.
> such that an outdated procedures could, programmatically, wind up in the field due to their inclusion in previously prepared packages. Licensee currective action adequate.
6/8/96 NEG IR 96-08 N Application of adder and scaffolding programs appears to be minimally compliant with licensee's self-imposed requirements. Many scaffolds and ladders required caution tags or had not been removed promptly after use.
11/6/95 OTHER 1R 95-21 S Failure of EDG 2A relay sockets. Equipment Failure Potential common mode failure.
12/9/95 OTHER 1R 95-22 L 2A2 RCP seal pkg lower seal destaged Filling RCS Before Coupling RCP due to reverse pressure across seal.
FROM: 10/18/95 TO: 10/18/ Page 5 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 12/20/95 OTHER 1R 95-22 S RX vessel flange inner O-ring groove Pitting - Localized Corrosion pitting resulted in cooldown and head removal for repair.
3/30/96 OTHER IR %-04 S Maintenance underwent major departmental reorganization.. Selected supervisors' qualifications found satisfactory per TS requirements.
5/22/96 OTHER L V 3483 (SDC Suction Relief) setpoint Root cause not established. Either found out-of-spec high, rendering valve tampering or poor maintenance incapable of performing its intended practices (most likely).
function. 4 6/3/96 OTHER 1R 96-08 N EDG reliaisility calculations indicate that EDG reliability is in keeping with SBO assumptions 6/8/96 OTHER IR 96-08 N Review of maintenance backlog indicated thatlicensee had a plan for backlog reduction in place but has yet to meet goals.
8/3/96 OTHER 1R 96-11 E N Licensce's activities regarding maintenance of rod control system were adequate.
9/7/96 OTHER 1R 96-14 N Apparent improper use of M&TE for Failure to follow procedure.
meggering NI cabling identified. Lack of tracability from M&TE to work order due to borrowing the equipment from one job for use on anotherjob. URI.
9/9/96 OTHER 1R 96-15 S Set screw / locknut in Trip Circuit Breaker 5 Root cause pending. Initialindications sheared off during surveillance testing and were of apparent hydrogen was later found in breaker cubicle. embritt!ement.
FROM: 10/18/95 TO: 10/18/ Page 6 of 26 21-Oct-96
SECONDARY DnTE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE I COMMENTS 2/17/96 POS IR 96-01 N Noted improvements in housekeeping and I material conditions.
l 3/30/96 POS IR 96-04 N 10 maintenance activities observed during inspection period. No significant deficiencies noted.
5/11/96 POS IR 96-06 N Observations of Pressurizer Code Safety No deficiencies noted Valve testing and repair N Preparations for Unit 1 reactor vessel ISI. In accordance with requirements and 5/11/96 POS IR 96-06 showed good outage planning.
POS IR 96-06 N Observations of maintenance activities in No deficencies noted.
5/11/96 containment (Unit 1 outage) involving valve packing replacement and modification.
N MSSV testing - Unit 1 Outage Review of test data and methodology 5/11/96 POS IR 96-06 sat.
POS IR 96-06 E N Polar crane load rating calc and Unit 1 No deficiencie.s identified.
5/11/96 head lift.
IR 96-08 N Repair work for Unit 1 fuel transfer tube Conducted satisfactorily 6!2/9G POS isolation valve.
IR 96-09 N Maintenance activities associated with Work conducted satisfactorily.
6/13/96 POS Unit i reactor head lift and Unit 2 feed reg valve work.
Page 7 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAtlSE / COMMENTS 6/20/96 POS IR 96-09 O L Loss cf 3 Wide Range Nuclear Instrument Operators prompt and accurate in Channels on Unit 1 resulted in entering TS verifying shutdown margin requirements.
AS for Nis.
7/20/96 POS 1R 96-11 O N Post-outage walkdown of Unit 1 containment indicated excellent cleanliness.
9/7/96 POS IR 96-14 N ESF response time testing procedure identified as weak in detail. CR resolution to change procedure appropriate. Review of last 4 performances of procedure for each unit indicated that TS satisfied for completion of all channels.
9/7/96 POS IR 96-14 N Review of 20 work orders indicated appropriate control of work scope.
2/24/96 VIO IR 96-04 N Acceptance criteria specified for CEDM Failure ofI&C System Supervisor to coil resistances in PC/M package found adhere to test criteria compounded by varied and unclear. Criteria were not failure of I&C management to identify properly applied and values outside of cbvious errors during post-work review.
specifications were not documented and resolved.
6/13/96 VIO IR 96-09 N A review of overtime for a one month Failure of management to track the use period indicated that overtime guidelines of overtime as specified in site were routinely exceeded without prior (or procedure. Procedure poorly defined subsequent) approval. 56 examples cited requirements.
for 5 individuals.
7/6/96 VIO IR 96-09 E N Review of testing activities for continment Failure to properly implement App. B blast dampers indicated that violations of and QA plan as they related to 10 CFR 50 App. B and site procedures documenting as-found and as-left data.
existed. Two violations cited.
FROM: 10/18/95 TO: 10/18/ Page 8 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPANENT CAUSEICOMMENTS 10/12/96 VIO IR 96-15 N M&TE used in testing control channel Ni M&TE was borrowed from anotherjob during installation was not logged out in violation of procedural controls.
against the work order for the jeb.
Tracability was thus lost.
10/18/96 VIO IR 96-17 N Failure to initiate a condition report for a Resulted in miswiring the detector.
deficiency when cable labeling for Unit 1 B channel Ni detector did not agree with drawing.
2/24/96 WEAK IR 96-04 N Maintenance practices for Steam Bypass Poor preventive maintenance on SCBC and Control System and Feedwater valve air lines and FRVs.
Regulating valves found weak in inspection following 2/22/96 Unit 1 trip.
OPERATIONS 1/7/96 N SALP CYCLE 12 BEGINS 3/31/96 EMERG IR 96-06 PS N Operator response to RCS leakage Operators effective at through CVCS system. identifying / isolating ieak; however, Unusual Event call was non-conservative in that the call was de'.ayed to a!!ow a 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> RCS inventory balance to be calc'd when other information indicated that excessive leakage existed.
7/13/96 EMERG IR 96-11 M L NOUE declared when 2C charging pump Check valve stuck open due to possibly check valve stuck open, creating bypass generic effects of pulsating low flow in a flowpath from charging pumps to VCT. continuous service valve.
Operators timely in declaring event.
8/9/96 EMERG IR 96-14 M L NOUE declared due to RCS leakage in Charging pump packing leakage excess of 1 gpm unidentified. identified as source ofleak. Operators correctly applied EAL.
FROM: 10/18/95 TO: 10/18/ Page 9 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCri SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 2/22/96 LER LER 335/96- M S Dropped CEA led to declaration of NOUE 002 and plant shutdown. During shutdown, failure of air line to a FRV led to manual trip.
5/29/96 LER M L Suspected loss of approximately 1200 condenser tube cleaning balls reported to state /NRC. Balls were found unaccounted for during an inventory balance.
Suspected that balls were released to Atlantic Ocean.
6/2/96 LER M L Non-safety related breaker alignments to Operators not aware that containment support Unit 1 outage resulted in loss of ampnfier was going to be affected by audible count rate amplifier for lineup. Control room amplifier not containment. Audible counts lost in af'ected.
containment for approximately 5 minutes during fuel movements.
10/18/95 NCV IR 95 L Missed RCS Boron sample surveillance. Personnel Error NCV 95-18-07 10/19/95 NCV IR 95 S Missed shiR CEA position indication Personnel Error NCV 95-18-06 surveillance.
11/21/95 NCV IR 95 L Failure to maintain Penetration Log. FTF Procedure NCV 95-21-04 1/5/96 NCV IR 95 PS N Several deficiencies in prodecure change Failure to Properly implement NCV 95-22-01 process implementation identified. Procedures Expired or cancelled TCs found in control rooms and hot shutdown panel.
FROM: 10/18/95 TO.10/181 Page 10 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE ICOMMENTS 4/22/96 NCV IR 96-06 E L Unauthorized breech in RAB fire barrier Operators showed good attention to during installation of CCW piping detail in identifying two holes bored in modification. wall. Engineering failed to account for the effects of modification installation in fire rated assembly, as required by procedure for engineering packages.
5/14/96 NCV IR 96-08 L Fuel movement begun with only one of Poor commuaication between control two required wide range Ni channels room operators performing surveillance operable. Condition identified and fuel testing (which inop'd NI) on the subject movement secured after approximately 1 channel and the refueling center.
ft of travel.
8/3/96 NCV IR 96-11 L QA audit discovered that corrective action Rush to close out STARS (old corrective documents had been closed without being action document) when CRs (new forwarded to originator for approval (as corrective action document) were required by procedure). NRC identified instituted.
that personnel without signature authority were closing documents.
8/6/96 NCV IR 96-14 N Operator observed not walking down control boards prior to assuming shift, as required by procedure. Operator terminated.
9/9/96 NCV IR 96-15 PS L Licensee had not complied with Failure to follow procedures.
requirements for ensuring that operators read training bulletins required to maintain requalification current. Licensee identified i, sue, with independent NRC findings.
9/18/96 NCV IR 96-15 L Licensee bypassed the wrong ESFAS Poor labeling of bypass key slots.
steam generator!cw level channelin response to channelinoperability.
Resulted in a failure to satisfy TS action statement requirements.
FROM: 10/18/95 TO: 10/18/ Page 11 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE ICOMMENTS 12/1/95 NEG IR 95-21 N Recurrent non-valid alarms when starting FTF Procedure fire pumps were not documented as operator workarounds. Voltage dips associated with such starts were contributors to a trip previously.
12/1/95 NEG IR 95-21 N Operators unabh to effectively ot,tain l&C Inadequate Operator Training setpoints from computer after hard copies were removed from control room.
12/1/95 NEG IR 95-21 N Unit 2 procedures and valve deviation log Valve Position Administratwe Controls used to cycle Unit 1 cross connect valves.
12/1/95 NEG IR 95-21 N SDC Procedure required natural circ- ProceduralInadequacy related surveillance prior to establishing RCS pressure boundary. Natural circ not possible without pressurization.
12/27/95 NEG IR 95-22 E S FRG meeting suffered / items deferred due Lack of Attendance at FRG to lack of OPS /Eng'g attendance at meeting. Major issues at meeting affected OPS /Eng'g.
1/5/96 NEG IR 95-22 N Several procedural deficiencies and inadequate Procedure Review and calculational errors identified in reload Execution physics test procedure.
2/15/96 NEG IR 96-01 M N Tours of ECCS rooms revealed several Material Condition active leaks. Licensee could not explain how (if) FSAR assumptions on ECCS leakage were satisfied. Later review of FSAR indbated leakage within assumptions.
3/7/96 NEG IR 96-04 N Licensee failed to place a CEA which had Operator oversight.
been declared administratively inoperable in the equipment out-of-service log. CEA was operable per TS.
FROM: 10/18/95 TO: 10/18/ Page 12 of 26 21-Oct-96
SECONDARY .
DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE / COMMENTS 3/7/96 NEG IR 96-04 N During MTC testing, inspector noted that Poor attention to detail.
boron concentration had been verified at 30 minute intervals, vice 15 minute intervals as called for in procedure.
6/3/96 NEG IR 96-08 N Poor practice observed in spent fuel pool "On deck" status was an effort to operations. Fuel assemblies were left expedite reload. Operator leaving hanging in an "on deck" status while machine was due to inadequate awaiting upender availability. Also, manpower-operator had to operate operator left machine unattended with fuel upender controls, which were mounted hanging at least once per movement. on wall.
7/16/96 NEG IR 96-11 L 2C auxilliary feedwater pump tripped on Operator error in not properly overspeed during post-maintenance implementing cautions in a procedure.
testing.
7/20/96 NEG IR 96-11 M L 2 operating charging pumps tripped when I&C failed to recogr.ize that reactor maintenance induced an erroneous level regulating system would be affected by signal into reactor regulating system. their activities. Operators had charging Letdown isolated by operators. Upon pump backup switch in wrong position, reinitiating letdown, minor waterhammer leading to cessation of charging flow.
event occurred.
10/1/96 NEG IR 96-15 O N 2B HPSI pump discharge pressure noted Poor attention to detail.
to be 880#. Operators could not explain it, had not noticed it. Was due to a pump run a week before.
11/16/95 OTHER IR 95-21 M S Unit 1 manually tripped when 1B MFRV Long-Standing Equipment Problem locked in 50% position. Root cause -
degraded power supply, compounded by voltage dip on starting both station fire pumps.
11/21/95 OTHER 1R 95-21 S Light socket failure during lamp Equipment Failure replacement results in loss cooling to 1 A Main Transformer. Unit downpower to
~60%.
FROM: 10/18/95 TO: 10/18/ Page 13 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 1/26/96 OTHER IR 96-01 N Inspection of corrective action program Corrective Actions revealed timely action on the part of management, but weaknesses in plans for tracking progress on personnel performance and procedure quality improvement.
3/1/96 OTHER L Management Changes -T. Plunkett succeeds G. Goldberg, C. Wood replaces L. Rogers as manager of SCE, C. Marple replaces C. Wood as Ops Supervisor.
3/10/96 OTHER IR 96-04 L Unit 1 downpowered to 97.5% due to hot Hot leg stratification.
leg stratification and flow swirl which i resulted in higher than actual indicated reactor power.
4/4/96 OTHER IR 96-06 L Interim Operations Manager (H. Johnson) named. ,
4/10/96 OTHER IR 96-300 N 4 of 4 SRO candidates passed SRO examination. In 3 of the cases, performance was marginally satisfactory.
No generic candidate weaknesses identified.
4/20/96 OTHtiR 1R 96-06 S Unit 2 downpowered and taken off-line Blockage in auto-stop oil line orifice due to low pressure condition in auto-stop which prevented buildup of auto-stop oil oil. Operators observed to control pressure. Only negative aspect was evolution well. crowding of control panels by control room SROs during portions of evolution.
5/31/96 OTHER 1R 96-08 M S Blown fuse resulted in closure of all Unit 2 Moisture found in a junction box MSR temperature control valves, resulting following heavy rain.
in a 5% load rejection. ,
FROM: 10/1B/95 TO: 10/18/ Page 14 of 26 21-Oct-96
. _ _ . _ . _ _ _ _ _ . - _ . - . - . _ _ _ _ _ _ _ . _ _ _ _ _ - . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ . _ _ . _ . _ _ _ _ _ _ _ _ - _ .---______________..__.____._-____.._.._.__.__________.___.__m_ _ _ . . _ - _ _ _ _ _ _ _ _ _ _ _ _ _ __ _
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 6/27/96 OTHER IR 96-09 E L Site reorganization announced which would place almost all engineering functions (system engineering, STAS, test engineers) under Engineering. Also.
Outage Management folded into a global ,
work planning group under the Plant General Manager.
3/12/96 POS IR 96-04 S Licensee disposition for deficiency noted !'
in 1 boroflex panel (top 15" missing) found satisfactory. FRG treatment ofissue found appropriate.
3/29/96 POS IR 96-04 N Operator requalification program found to be supporting management expectations for operations and covering timely snd important topics.
3/30/96 POS IR 96-04 N Review of 5 clearances indicates better attention to detail than had been observed in past.
4/10/96 POS IR 96-300 N Simulator performed well throughout SRO qualification testing.
4/28/96 POS IR 96-06 N Operators performed well during Unit 1 Communications formal, excellent use RFO shutdown. of annunciator response procedure.
Performance of rod drop time testing a noteworthy initiative.
5/2/96 POS IR 96-06 N Good performance by operators and test personnel during integrated safeguards testing on Unit 1.1B EDG output breaker failed to close during first test. Operators handled situation well.
5/5/96 POS IR 96-06 N Reduced inventory operations conducted well by operators.
FROM: 10/18/95 TO: 10/18/ Page 15 of 26 21-Oct-96
m SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 5/11/96 POS IR 96-06 N 2 clearances audited, both correct.
5/14/96 POS IR 96-08 N Fuel movements during Unit 1 core offload and reload performed well.
5/24/96 POS IR 96-08 M S Rod control system failure resulted in Operators conservative in interpreting inability to move (electrically) 4 CEAs. TS, plant organizations provided timely Operators conservatively interpreted TS to support with lists of equipment which require shutdown in this instance. would be inoperable when the main Situation complicated by an out of service generator was tripped.
Startup Transformer.
IR 96-08 S Unit 2 manually tripped due to high main Operators acted promptly and correctly 6/6/96 POS generator gas temperature due to failed in tripping the unit. Post trip response of temperature control valve. both plant and operators was good.
IR 96-08 N 3 QA audits reviewed Broad in scope, appropriately focused, 6/8/96 POS indicated an aggressive application of quality standards.
IR 96-08 N 3 QA Audits reviewed Broad in scope, focused on weak 6/8/96 POS areas. Agres.sive application of standards evident in the number of findings cited.
IR 96-09 N Unit i reduced inventory preparaMns and Controls were appropriate.
6/19/96 POS execution.
IR 96-09 N Unit 1 reduced inventory preparations and Mid-Loop controis effective. Licensee 7/5/96 POS I execution. attention and management oversight excellent.
Page 16 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
b SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE I COMMENTS 7/8/96 POS IR 96-11 M N Licensee preparations for Hurricane Hurricane forcasts showed storm e Bertha proactive and responsible. missing area, but licensee prepared as though it would change course.
8/01/96 POS IR 96-14 M L Operators manually tripped Unit 1 due to Operators acted quickly, conservatively, indications of gas accumulating in the 18 and in accordance with plant transformer. Operating crew self- procedures.
assessment fobowing event viewed as excellent.
9/2/96 POS IR 96-14 N Unit 1 startup conducted well. Ooerator action to terminated first approach to t criticality when Xe decay drove estimated critical conditions near allowed band limits was appropriate.
9/9/96 POS IR 96-15 PS N Control room watchstanding practices satisfactory. Watchstanders maintained a professional environment and were attentive to plant paramenters.
10/9/96 POS IR 96-15 N Surveillance testing of 2A EDG performed well. Good use of Real Time Training Coordinators 7/9/96 STREN IR 96-11 N Two entries into reduced inventory made during inspection period. Strong '
management involvement in scheduling around Hurricane Bertha. Reduced inventory operations continues to be a strength.
11/11/95 VIO IR 95 N Tech. Spec. equipment not specified for IV FTF Procedure VIO 95-21-02 on Equipment Clearance Order.
! FTF Procedure 11/20/95 VIO IR 95 N Valve discovered Closed vice Locked VIO 95-21-01 Closed as specified on Equipment Clearance Order.
Page 17 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 11/27/95 VIO IR 95 L Missed RCS Boron sample surveillance - Personnel Error VIO 95-21-03 Repeat from IR 95-18.
1/5/96 VIO IR 96-04 L NLO failed to employ procedure when Failure to use procedure, failure to notify placing EDG fuel oil tank on recirculation control room of evolution.
for chemistry. As a result, he improperly performed the evolution by isolating the discharge of the EDGFO transfer pump, which resulted in an inoperable EDG.
1/22/96 VIO 1R 96 EA E L Boron dilution event due to operator Operator error, poor short term 96-040 leaving control panel while dilution was in tumover, poor command and control progress. Weak command and control, i
procedural adherence, and short-term tumover. Additionally, OP for ;
boration/ dilution not consistent with FSAR and no 50.59 performed.
1/26/96 VIO IR 96 N Violation identified regarding temporary Procedure Control VIO 96-01-01 changes to procedure which changed intent and which were approved for use without prior FRG review.
VIO IR 96-04 O N Operators found adding boric acid to VCT Procedures were put away to tidy up 2/22/96 without procedure in hand, as required by control room prior tc NRC senior
~
conduct of operations procedure. managers' tour prior to SALP meeting.
Additional example of EEA 96-040.
3/27/96 VIO IR 96-04 N Operators failed to propedy log boron Management direction to operators dilution evolutions. Globallog entry was allowing globallog entries for reactivity made at the beginning of the shift stating manipulations during transient dilutions would be made; however, conditions (e.g. uppower) which was procedure required each dilution to be not in accordance with Conduct of logged. Operations procedure.
8/19/96 ViO IR 96-16 N Operations key controls found inadequate Keys found uncontro!!ed at for keys associated with control room normal / isolate switch boxes for unit 2 evacuation / remote shutdown PORVs.
FROM: 10/18/95 TO: 10/18/ Page 18 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE I COMMENTS 12/1/95 VEAK IR 95-21 N SDC procedure contained conflicting ProceduralWeakness/ Inadequate values for RX cavity level requirements. Review Procedure had been approved since emphasis on accuracy stressed.
12/1/95 WEAK IR 95-21 N CCW sample valve showed dual FTF Procedure indication without corrective action documentation initiated.
92/1/95 WEAK IR 95-21 N Clearance in place to isolate N2 from CST Poor Corrective Actions to facilitate pressure switch replacement for nine days without work order being written.
12/1/95 WEAK 1R 95-21 N Followup to previous inspection findings Corrective Actions indicated a weakness in followthrough in addressing deficiencies.
12/5/95 WEAK IR 95 22 M N ESFAS cabinet doors found unlocked Poor Logkeeping/ Attn to Detail following maintenance work - I&C error.
Log entries associated with work were not complete.
1/5/96 WEAK 1R 95-22 M L U2 manual RX trip on high generator H2 Temp Control Valve Failure.
temp due to failure of temp control valve. Additionally, failure to identify Operator awareness of RPS status post- unexpected reactor trip signals which trip poor. Inspection of post-trip review (for came in during trip. i current trip as well as past trips) indicated weaknesses in the rigor of post-trip reviews 2/17/96 WEAK IR 96-01 E N Numerous deficiencies i@ntified in Proceduralinadequacy instrument air system walkdowns, including drawings accuracy, ONOP adequacy, and annunciator response procedure accuracy.
4 FROM: 10/18/95 TO: 10/18/ Page 19 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SAIT AREA ID ITEM APPARENT CAUSE I COMMENTS WEAK IR 96-04 S Procedural weakness results in attempting Procedure review weakness -lack of 2/24/96 to synchronize main generator with grid venfication that disconnect links were with generator disconnect links open. closed.
N Configuration Controlissues resulted from Walksdowns of both units' CS, ICW and 4/14/96 WEAK IR 96-06 E ESF system walkdowns. IA systems indicate programmatic failures in incorporating design changes into drawings, the FSAR and operating procedures. Unresolved item tracking expansion ofinspection scope to include instrumentation setpoints.
IR 96-06 E N ICW system walkdown. Results indicate weaknesses in 4/14/96 WEAK ,
procedure-to-procedure agreement, labeling, and surveillance requirements, in addition to configuration contrc issues disussed separately.
N Operator aids found in various areas of Type of aids identified did not meet 8/6/96 WEAK IR 96-14 the plant which were not in agreement enteria for inclusion in operator aid with system operating procedures. program and were not controlled.
PLANT SUPPORT O L NOUE declared due to security alert Event was similar to discoveries made i 8/1 96 EMERG IR 96-16 I resulting from discovery of tampering. A in July of a glue-like substance in glue-like substance had been injected into padlocks.
Unit 1 and 2 hot shutdown panel key lock switches.
N Inspection of Hot Tool Room identified Attention to detail in toot storace and 3/1/96 NCV IR 96-04 several tools which were either not surveying.
painted purple (as required) or which slightly exceeded limits for contamination.
O L Failure to follow procedure resulted in the Poorly written procedure, compounded ,
8/12/96 NCV IR 96-15 inoperability of the Unit 1 containment by weak execution by chemistry radiation monitor following PASS panel personnel. Good attention to detail be operability check. NLO in identifying condition.
Page 20 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE I COMMENTS ,
12/1/95 NEG IR 95-21 N Rad survey results unavailable for B hot Failure to Dc-r" ment RAD Survey leg work. Surveys performed but not documented.
2/7/96 NEG IR 96-02 N Two areas for improvement identified in inconsistencies in the use of Florida graded EP exercise - Need for Notification Message Form. Confusion management to become more involved in existed between NLOs dispatched from assuring correctness ofinfo being OSC and Control room for similar repair provided in offsite notification forms and missions.
need to refine C&C for damage control teams.
5/15/96 NEG IR 96-08 N Observations of radiation worker practices revealed inconsistencies in the application of site practices (e.g. wearing of dosimetry, donning / doffing PCs) 7/26/96 NEG IR 96-10 L QA audit of Fitness for Duty program Failure to follow procedures and lack of identified problems including personnel both attention to detail and self-checking with negative tests being recoded as cited as root causes.
positive (and vice versa) and personnel randomly selected for testing not being tested (even though they were available).
8/9/96 NEG IR 96-14 N Examples of poor radiolaogica!
housekeeping observed. Barrels for anti-C collection located outside of contaminated areas, use of multiple, undefined, stepoff pads, contaminated trash overflowing contaminated arco boundaries.
8/23/96 NEG IR 96-16 N Licensee extended control room access to a large number of personnel, potentially in excess of those needing access.
FROM: 10/18/95 TO: 10/18/ Page 21 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 9/19/96 NEG IR 96-16 N Licensee resp. .nse to identification of glue Events believed to have occurred at in padlocks in July not thorough, as glue same time, and licensee's intitial audits was later found in key lock switches. included only padlocks, door locks and valve locks.
2/7/96 OTHER 1R 96-02 N EP exercise demonstrated that onsite emergency plans were adequate and that licensee was capable of implementing them.
3/1/96 OTHER 1R 96-04 N Licensee found to be utilizing ALARA techniques and making progress at reducing collective doses for staff.
3/1/96 OTHER 1R 96-04 N Licensee found to be implementing adequate RP controls and monitoring individual exposures per code requirements.
3/1/96 OTHER IR 96-04 N Housekeeping in RABs generally good, however, equipment storage areas found cluttered and untidy.
3/14/96 OTHER L Management change. A. Desoiza (human resources manager) replaced by Lynn Morgan (from TP) 8/12/96 OTHER 1R 96-14 O L Operatoridetified low flow in Unit 1 Failure to follow procedure.
containment air monitor. Condition the result of Chemistry personnel failing to properly secure from a PASS system surveillance. URI 2/7/96 POS IR 96-02 N Observations of licensee performance in CR, TSC, OSC, and EOF indicated good command and control, staff utilization and staff demeanor during graded exercise.
FROM: 10/18/95 TO: 10/18/ Page 22 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 2/7/96 POS IR 96-02 N Licensee's onsite emergency organization was found to be well-defined and general!y effective at dealing with simulated emergency during graded exercise.
2/7/96 POS IR 96-02 N Communication among the licensee's emergency response facilities and emergency organization and emergency response organization and offsite authorities were good during graded exercise.
2/7/96 POS IR 96-02 N Licensee made significant observation of Licensee objectively questioning overall E-Plan execution - 2 practice drills were state of readiness.
required prior to graded exercise for management to be satisfied with performance. Management determined that more frequent drills were required to ensure readiness.
3/1/96 POS IR 96-04 N Ongoing HP efforts to obtain accreditation of FPL electronic dosimetry program identified as a good example of department's technical capabilities.
5/3/96 POS IR 96-05 N Inspection of FPL Speakout program. Progra&T active in handling and resolving cro -e safety concems.
6/8/96 POS IR 96-08 N Fire barrier inspections performed by the licensee were found to employ conservative criteria and be detailed.
7/6/96 POS IR 96-09 N Review of RCP oil collection system. System met description in FSAR and was in accordance with App R, except as allowed by approved exemption.
FROM: 10/18/95 TO.10/18/ Page 23 of 26 21-Oct-96 r
- wm n- - - - - - - --------.__a ,,_m A ---------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
SECONDARY DATE TYPE SOURCE SA1.P AREA ID ITEM APPARENT CAUSEI COMMENTS 9/19/96 POS IR 96-16 N Licensee response to August discovery of glued key lock switches satisfactory.
2/24/96 VIO IR 96-04 O L Unit 1 containment radiation monitor found Failure t z follow procedure on the part of out-of-service due to isolation valve which HP personnel, compounded by failure to was closed to support a grab sample prior identify condition by operators during to a containment entry and not retumed to rounds.
the open position. Condition existed for 2 '
days, unknown to licensee.
5/7/96 VIO IR 96-06 N Programmatic weaknesses identified in 11'62 members had expired medicals.
Fire Protection Program for medical 9/65 with expired medicals worked 60 qualification of fire brigade members. shifts in Apnl. 2 Fire Team leaders not listed on roster worked 31 shifts in April.1 Fire Team member with expired medical and not on roster worked 1 shift.
8/23/96 VIO IR 96-16 N Failure to report tampering which occurred Licensee made decision at the time that in July to NRC in accordance with 10 CFR tampering did not affect operation of the 73 requirements. unit.
9/14/96 VIO IR 96-15 O N Unit 1 containment radiation monitor HP tech failed to employ a procedure for rendered inoperable after obtaining grab restoring the monitor to service.
sample due to mispositioned valve. Independent verifications were not !
Repeat of previous violation. performed.
10/18/96 VIO IR 96-18 N Failure to implement requirements of E Autodialer was inoperable and backup Plan with respect to arrangements to staff (manual) ca!!out capability hindered by and activate emergency response lack of distribution of controlled and facilities from 7/22 to 10/3. current phone number lists.
10/18/96 VIO IR 96-18 N Failure to tai <e corrective actions for Corrective actions were still in dratft critique items identified after Hurricane format and had not been acted upon.
Erin in August,1995.
FROM: 10/18/95 TO: 10/18/ Page 24 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS VIO IR 96-18 N Failure to implement training prog am for Filures to provide training for rnultiple S0/18/96 EP as specified in E Plan. positions for 3 years, failure to provide initial and requal training to multiple personnel, and other examples.
10/18/96 VIO IR 96-18 N Failure to provide adequate EPIP for EPIP provided no more detail than plan, transferring OSC functions to an attemate which said that EC would determine if location in event an evacuation of the relocation was required. No specifice OSC is required. on possible attematives.
5/3/96 VEAK IR 96-05 N Response letters prepared by Speakout to concemed employees did not contain adequate feedback to concemed employees.
IR 96-05 N Investigative techniques of Speakout No requirement to develop plans to 5/3/96 WEAK program have the potential to reveal, ensure identity is protected.
inadvertently, of concemed empicyees.
N Speakout program corrective actions were Lack of procedural specificity.
5/3/96 WEAK IR 96-05 -
not tracked through implementation as required.
WEAK IR 96-16 N Interviews with maintenance personnel ineffective communication of 8/16/96 assigned to observe access to critical expectations during rapid development areas of the plant as a result of tampering of an augmented security posture.
event revealed that they had not been told what to look for, how to react, who to contact in the event of a problem, etc.
Too many colateral duties assigned to .!
10/18/96 VEAK IR 96-18 N Unreliable ability to notify state within 15
- minutes of a declared emergency. Emergency Coordinator.
N Inadequate program ot drills to ensure No drills conducted since graded 10/18/96 WEAK IR S6-18 availability of sufficient personnel and exercise in February and no timiiness of ERF staffing. programmatic requirement to perform drills.
i Page 25 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEi COMMENTS SALP Functional Areas: ID Code:
IE ' ENGINEERING !L LICENSEE
!M MAINTENANCE lN fNRC O OPERATIONS is lSELF-REVEALED I
PS PLANT SUPPORT SA . SAFETY ASSESSMENT & QV
(
I Page 26 of 26 21-Oct-96 FROM: 10/18/95 TO: 10/18/
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[
I Exposure (hREM) \
PWR Aversgo Forced Outage Rate (%) Number of Events Number of Scrams o E $ $ 8 o 8 8 8 E $ ,. Oi $ $ 5 o u u s' $ k
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PREDECISIONAL ST. LUCIE 1 l tevena: seasocei sien,ric.nce sion Peer Group:Comeuscon Engineenng w/o CPC .' Mecium m 93-3 to 96-2 Tronos and Devianons l l
l Deviations From Plant Peer Group l
l Self-Trend Median l Short Term Long Term I oncened improved Mrse semer OPERATIONS Automatic Scrams While Critical - 0
. 0.1 f 1
Safety System Actuations - 0 0
Significant Events - 0 -
0 Safety System Failures - -0.24 : 1 0
- i l 3 l
i Cause Codes (All LERs) I !
l l
l a. Aemmessieve conses Preseems -1 M 0.68 '
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-1.24 Significant Events - 0 <
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Cause Codes (All LERs)
- a. Aamousseeve conesi Preemans - 0 <
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0
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- f. - - 0 -
0 FORCED OUTAGES i
Forced Outage Rate * - 1.43 *
-0.27 l Equipment Forced Outages / * & ep,
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! Performance tnoex Performance inoez cem e me c . . -
cycm i
m.
1 PREDECICIONAL l ST. LUCIE.1 l
l PI EVENTS FOR 95-3 l
l SCRAM 07/08/95 LER# 33595003 50.728: 29039 PWR HIST: POWER OPERATIONS AT 100%
l DESC THE REACTOR TRIPPED ON HIGH PRESSURIZER PRESSURE WNEW THE MAIN TURBINE GOVERNOR AND INTERCEPT VALVES WENT CLOSED DURING TESTING. THIS EVENT WAS CAUSED BY AN OPERATOR OMITTING A TEST PROCEDURE l STEP. !
. I
! SSF 08/09/95 LER# 33595005 50.728: 29178 Pnat NIST: CCedDITION EXISTED IN ALL M(X)ES UP TO 100% POWER SINCE 1994
- GROUP : SAFETT AND RELIEF VALVES GROUP SYSTEM : REACTOR COOLANT SYSTEM . .
DESC ,a TNE POWER OPERATED RELIEF VALVES WERE FOUND INOPERASLE DURING TESTING. THE MAIN D!$C GUIDES WERE INSTALLED INCORRECTLT DURING THE 1994 REFUELING OUTAGE.
l SSF 08/10/95 LER# 33595006 50.728: l Pn2 NIST: EVENT OCCURRED IN COLD SMUTDOWN group : RESIDUAL HEAT REMOVAL SYSTEMS GROUP SYSTEM : RESIDUAL HEAT REMOVAL SYSTEM DESC : BOTH TRAINS OF RESIDUAL NEAT REMOVAL WERE RENDERED INOPERABLE AS A RESULT OF A FAILED OPEN SUCTION i RELIEF VALVE. THE ROOT CAUSE WAS IhADEQUATE DES!GN MARGIN BETWEEN THE RELIEF AND BLOWOWN SETPCINTS l AND WORMAL SYSTEM OPERATING PRESSURE.
PI EVENTS FOR 95-4 NONE PI EVENTS FOR 96-1 SSF 02/19/96 LER8 33596001 5 0.72#: 29994 PWR HIST: EVENT OCCURRED DURING OPERATION AT 100% POWER GROUP CONTROL ROON EMERGENCY VENTILATION SYSTEM GROUP SYSTEM : CONTROL BUILDING / CONTROL CCMPLEX ENVIRONMENTAL CONTROL SYSTEM
! DESC : THE CONTROL ROOM VENTILATION SYSTEM WAS RENDERED INCAPABLE OF PERFORMING ITS DESIGN FUNCTION WHEN TWO CONTROL ROOM ACCESS NATCHES WERE LEFT OPEN FOLLOWING MAINTENANCE. THE CAUSE WAS INADEQUATE GUIDANCE AND WORK CONTROLS FOR MAINTAINING THE BOUNDARY.
PI EVENTS FOR 96-2 SSA 06/07/96 LER# 33596007 50.728: 30603 PWR HIST: REFUELING DESC : AN EDG STARTED AND LOADED WHEN A BUS LOAD SNED OCCURRED DURING A CONTAINMENT ISOLATION ACTUAf tDN SIGNAL TEST. AN INADEQUATE PROCEDURE CONTAINED No INSTRUCTIONS TO REINSTALL FUSES WHICH WERE REMOVED AS PART OF A PREVIOUS TEST.
SSA 06/08/96 LERW 33596008 50.728: 30604 PWR HIST: REFUELING DESC : A 4.16KV ELECTRICAL Bus LOST POWER DURING MAINTENANCE ON THE ESF SYSTEM POWER SUPPLIES. THE EDG DID NOT START BECAUSE IT WAS OUT OF SERVICE. THE POWER SUPPLY FAILED DURING INSTALLATION OF A CIRCUIT CARD.
SSA 06/08/96 LER8 33596008 50.72s: 30604 PWR HIST: REFUELING DESC : A SAFETY INJECTION ACTUATION SIGNAL WAS GENERATED DURING MAINTENANCE ON THE ESF SYSTEM POWER SUPPLIES. THE POWER SUPPLY FAILED DURING INSTALLATION OF A CIRCUIT CARD.
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ST. LUCIE 2 me,in, R o,e,etion ,,,,
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93 3 to 962 Quarteny Data Notshown using Op.Cvde E55EEE l l 4 I I l 4 l 1
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PREDECIBIONAL i
ST. LUCIE 2 t.eeaa c= sion*=a=e n j Peer Grog:Combuseon Engineenng w/o CPC j NW M 933 m 962 Tronos and Dewaeonsi 4 6 l Dewatens From
- Plant Peer Group l
Self-Trend Median !
Short Term Long Term Deaknee lenaroues weeue esser l
OPERATIONS (including startup) l Automatic Scrams While Critical - 0 0
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Safety System Failures M .0 45 l! 0.30 Cause Codes (All LERs) I
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' Cause Codes (All LERs) ,
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ST. LUCIE 2 1
PI EVENTS FOR 95-3 l
NONE l 1
I PI EVENTS FOR 95-4 i
. SSF 11/20/95 LER# 38995005 50.728: 29626 l
PWR HIST: Cos! TION EXISTED FOR AN INDETERMINATE PERICO OF TIME GRIXJP EMAGENCY AC/DC POWER SYSTEMS GROUP SYSTEM : EMAGENC7 DNSITE POWER SUPPLY SYSTEM a
DESC : DEMADID RELAY SOCKET CONNECTIONS CAUSED THE FAILURE OF ONE EDG, AND THE POTENTIAL FAILWE CF THE OTNER. VISRATION INDUCED FATIGUE CAUSED THE SOCKET CONNECTION DEGRADATION.
4 PI EVENT 3 FOR 96-1 NONE 1
PI EVENTS FOR 96-2 4 SSF 06/25/96 LERW 50.72#: 30676 PWR HIST: CONDITION EXISTED FOR AN INDETERMINATE PEk!CD OF TIME GROUP : EMERGENCY CORE COOLING SYSTEMS GROUP SYSTEM : LOW PRESSURE SAFETT INJECTION SYSTEM i DESC : THE PLANT PRACTICE OF DCENERGIZING THE SAFETY INJECTION TANC !$0LATION VALVES AFTER CLOSURE IN MODE i
FOUR DEFEATS THE AUTOMATIC OPEN FEATURE AT 515 PSIA AND ON A S! AS. THIS CONDITION WAS CAUGED BY 2
INADEcuATE PLANT PROCEDURES.
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ENFORCEMENT HISTORY EA 95-026 - Weaknesses in the control of maintenance and testing that resulted in inoperability of both of the U1 PORVs during periods that the PORVs were relied upon to provide low temperature overpressure protection (CP issued on 11/13/95: SL III: 550.000) l l
EA 96-003 - Overdilution -event occurred when a licensed operator left the !
controls without informing his relief that a dilution.was in progress (CP issued on 3/18/96: SL III: $50.000) l l
i A1TADOUT 6 I l
3 I
l ST LUCIE MAJOR ASSESSMENTS i DATI TYPE OF ASSESSENT [
I JJLY 1995 INPO ASSESSENT - CATEGORY 1 AUGUST 1995 DR. CHOU ANALYSIS BY REGION II TO IDENTIFY ROOT CAUSES OF THE RECENT DECLINE IN !
PERFORMANCE AND MULTIPLE EVENTS ,
1 The team concluded that the predominant root cause for the events observed at St Lucie '
was insufficient detail and scope in site programs and procedure's. This causal factor j
' was found to result in recent events which' demonstrated deficiencies in the following j areas:
e jobskills,workpractices,anddecisionmaking:
e interface among organizations as evidenced by a lack of interface formality:
e organizational authority for program implementation as evidenced by instances .
of unclear responsibility and accountability. !
AUGUST 1995 LICENSEE SELF-ASSESSENT: A SPECIAL TEAM PERFORED AN ASSESSENT OF OPERATIONAL PROBLEMS t AND IDENTIFIED ROOT CAUSES: MANAGEENT AND STAFF COMPLACENCY - P00R PERFORMANCE, l ACCEPTING LONGSTANDING EQUIPENT PROB! EMS. AND NOT KEEPING UP WITH IPOUSTRY IMPROVEENTS.
GENERIC ISSUES ST. LUCIE ISSUE STATUS NRC Bulletin 92 Failure of Thermo-Lag 330 The licensee has identified those areas with installed thermo-lag and implemented compensatory measures IAM NRC Bulletin 92-01 and Supplement 1. Compensatory measures will remain in effect until an acceptable solution is implemented.
e NRCB 92-01, response dated July 27, 1992 o NRCB 92-01 Supp 1, response dated September 29, 1992 GL 92 Thermo-Lag 330-1 The licensee has outstanding commitments to GL 92-08 in the following areas:
e Update response on status of ampacity, exemptions and schedule for modifications (8/30/96)
Unit 1 .
- Evaluate Thermo-Lag barriers to NEI App. guide or select alternate option (due 1/30/97) e Determine acceptability of Thermo-Lag wall configurations and radiant heat shields combustibility issues (due 1/31/97) e Complete evaluations and submit Thermo-Lag exemptions (due 4/30/97) e Complete design changes to support implementation of modification during spring 1998 outage (Spring 1998) e Submit suusiery report to NRC within 180 days of end of Spring 1998 outage (due 180 days after breaker closed Spring 1998)
Unit 2 e Evaluate Thermo-Lag barriers to NEI App. guide or select alternate option (due 5/31/96) e Submit Thermo-Lag exemptions (due 8/30/96) e complete design changes to support implementation of modification during spring 1997 outage (Spring 1997)
- Unit 2 - Submit summary report to NRC within 180 days of end of Spring 1997 outage (due 180 days after breaker closed Spring 1997)
NRC Bulletin 96 Control Rod Insertion N/A Action requested from Westinghouse-designed plants only.
Problems GL 89-10 Safety Related NOVs Testing & The licensee has completed the design bases verification of safety-related motor operated Surveillance valves (Nova) and is available to meet with tno NRC to discuss alternatives for closing the NRC ,
GL 89-10 program.
e GL response, dated February 2, 1994 (Unit 1) e GL response, dated Narch 14, 1996 (Unit 2)
Unit 1 Completed during the Fall 1994 refueling outage (SL1-13)
Unit 2 Completed during the Fall 1995 refueling outage (SL2-9)
PWR generic.iss
w- :-
ST. LUCIE ISSUE STATUS GL 95 Pressure Locking and Thermal The licas.eee has completed the assessment and evaluation of both Unit 1 and Unit 2 power Binding (PL/TB) of SR Power Operated Gate operated valves (POVs) susceptible to PL/TB.
Valves e CL response, dated February 13, 1996 The licensee has outstanding commitments to CL 92-07 in the following areas Unit 2 o Schedule submitted including justification for modification to shutdown cooling valves V-3480 V-3652 and V-3651 during Spring 1997 refueling outage (SL2-10)
Boraflex Boraflex installed on Unit 1 in 1988. Two successful blackness testing campaigns completed (5 year surveillance). vpper 15 inches of one panel discovered missing. Engineering Evaluation (JPN-PSL-SEFJ-95-023, Rev. 3) completed March 5, 1996. Licensee reviewed manuf-:turer's fabrication records and concluded that the missing boraflex in PSL1 spent fuel pool was an isolated incident and did not affect SPF criticality.
Boraflex not installed on Unit 2.
t
?
l
- - - .- - - - - - - - _ . - - - _ _ _ . < . - - . - - - _ _ _ .-_ - . - - , - - - - - - - - _ _ _ _ _ - - - _ - - __ -- - - _ - - . _______-----_----_a__--__e----w- a - . , - - - -
ST. LUCIE ISSUE STATUS Spent Fuel Full Offload Permitted From the UFSAR:
malt 1 Two thermal analyses were performed; the Normal Batch Discharge and the Full Core Discharge.
In the case of the Normal Batch Discharge, the analysis assumes 80 assemblies each have been discharged from the core in 18 month intervals. A refueling batch of 80 assemblies is added 150 hours0.00174 days <br />0.0417 hours <br />2.480159e-4 weeks <br />5.7075e-5 months <br /> after reactor shutdown. This analysis shows a maaimum pool bulk [
temperature of 133.3 degrees F with the fuel pool cooling system in service. j 3
For the Full Core Discharge, assuming that 73 of the assemblies have 90 days of ,
irradiation, 72 have 21 months of irradiation and the remaining 72 assemblies have 39 months of irradiation (217 assemblies total), the analysis shows a maximum pool bulk temperature of 150.8 degrees F with the fuel pool cooling system in service.
Unit 2 r
. Two thermal analyses have been performeds the Normal and the Accident Case Assumptions. [
The Normal Case assumens i
. a. 11 batches (each 1/3 core) discharged
- b. Most recent batch cooling for five days af ter shutdown [
- c. Adiabatic heat up of the pool L The analysis shows a maximum pool bulk temperature of 131 degrees F with the fuel pool [
cooling system in service. .
t The Accident Case assumess
- a. 11 batches plus one full core discharged
- b. One (1) core cools for 7 days
- c. Most recent 1/3 core batch cools for 90 days j This analysis shows a maximum pool bulk temperature of 148 Cagrees F with the fuel pool i cooling system in service.
The licensee has furnished a tabulated SFP Storage Data on both Units for FM on site inspection the week of March 25, 1996. ,
t Improved Standardized Technical Specifications No Licensee commitment t
i a
generic.iss PWR
ST. LUCIE ISSUE STATUS Steam Generator Issues NRC Bulletin 89 Westinghouse Alloy 600 The licensee has addressed the predicted service life of Thermally Treated (TT) Alloy 600 Steam Generator Mechanical Tube Plugs Mechanical Tube Plugs identified by Westinghouse.
Unit 1 e Tube plug repair plan formulated for April 1996 refueling outage. All plugs will be visually inspected and repaired or replaced, if leaking.
- Both SGs scheduled for replacement let quarter 1998.
Unit 2 e No installed Westinghouse mechanical plugs.
GL 95 Circumferential Cracking of Steam The licensee hem addressed the detection and sizing of circumferential indications to determine Generator Tubes applicability including the requested RAI dated September 26. 1995. No tube leaks have occurred on either unit due to circumferential cracks.
The licensee has outstanding commitments to GL 95-03 in the fc11owing areas amit 1
- 100% tube inepection of all active tuben using both full length bobbin coil and conventional motorized re sting pancake coil (NRPC) technique for selected bobbin indications, i.e. 100% Not Leg and 3% Cold Leg, during Spring 1996 outage.
Maintenance Rule Program defined and implemented. Resident Inspectors confirmed. A Maintenance Rule Team inspection completed on 9/20/96. Although the licensee's maintenance rule implementation program found to be satisfactory three apparent violations were identified in the areas of program design 1 sues, system scoping issues, and procedure implementation.
IPEEE Submitted PSL-IPEEE Rev. O, submitted December 1994 which met the objectives of GL 88-20 Supplement 4.
The licensee has one outstanding connaitment to GL 88-20, supplement 4,,in response to RAI dated January 9, 1996.
- Action 1 The Engineering evaluation has been completed to allow use of the station blackout crosstie between the 'anits to mitigate an IPEEE fire and plant operating procedure changes are scheduled to be completed by August 1996.
r t
PLANT IPE CORE DAMAGE FREQUENCY INFORMATION i
I ca.e oemeen no,sene7 rw messeni anos reseni .e ene seemse no,- e, rw moeteese asse Plant IPE Iriecor see a7we 7.e e toca .07R istoca l = noe. s.O .7we v.e sio e toca .07=
ist0ca l =.i nese j General Electric BWR 1 Sig Hock Poet 5.4E45 5.10E-07 3.00E-06 S.50E-08 4.32E45 - noghylde 1.10E-Op 1% 7% 12% D0% - 0% 0%
General Electric BWRs 2 and 3 lisoletion Condensers! .l 8ene Mde Point 1 5 SE-08 3.50E-08 5.40E-07 7.90E 47 7.00E 07 - 2 00E-08 neghylde 64 % 10% 14 % 13% .- 0% 0%
Oyster Creet (see Note sin 3.9E 46 2.30E-06 2.40E-07 8.20E-07 2.50E-07 - 1.03E-07 2.10E-07 59% 6% 21 % 8% - 3% 5% i i
Oresden 2/3 ISWR 36 1.9E-05 9.30E-07 5.30E-07 1.4eE-05 1.80E-06 - 4.34E-10 noghese 5% 3% 83% 9% - 0% 0% [
t Muistone 118WR 36 1.1E-05 7.00E-08 8 00E-07 1.SOE-OS E 84E-07 - 1.30E-07 2.50E-07 65% 7% 18% 0% - 1% 2%
i Pilgnm 1 (SWR 31 5.OE-05 neghylde 4.10E-06 5.05E-05 3.20E-06 - 1.00E-07 7.8 7E-07 0% 7% 86 % 0% - 0% 1%
[
f General Electric BWRs 3 and 4 i MenticeNo ieWR 31 2.9E 05 1.20E-05 2.80E-08 3.47E-08 1.20E-08 - 3.20E 10 S.80E-06 46 % 10 % 13% 5% - 0% 20 % !
f Qued Cities 1/218WR 31 1.2E 06 5.72E 07 7.81E-06 2.95E-07 2.00E-07 - noghytdo neghome 50 % 7% 26 % 18% - 0% 0%
I Orowns Ferry 2 4 OE-05 1.30E-05 1.30E-06 2.79E-05 4.00E-07 - 4.60E-08 4.70E-08 27% 3% 50% 1% - 0% 10% ;
I trunsmch 112 2.7E-05 1.90E-05 7.00E 07 S.72E-OS 1.00E-07 - 5.10E-08 1.90E-06 67% 3% 25 % 1% - 0% 7% ;
noghytdo neghylde 35 % 5% 50% 10% 0% 0% [
Cooper ' . 8.0E-05 2.90E 05 3.90E-06 3.97E-05 1 S.33E-08 - -
Duone Arnoed 7.5E-06 1.90E-OS 1.90E-06 3.90E-08 1.80E47 - neghgMe noghytdo 24 % 24% 50% 2% '- 0% 0%
Fermi 2 5.7E 08 1.30E-07 1.00E-06 3.50E-06 noghgWe - 2.00E-07 9.77E 08 2% 32 % S1% [0% - 4% 2%
t FMapetnck 1.9E-08 1.75E-08 1.20E-08 1.51E47 7.40E-09 - neghgue neghgees 91 % 1% 8% 0% - 0% 0% ,
Hetch 1 2.2E-05 3.30E-08 5.10E 07 2.07E-05 2.22E-07 - 1.71E-07 1.20E-07 15% 2% 90% 1% - 1% 1%
3 Hetch 2 2.4E-05 3.23E-OS 6.37E-07 1.90E-05 . 2.22E-07 - 1.77E 07 1 SOE-07 14 % 3% 00 % 1% ~ 1% 1% !
noghese 5.50E-07 76 % 1% 14% 7% 0% 1% i Hope Creek 4.8E-05 3.30E-05 7.45E-07 8.42E-08 3.03E-08 - -
timonck 1/2 4.3E-08 1.00E-07 9.30E-07 2.43E-08 1.20E-07 - negagWe 1.90E47 2% 22 % St% , 3% - 0% 4% ,
i Peach Bottom 2/3 S.9E-08 4.81E-07 1.44E-08 2.07E 5.92E-07 - negag We 1.47E-07 9% 25 % 52% 11% - 0% 3%
Vermont Yankee 4.4E-06 8.24E-07 7.99E-07 2.70E-OS 8.42E-00 - 2.33E-00 noghylde 14 % 18% S2% 1% - 1% 0%
FitE:IPE-COF.75t j
's L
t f
PLANT IPE CORE DAMAGE FREQUENCY INFORMATION -
co e o eee ,,e, - a e es.ee= ee co e oes e e , ,e, nee a 1 w n.e. sera !
Plant IPE IP=a coF se0 atws 1- toca sofa istoca se0 a7ws 7,en Loca istoca lw n.e.
- General Electric BWR S 7.30E-00 2.83E-00 negheMe 3.39E-08 81 % 0% 18% 0% - 7%
La5.Ne 1/2 4.7E-05 3.82E-05 1.87E-07 -
1.10E 06 2.31E-05 7.40E .07 2.50E 08 1.50F, 06 18% 4% 75 % 2% - 0% 5% f N.no fMe Pont 2 3.1E-05 5.50E-06 -
i neghedde 2.52E-06 63% 4% 15% 3% - 0% 14%
WNP 2 1.8E-05 1.10E 05 6.25E-07 2.83E 06 5.10E-07 -
General Electric BWR 6 neghgWe 1.60E-06 30% 1% 53% 4% - 0% 0%
Chntan 2.7E m 100E-05 1.40E 07 .1.40E-06 1.10E-06 -
l neghedde 1.96E-07 43% 0% 54 % 3% - 0% 1%
Orend Gulf 1 1.7E-05 7 46E.06 5 58E-08 9.35E-08 5.15E-07 -
neghgeble 1.50E-06 17 % 36 % 33% 3% - 0% 12%
Pe.ry 1 1.3E-05 2 25E-06 4.70E-06 4.30E-06 4.50E-07 -
l neghgMe 1.80E 08 87% 0% 13% 0% - 0% 0%
thver Bond 1.8E 05 1 35E-05 neghgMe 2.05E.06 noghgWe -
Babcock and Wilcox PWR 2-Loop ,
9.20E-08 6.90Em 9.34E-07 34 % 2% 32% 34 % 0% 0% 2%
ANO1 4.7E-05 158E-05 9 93E-07 ~ 1.40E-05 1.57E 06 8.70E-07 neghghe 1.25E-06 21 % 0% 6% 59% 4% 0% 8%
Cryst.t thver 3 1.5E-05 3.20E-06 neghgMe 3 45E 07 9.00E 06 8 80E 07 2.00E-06 " 1% 86 % 8% t% 1% 3%
Oeves Besse G.OE-05 " 3 '54E-07 5.71E-05 5.24Em 4.80E-07 4.50E 10 5.50E m 0% 23% 42% 1% 0% 24 %
Oconee 1.2.3 2.3E-05 2.5 7E-06 1.00E-07 5.33E-06 9.70EG 2.10E-07 11 % >
0.94E-07 1.00E-07 3.00E-06 3% 0% 52% 35 % 2% 0% 7% l TMt1 4.5E-06 1.57E-06 neghe me 2.30E-05 1.57E-05 t Combustion Engineering PWR 24oop .
3.36E-07 noghgWe 4% 3% 79 % 14% 0% 1% 0%
ANO 2 3.4E-05 1.23E-06 1.02E-06 2.67E 05 4.80E-08 9.53E-08 1.90E-06 1.55E-05 " 10 % 54 % 28 % 2% t% 8%
C.tvert Chtts 1/2 2.4E-04 " 2.40E-05 1.30E 04 8.65E-05 4.49E-06
" 8.93E-06 1.07E-06 7.67E-07 6.74E-07 1.87E-06 " 2% 66 % 0% 5% 5% 14%
Fort Camoun 1 1.4E-05 2.89E-07 5.00E-07 12% 2% 23% 53% 4% 8% 2% ;
St Luck 1 2.3E-05 2.65E-OS 4.13E-07 5.30E-06 1.22E-06 0.10E d. g 1.74E-06 2.72E-OS 5.00E-07 10% 7% 20 % 49 % 3% 50 % 2% ;
5:tucio 2 2.8E-05 2.84E-08 1.70E-08 5.31E 08 1.29E-05 8.90E-07 i 8.00E-08 2.00E-07 1% 4% 74% 18% 2% 0% 1% }
Muistone 2 3.4E-05 4.3E-07 1.9E-06 2.5E 05 0.01E 08 5.22E-07 l
3E-07 10% 0% 39% 31 % 5% 0% 0% i 5.1E-05 9.01Em 4.00Em 2.00E-05 1.57E-05 2.54E m 3E-07 Pohsedes I I
FILE:IPE CDF.TSL ;
. Men Men "to 1998(1 73rimi i I
__-__ _ _ _ _ - - _ _ _ . . _ _ _ _ _ = . _ _ - _ _ - _ _ _ ~ . . ,_.._.___---._,.m~,--. , - - _ _ _m-- . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______________._._.__J
I u
PL4NT IPE CORE DAMAGE FREQUENCY INFORMATION i Core Desungo pseepsency Per acendent cInse Percent of Core Dunege Pew Per assident (3mme Plant IN eimni cos so '
aiw8 v.e o toca sovii i8toca ini rimod soo arws evencionie toca sevii i8toca imi rised Pete Verde 11213 9.0EM 1.91E-05 3 08E-08 5.00E G 6.57E-06 1.8tE-06 t 80E-07 neghgMe 21 % 3% 64 % 7% 2% 0% 0% l t
Sen Onofre 213 3 0E-05 2.10E-06 2.70E-06 1.t ?E-05 1.17E-05 1.20E-06 6 00E-07 noghgMe 7% 9% 39 % 39 % 4% '2% 0% f b
1.7E-05 6 24E-06 1.30E-07 2.40E-06 6.82E M 8.26E-07 5.10E-07 neghg Me 37% 1% 14% 39 % 5% 3% 0%
Waterford 3 Moine Yankee (3 toopi 7.4E-05 1.11E-05 3.68E-07 3.10E-05 3.00E 05 8.77E-07 2.67E-07 deferred - 15 % 0% 42% 41% 1% 0% deferred l t
Westinghouse PWR 2-loop 1.00E-07 2.40E-05 2.30E-05 2.70E-05 7.70E-06 5.00E M 1% 0% 27% 26 % 31 % 9% 6% ;
Ginne 0.7E-05 1.00E-06 1.40E-06 2 42E-07 40 % 0% 16 % 36 % 8% 2% 0% I Kewounee 8.7E-05 2 64E-05 8.85E-08 1.04E-05 2.37E-05 5.29E 06 f 2.72E-07 4.33E-05 3.85E-05 6.25E m 7.20E-08 1.08E-05 13% 0% 38 % 33% 5% 0% 9% [
Point Beech 112 1.2E-04 t.51E M t
2.00E-05 1.20E-05 6.00E M 2.30E-07 1.00E-05 6% 1% 40% 24 % 13% 0% 20 % !
Presne sstend 1/2 5.1E-05 310E-06 3.20E-07 Westinghouse PWR 3-loop 8.85E m 1.80E-05 7.28E 06 7.28E-06 3.00E-06 30 % 20 % 32 % 8% 3% 3% 1%
Seever Veney 1 2.1E 04 4 SIE-OS. 4.30E-05 4.20E-05 7.10E-05 2.11E-06 7.30E-06 25% 4% 40 % 22% 4% 1% 4%
Beevee Vomey 2 1.9E-04 4 86E-05 8.00E 06 7.68E-05 8.18E-05 2.47E-05 2.60E-07 1.30E-07 1.17E-05 9% 0% 63% .19% 0% 0% 9% [
Ferley 1/2 1.3E-04 122E-05 7.30E-08 5.70E-06 1.30E-04 7.50E-05 5.70E-06 4 00E-06 6.80E-05 8% 2% 43% 23% 2% 1% 21 %
H.B. RotMnson 2 3.2E-04 2 60E-05 7.2E-05 8 00E-06 4.20E-07 3.00E-05 2.10EG 7.00E-06 1.60E M 3 60E-06 18% 1% 42% 29 % 10% 2% 5%
North Anne t/2 3.03E 05 2.13E-06 5 00E-07 4.98E 06 24 % 7% 16 % 43% 3% 1% 7%
Sheaeon herns 1 7.0EM 1.7tE 05 5.00E-06 1.15E-05 4.90EM 2.03E-06 1.10E-04 3.80E-05 1.00E-06 1.78E-07 1.51E-06 25% 1% 55% 19% 1% 0% 1%
! Sumenet 2.0E-04 Surry 1/2 (see Note (2H 1.3E 04 8.09E-06 3.20E-07 3.20EG 2.10E-05 1.00E-05 1.60E-06 5.10E-05 6% 0% - 26% 17% 0% 1% 41 %
Turkey Poent 314 tsee Note 3.7E-04 4.70E 06 4.40EG 3.10E-04 3.93E-05 5.00E-06 6.20E-06 neghome 1% 1% 83% 11 % 2% 2% 0%
l FILE: IPE-CDF.TOL
. . . . an .a ......
i 1
. i PLANT IPE CORE DAMAGE FREQUENCY INFORMATION l
[
rweeat et c== ommese ree,=ney per acessent ases t l c Oomoso p.egeener rw acessent osee arws 9 1% mOca == nes.
Plant IPE lne-icOr s.0 arws 1 toca s.1= mOca i.i ne 30 i.e sie t. toca
, i Westinghouse PWR 4-loop 2.00E-08 1.50E-09 3.90E 09 23% 1% 73% 4% 0% 0% 0%
Oreutwood 112 2.7E-05 6.20E-06 3.70E-07 2.00E-05 1.50E-06 2.20E-09 4 80E 09 14 % 1% 84% 4% 0% 0% 0% ;
Syron II2 3.1E-05 4.30E-06 4.20E-07 2.60E-05 1.30E-06 3.50E-06 1.70E-07 1.80E 05 31 % 1% 19% 19% 1% 0% 31%
Comewey 5.9E 05 1.90E-05 4.00E-07 1.10E-05 1.10E-05 8.50E 07 1.10E-05 9.50E-06 3.50E-06 1.60E-07 1.30E 05 26 % 3% 19% 17% 6% 0% 23 % 3 Cemenche Peak 1/2 5.7E-05 1.50E-05 5.00E-06 3IDE-06 6% 1% 79% 9% 2% 0% 4%
06et4e Canyon 172 S.8E-05 5.00E-06 7.00E 07 8 95E-05 7.94E-06 1.00E-06 8.40E-00 3 59E-06 9 78E-06 5% 1% 63% 32 % 4% 2% 5% ,
Hoddom Neck 1.9E-04 8.70E M 1.70E-06 1.00E-04 5.99E-05 8.00E-06 2.70E-08 deferred 14 % 6% 42% 32% 5% 0% deterred i Indien Point 2 3.1E-05 4.4 7E-06 1.01E-06 1.30EM 1.01E-05 1.00E.06 I i
2.50E-07 6 50E-06 11 % 20 % 29% 20 % 5% 1% 15%
I truhen Point 3 4.4E-05 4.80E-00 0.70E-06 1.20E-05 S.09E M 2.40E-06 2.20E-07 8.50E-07 9% 6% 45% 37% 2% 0% 2%
Miestone 3 5.eEM 5.10E-06 3.40E-06 2.50E-05 2.10E-06 1.20E-06 3.20E-07 5 80E-07 7.30E-06 40 % 3% 25 % 14% 1% 1% 14 %
Setem 1 tsee Note tell 5 2E-05 2.10E-06 1.40E-06 1.30E-06 7.40E-06 I 18 % 0% 1% 13% j 1.70E-05 1.30E-06 1.99E-05 B.00E-06 1.90E-07 5.60E-07 7.30E-06 31 % 2% 36 %
Setem 21see Note t4n 5.5E-05 1.34E-06 3.35E-08 5.83E-06 21 % 10% 48% .9% 2% 0% 9%
Seetwook 6.0E-05 1.40E-05 6.63E-06 3.20E-05 6.18E-06 Y
1.14E-06 5.00E-07 35 % 1% 49% 8% 5% 3% 1%
South Tomas 112 4.3E 05 1.50EM 3.00E-07 2.10EM 3.35E-06 2.00E-06 4.90E-Os negng@e 61% 0% 16 % 19% 4% 0% 0%
Vogtte 112 4 SE 05 2 97E-05 1.13E-07 7.7BE-06 9.31E 06 1.78E 06 i
6.11E-08 7.57E-06 45% 0% 25 % 9% 1% 0% 18 %
Wolf Ceeet 4.2E-05 1 99E-05 3.10E-08 1.06E-05 3.89E-06 6.20E-07 ti% 0% 13% 46 % 30 % 0% 0%
zi.n ira 4.0E46 4 40E 07 9.e0E-09 5.30E 07 1.80E 46 i.20E 46 4.50E-09 n.oeme n
! Westinghouse PWR 4-Loop ice Condensers' 0% 24 %
6.90E-08 1.40E 05 1% 2% SO% 13% 0%
Catawbe 112 5.8E-05 6 00E 07 1.00E-06 3.50E-06 7.90E-06 neghgme 2.00E47 2% 5% 26 % 68 % 11 % 0% 0%
6.3E-05 1 13E-06 2.SSE-06 1.82E-05 3.SOE-05 7.07E-06 5.3eE-00 0.C. Cook 1/2 4% 33% 38 % 0% 0% 0%
4.0E-06 9 32E-06 1.50E-06 1.32E-06 1.SOE46 0.00E 00 8.10E-00 negusten 23 %
i eseGuire If2 3% 4% 88 % 18% 4% 0% 4%
Seguoveh 112 1.7E-04 5.32E-06 7.10E-06 1.19E-04 3.10E-06 S.00E-00 9.90E-09 0.00E 06 5.00E-00 9.10E-06 22% 6% 27% 30% 6% 0% 11 %
I Watts See 11see Note 1561 8.0E-05 1.73E-C6 3.00E-06 2.10E-05 2;40E-05 4.00E-06 l FILE: IPE-CDF.TOL
PLANT IPE CORE DAMAGE FREQUENCY INFORMATION <
Co.e os o e e,.o , per a mo Cinee ro e .e Co,e oome.e %,or a.eus C=se lriantCDF 3
Plant IPE ar*s no arws Tre sis e toCa sarn no t- toCa sorR iStoCa i i nsed istoCa iiF*ed 10stee os. CDF welues:
- For Dans Besse. Calve <t Chtts. & Fort Calhouri, seperate 590 CDF was unewedoble, so Transeeni For Tu tey Pomt the CDF hsted in the emec summery of the suberuttet, wtuch CDF and % CDF includes 500 contreutecri coreesponds to "alllevers of recovery.* was used The detsbese values for Oyster Creek do noe oppear to enetude the CDF for entemel floods; the 'For Setem i & 2. the revised flood and plant CDFs hated let the submstteiletter for the IPi values ksted here include the CDF for internal flood were used The Surry meernal flood CDF es from page 9 of 4/21/92 NRR letter which bsts a revised value from 11126191 Surry connelysis sutWttet For Watts Ber. the CDFs from the .ewsed suberuttal woes used i Deferred means that hconsee included Intemet flood onetysis in thee IPEEE I
i 6
FILE: IPE-CDF.TBL
I i
PL ANT IPE CONTAWeMENT FAILURE FREQUENCY INFORP".Seit0N Cees Damage Feespsoncy Sy Containenent Feewe Mode Percent of Cove Donage Feestuency Per Canaphunent Festwe 80ede pg,,,
NCF Sypene EF LF NCF Plant tPE COF Sypese EF LF i
General Electdc - Leege Dry m 1% 4% 0% 94 %
SIG ROCK POINT 5. 4E-05 7.56E-07 2.32E-06 noghoel 5 09E-05l l i
, Generet Electric Mort I s 1.25E-05 1.3 3E-05 1% 45% 26 % 28%
OROWNS FERRY 2 4 SE-OS 4.46E 07 2.18E-05 f
1.63E 05 8 33E-06 1% 9% 60 % 31%
ORUNSWICK 1&2 2.7E-05 6 2 tE 08 2.38E-06 0% 16% 72% 11 %
8 OE-05 neghgMe 1.29E-05 5.77E 05 913E 06 COOPER 1.59E-05 2.04E-06 0% 3% 86% tt%
ORESDEN 2&3 1.k-05 neghede 5.55E-07 1.68E-06 0% 47% 32 % 21 %
7.8E-06 neghges 3.67E-06 2.49E-06 DUANE ARNOLD 4% 30 % 39% 28 % {
5.7E 06 2.00E-07 1.71E-06 2.22E-06 1.57E-06 FERMI 2 16% i 4.16E-07 3 03E-07 0% 63% 22%
1 9E-06 neghgde 1.20E-06 FITZPATRICK 1.10E 05 1% 25% 26 % 43% .
2.2E-05 1 85E-07 5.47E 06 5.70E-06 HATCHI i 1.25E-05 1% 21 % 25 % 53%
2.4E 05 ' 1.94E-07 5.00E-06 5.91E 06 HATCH 2 5 56E-06 0% 62% 26 % 12%
4 6E-05 neghe se 2,87E-05 1.20E-05 HOPE CREEK 3 87E-06 1% 34% 30 % 35 % f MILLSTONE I 1.1 E -05 1.25E-07 3.74E-06 3.27E 06 l 1% 16% 24% 80 %
2.8E-05 5.201-09 4.15E-06 6.24E 06 1.56E-05 MONTICELLO 7.12E-07 1% 24 % 62% 13% f 5.5E-06 7.48E-08 1.31E-06 3.40E 06 NINE MILE POINT 1 1.86E-06 7% 16% 26% 51%
3.7E-06 2.70E-07 5.87E-07 9.69E-07 OYSTER CREEK 2.57E-06 1% 28 % 25 % 48%
5.5E-06 6 64E-09 1.55E-06 1.40E-06 PEACH BOTTOM 2&3 1.25E-05 3 54E-05 9 86E-06 1% 22 % 6t% 17% f PILGRIM I 5.8E-05 2.32E-07 f 1% 24% 55% 21 %
1.2E-06 6.00E-10 2.84E-07 6.62E-07 2.53E-07 OUAD CITIES 1&2 i 9.89E 07 1.16E-06 1% 49% 23% 27% i VERMONT YANKEE 4.3E-06 4.30E-08 2.11E-06 I
I r-k t
t IPE-CFF.TOL September 30,1996 e f
s Pt ANT IPE CONTAINMENT FAILURE FRE0utNCY INFORMAil0N Core Dornage Fressmency Sy Centabiment Feture Mode Percent of Core Demage Fw Por Conenhunent Fatse Mode CDF Oypese EF LE NCF Bypees EF LF NCF Plant IPE l Generet Electrle - Mark It LA SALLE 1&2- 5305 4.7E-05 neghylde 1.66E-05 2.42E-05 8 64E-06 0% '35% 51% 14 % j 4.3E-06 neghtble 3 96E-07 1.16E 06 2.75E-06 0% 9% 27% 64 % ,
LIMERICK 1&2 2.79E-08 2.32E-06 2.04E-05 8.30E-06 1% 7% 66% 27% ,
NINE MILE POINT 2 3.1 E-05 5.34E-06 5.30E-06 6 83E 06 1% 31% 30 % 39 %
WNP 2 1.8E -05 2.98E-08 i
General Electric - Mark sti l 2.6E-05 neghetdo 8.27E 07 4.84E-07 2.4 7E-05 0% 3% 2% 95 %
CLINTON
- 8 05E 06 5 66E 06 3.b1E-06 0% 47% 33% 20%
GRAND GULF 1 1.7E 05 neghg ble 3.14E-06 4.76E 06 5.30E-06 C% 24 % 36 % 40%
PERRY I 1.3E-05 neghgetdo l neghgeble 4.3FE-06 2.14E-06 8 9BE-06 0% 28% 14 % 58%
RIVER BEND 1 6E-05 t
6 PWR - Ice Condenser i 2.31E-07 2.02E-05 2.2 7E-05 1% 1% 47% 53%
CATAWBA 1&2 4.3E-05 7.71E-08 9.26E-07 1.13E-06 5.40E 05 11% .1% 2% 86%
D.C. COOK 1&2 6.3E-05 7.11E-06 4.0E-05 9.60E-07 9 50E-07 1.64E 05 2.20E-05 2% 2% 40% 54 %
MCGUIRE 1&2 2 81E-06 8 32E-05 7.60E 05 5% 2% 49% 45% I SEOUOY AH 1&2 1. 7E-04 7.99E-06 1.72E-05 5 27E-05 7% 5% 22 % 66 %
WATTS GAR 1&2 8.0E-05 5 95E-06 4.03E 06 i
PWR Subetenospheric 6.17E-05 5% 23% 44 % 29 %
OEAVER VALLEY 1 2.1 E-04 1.02E-05 4.73E-05 9.15E-OS 4.74E-05 8 54E 05 4.69E-05 5% 25% 45% 25%
SEAVER VALLEY 2 1.9E-04 9 84E-06 1.0$E-06 7.68E-06 5.03E-05 13% 2% 11 % 74%
NORTH ANNA 1&2 6.8E-05 8 98E-06 i SuRRv i&2 2.24E-00 1.10E-05 4.47E-05 1% 1% 20 % 80 % !
MILLSTONE 3 5 8E-05 3.90E-07 i
l IPE-CFF.T8L i et.or.n+., in t egn
PL ANT IPE CONTAINMENT FAILURE FREOUENCY INFORMATION Core Demage Fregeency By Centoinenent Focure Mode Percent of Core Demage Fvapency Por Centeenment Fs8mre 80ede Bypese EF LF NCF Sypese EF LF NCF Plant LPE CDF PWR - Leege Dry 5.95E-06 3.96E-05 1% 6% 12% 81 %
ARKANSAS NUCLEAR ONE 1 4.9E-05 2.08E-07 3.03E-06 4 07E-07 4.51E-06 5.14E 06 2.69E-05 1% 12% 14 % 73%
ARKANSAS NUCLEAR ONE 2 3 7E 05 2.54E-06 2.48E-05 1% 1% 9% 90 %
BRAIDWOOD 1&2 2.7E-05 1.10E-08 5 48E-08 1.24E-08 2.13E-07 2.50E-06 2.82E-05 1% 1% 8% 91%
BYRON 1&2 3.1E 05 1.17E-07 3 09E-05 2 63E-05 2% 1% 53% 45%
CALLAWAY 5 BE-05 1.17E-06 40 % 48% t 2.4E-04 7.44E-06 2.11E-05 9.53E-05 1.16E-04 3% 9%
CALVERT CLtFFS 1&2 6.75E 07 2.93E-05 2.26E-05 8% 1% 51% 39%
COMANCHE PEAK 1&2 5.7E-05 4.6)E-06 !
5.53E-07 9.56E-06 4.42E 06 5% 4% 63% 29 %
CRYSTAL RIVER 3 1.5E-05 7.39E-07 4.16E-06 4 95E-06 5.52E-05 3% 6% 8% 84 %
DAVIS-8 ESSE 6.6E-05 t.72E-06 1.01E-05 3 9BE 05 3 65E-05 2% 11% 45% 41 % <
DIABLO CANYON 1&2 8.8E-05 1.63E-06 f 4.47E-07 7.19E-08 3.90E-06 1.20E-04 1% 1% 3% 96 %
FARLEY 1&2 1.2E-04 3 80E 06 8.13E-06 11% 2% 28% 60% j FORT CALHOUN 1 1.4E435 1.44E-06 2.23E-07 3.50E-05 42% 3% 15% 40 %
GINNA 8.7E 05 3.71E-05 2.67E M l.2 7E-05 3.20E-05 2.40E-04 2% 13% 10% 75%
H.B. ROBINSON 2 3.2E-04 6.37EM 4.19E-05 9.70E-05 7.01E-05 6% 1% 54% 39%
HADDAM NECK 1.8E-04 1.16E-05 1.21E-06 2.82E-06 2.65E-05 6% 1% 9% 85%
INOtAN POINT 2 3.1 E-05 1.94E-06 5.61E-08 1.07E-05 3.05E-05 6% 1% 24% 69%
INDIAN POINT 3 4.4E-05. 2.44E-06 3.12E-07 1.48E-08 3.22E-05 2.88E-05 8% 1% 49% 43%
KEWAUNEE 6.6E-05 5.28E-06 5.79E-06 3 54E-05 3.16E-05 2% .8% 48% 42%
MAINE YANKEE 7.4E-05 1.21E-06 1.11E-05 1.91E-05 2% 9% 32% 56%
MILLSTONE 2 3.4E-05 7.66E-07 3.22E-06 1.71E-05 5.61E-06 0% 1% 74 % 24 %
OCONEE 1.2.&3 2.3E-05 4.60E-10 2.61E-07 2.35E-05 8% -33% 16% 46%
PALISADES 5.1E-05 2.89E-06 1.67EG 7.66E-06 9.41E-08 1.21E-06 8.53E-05 4% 10 % 13% 73%
PALO VERDE 1,2.&3 9.0E-06 3.26E-06 7.97E-06 8% 1% 17% 7T%
POINT BEACH 1&2 1.0E-04 8.32E-06 3.24E-08 1.81E-06 4.15E-07 1.11E-05 1.56E-05 44% 1% 22% 31%
PRAIRIE ISLANO 1&2 4.9E-05 2.19E-05 tPE-CFF.T8L Seriemher in 1996 I
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M U O A O O O C D la A A A E H T T V W W I y F F N t E L 0 '
P S S S S S S S S S T T Z 9
Pre-Decisional Semiannual Plant Performance Assessment St. Lucie 1 and 2 Current SALP Assessment Period: 1/7/96 through 6/97 Last SALP Rating Previous SALP Rating 1/2/94 - 1/6/96 5/3/92 - 1/1/94 l Operations 2 1
, Maintenance 2 1 Engineering 1 1 Plant Support 1 1
- 1. Performance Overview -
Since July 1995, there have been a series of events that led to questioning the plant's overall performance. These have included:
A Unit I turbine trip due to procedural weaknesses, !
poor operator performance, and weak supervisory oversight. l The attempt to restage an RCP seal using inadequate and I inappropriate procedural guidance. The evolution was compounded by failing to follow aspects of the guidance that did exist, which ,
led to the failure of the second and third stage seals. '
A main steam isolation signal due to an operator failing to block the MSIS signal during a cooldown when an annunciator indicated that the block was enabled. This failure occurred despite the j fact that the operator's attention was directed to the annunciator on at least two different occasions.
! Both pressurizer power operated relief valves being found inoperable due to incorrect assembly during a refueling outage.
The conditions had existed for approximately 10 months (SL3,CP).
l An loss of RCS inventory (4000 gallons) due to a shutdown cooling relief valve which lifted and then failed to resent due to incorrect setpoint margins (a generic problem involving several valves) . The licensee had sufficient evidence that this generic
! condition existed, but had failed to act promptly to evaluate the conditions (SL4).
l The spraydown of containment due to an inadequate procedure and operator error co'upled with an existing operator-work-around.
The significant operator inattentiveness which resulted in the
. overdilution event on January 22, 1996, highlighted the recent large number of personnel errors and lack of command and control
. in the control room.
! These and several other recent deficiencies involving weak procedures, a
general lack of procedural compliance, equipment failures, and personnel i errors clearly indicated that the plant's past high level of performance ;
had declined. An NRC root cause effort determined that,_in addition to procedural adherence / adequacy weaknesses, the licensee suffered from )
weaknesses in both interfaces across organizational lines and corrective l actions.
II. Functional Area Assessment - Operations A. Assessment A SALP board convened on January 18, 1996. The board concluded l that the licensee's performance in the areas of Operations had declined from an excellent level of performance to good., The decline in Operations' performance particularly occurred in the final six months of the assessment period. The licensee undertook a number of efforts to reverse declining performance following the onset of the operational events described above. Verbatim procedural compliance was established as the norm for the site, which resulted in the need for literally hundreds of_ procedural l changes and around-the-clock on-site review committee meetings.
- An increased emphasis on the initiation of corrective action
- documentation resulted in an increase in the number of documents l initiated, but has also resulted in increases in backlogs.
l l B. Basis l l
- As basis, the board noted an increase in the number of operational l events attributable to
Weaknesses in operator performance Acceptance ref long-standing equipment deficiencies Management expectations were not effectively communicated to l personnel and enforced ., ;
Weaknesses in procedural adequacy and adherence Implementation and adequacy of corrective actions l
C. Future Inspections Increase staffing at St Lucie to N + 1 and focus greater inspection effort in the areas of: routine operator perfomance -
professionalism in CR; procedural compliance and enhancements; operator problem identification and corrective action; management communication of expectations; interdepartmental interface; i= resolving impact of operator work arounds; and operation contribution to adequacy of safety evaluations.
i h
I l
l l
l III. Functional Area Assessment - Maintenance A. Assessment Adverse trends were noted in maintenance and the board concluded
! that the licensee's performance in the area of Maintenance had i declined from an excellent . level of performance to good. The EDG j problems indicate a weakness in EDG Maintenance. The number of
, problems related to personnel errors and procedure problems may i ' indicate possibly attitude problems. Also, Safety Equipment ,
performance has failed to meet the industry average on all safety '
system. Maintenance performance has declined.
B. Basis ,
- 1. Adverse trends were noted on the Site Integration Matrix.
Recent Equipment Failures:
l 01/23/96 - Elect. arc during maint. caused loss of 25% of control room annunciators
[ 12/20/95 - Pitting of reactor flange o' ring groove i l 11/06/95 - Failure of EDG 2A relay sockets 1 l 10/05/95 - EDG 1B fuel oil leak at threaded connection ,
l 09/20/95 - EDG 1A/1B governor control problems resulted in load j oscillations l 1
Recent Personnel Errors:
I 01/01/96 - ICI wiring error during Rx head installation l 08/31/95 - Damaged cy. head on IB EDG due to loose lash adjustment 08/09/95 - Inoperable Unit 1 PORV due to maintenance error / testing inadequacy Recent Procedure Problems: ,
12/09/95 - 2A2 RCP seal destaged due to inadeq'u ate or weak procedure 09/15/95 - Failure to have clearance for work on cond. water box 08/25/95 - Failure to sign off procedure steps as work completed :
- 2. Safety Equipment Performance (Availability %) has been below industry a average.
Actual Industry Averages Unit 1 Unit 2 ,
AFW 99.5 97.8 99.6 - 99.1 HPSI 96.0 98.8 99.7 - 99.2 EDGs 95.6 99.8 99.1 - 98.6
- 2C AFW steam admission valve did not open and mechanical
! trip linkage problem
- HPIC 2B Breaker Failure l
r l
1 l
l 1
l L
- 3. Numerous equipment failures have Caused power reductions )
during the last 6 months.
- 10/95 Unit 1 Heater Level Control
- 10/95 Unit 1 IB Heater Drain Pump !
- 11/95 Unit 1 FW Reg. Viv. Control !
- 11/95 Unit 1 1A Main Transformer
- 01/96 Unit 1 FW Viv. LSV-24-A2 l
- 08/95 Unit 2 Heater Drain Valve !
- 08/95 Unit 2 Heater Drain Pump !
- 08/95 Unit 2 Circ. Water Valve :
- 08/95 Unit 2 Htr. Drn. Pop. PCM i j ' 01/96 Unit 2 Hydrogen Sys. Prob.
- 01/96 Unit 2 MFW Pump ,
C. Future Inspections: Assist the Resident inspector with the routine Resident Maintenance / Surveillance Inspections program.
Conduct Regional Initiative inspection, focus on outage activities BOP and EDG maintenance, procedure adequacy and safety system performance. Perform maintenance rule inspection in September 1996. Conduct the ISI inspection.
l IV. Functional Area Assessment - Engineering A. Assessment Engineering performance at St. Lucie remained superior during the SALP period ending January 6,1996, and has not changed since then. Continue with core inspections in the engineering area.
B. Basis l
The basis for the above assessment was the SALP report issued on l February 8,1996, and a continued low number of engineering l
issues. A recent inspection. identified weakness in engineering l safety evaluations.
C. Future Inspection L Conduct the following core inspections: engineering core
! inspection which focus on operability,10 CFR 50.59 evaluations, I
engineering support to maintenance and FSAR review; employee concern program due to increased number of allegations in the last year; and corrective action plan implementation.
V. Functional Area Assessment - Plant Support 3 A. Assessment Most of the assessment information in the past six months has been
- captured in.the most recent SALP report 95-99 dated February 8, i
1996. There were no specific inspections of the Radiation !
l Protection (RP) program during the past 6 months. However, !
4 Resident Inspectors observed RP activities throughout the ,
l I
I
- l. - _ . - _ - -
1
l assessment period and performance was satisfactory. The RP program continues to adequately maintain external and internal radiation exposures within regulatory limits. The plant programs for plant chemistry, radiochemical analysis, radiological effluent and environmental monitoring, and radioactive waste shipping i continued to be effective although some issues were identified. !
The EP program continued to provide an adequate level of readiness to respond to events. Overall, site security has been adequate.
Implementation of the fire protection program continued to be satisfactory. Potential problem exists with " Speak Out" employee concerns program (ECP).
B. Basis i Near the end of the assessment period the liceasse missed some RCS boron surveillances. The surveillance was missed in October and a NCV 95-18-06 was identified. However the I
licensee's corrective actions were not sufficient to prevent a recurrence in November and a VIO 0S-21-03 was issued.
Unit I was suspected of having some leaking fuel that was not evident prior to this assessment period.
No Exercise Weaknesses were identified in the Feb 1996 Full Participation Exercise. Site Management expressed concern that two practice drills were necessary before the NRC graded exercise to assure no NRC findings. l The licensee reported a training and qualification error in which security personnel were qualified using only half the required rounds, a failure to compensate within 10 minutes and problems with protected area barriers.
Fire protection inspections, conducted by resident
. inspectors, identified overall good performance but weaknesses in fire fighting techniques and respirator qualification program.
A large number of allegations have been received. No pattern to organization but some against " Speak Out" program C. Future Inspections Conduct the following core inspections in the areas of:
occupational exposure to observe RP practices; security - to review audits, corrective action, plans, management support, review PA equipment, vital access and alarms; and employee concerns program implementation due to large number of allegations dealing with adequacy of employee concern program.
VI. Attachments i A. Inspection Schedule
- B. Power Profile (last six months) j C. Site Integration Matrix
ST. LUCIE - INSPECTION PLAN I i
INSPECTION NUN 8ER OF PLAMED PROCEDURE / TITLE /PROGRM AREA INSPECTORS INSPECTION TYPE OF INSPECTION -
- TEMPORARY DATES COMENTS INSTRUCTION INITIAL OPERATOR EXAMINATION 1 3/11/96 PREPARATION INITIAL OPERATOR EXAMINATON 2 3/25/96 AONINISTRATION OF EXAM l
l 71001 LICENSED OPERATOR REQUALIFICATION 1 3/25/96 REQUALIFICATION PROGRAM PROGRAM EVALUATION INSPECTION I 61726 MAINTENANCE OBSERVATIONS ! 3/25/96 CORE INSPECTION 62703 SURVEILLANCE OBSERVATIONS 81700 PHYSICAL SECURITY PROGRAM FOR 1 4/1/96 CORE - SAFEGUAROS PONER REACTORS ;
4XXXX EMPLOYEE CONCERNS PROGRAM 2 4/29/96 REGIONAL INITIATIVE j 62700 MAINTENANCE IMPLEMENTATION 2 5/6/96 REGIONAL INITIATIVE - i MAINTENANCE - OUTAGE ACTIVITIES; PROCEDURES i
CORE 50.59 FOCUS ;
37550 ENGINEERING 1 5/13/96 73753 INSERVICE INSPECTION 1 5/13/96 CORD - MAINTENANCE 40500 EFFECTIVENESS OF LICENSEE 3 6/24/96 INSPECT STATUS OF !
i PERFORMANCE IMP!:0VEMENT !
CONTROLS IN IDENTIFYING PROGRAM; I RESOLVING, AND PREVENTING 92720 PROBLENS; CORRECTIVE ACTION DILUTION EVENT FOLLOW-UP
- REVIEW 61726 MAINTENANCE OBSERVATION 1 6/24/96 CORE MAINTENANCE AND ;
62703 SURVEILLANCE OBSERVATION SURVEILLANCE l 37500 ENGINEERING 1 7/22/96 FSAR CORRECTIVE ACTIONS ,
I i
s
I 2
INSPECTION NUMBER OF PLAMED PROCEDURE / TITLE / PROGRAM AREA INSPECTORS INSPECTION TYPE OF INSPECTION - '
TEMPORARY DATES COMENTS INSTRUCTION 81700 PHYSICAL SECURITY PROGRAN FOR 1 7/22/96 CORE - SAFEGUARDS POWER REACTORS 84750 RADI0 ACTIVE WASTE TREATMENT AND 1 8/5/96 CORE !
EFFLUENT AND ENVIRONMENTAL MONITORING; SOLID RADI0 ACTIVE 86750 WASTE MANAGEMENT AND TRANSPORTATION OF RADI0 ACTIVE '
MATERIAL 62700 MAINTENANCE IMPLEMENTATION 2 8/19/96 FOCUS ON BOP AND EDG MAINTENANCE 71715 LICENSED OPERATOR REQUALIFICATION 1 9/9/96 PLANT OPERATIONS - FOCUS PROGRAM EVALUATION ON COMAND, CONTROL, COMUNICATION AND NORMAL CR OBSERVATION 83750 OCCUPATIONAL RADIATION EXPOSURE 1 9/9/96 CORE INSPECTION 62706 MAINTENANCE RULE INSPECTION 5 9/16/96 EDG MAINTENANCE PROCEDURE ,
PROCEDURE ADEQUACY AND SAFETY SYSTEM PERFORMANCE 40500 EFFECTIVENESS OF LICENSEE 3 10/7/96 INSPECT STATUS OF CONTROLS IN IDENTIFYING, PERFORMANCE IMPROVEMENT RESOLVING, AND PREVENTING PROGRAM PROBLEMS y
71001 LICENSED OPERATOR REQUALIFICATION 2 11/18/96 REQUALIFICATION PROGRAM PROGRAM EVALUATION INSPECTION 1
ST. LUCIE UNIT 1 Operational Period Sep te rn b er 1995 through March 15, 1996 L OO - .
On November 19,1995, 80- a manual reactor trip was Z End of outage following initiated to perform MFRV
$ Hurricane E in maintenance.
@ 60 -
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y 40 - On February 24,1996, .
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S O N D J F M PERIOD OF OPERATIdN Graph does not include power reductions for routi n e repairs, waterbox cleaning, or required repairs.
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ST. LUCIE UNIT 2 O p e ra ti o n a l Period Se p te rn b e r 1995 th ro u gh March 27, 1996 100 =
On October 9,1995, the 80 - unit was shut down for a p::
N scheduled refueling outage.
p
@ 60-H 40- On January 5,1996, the .
t; unit was manually In.pped ce: ]
$ 20-due to high generator I
hydrogen gas temperature l
O iiiiiiiiii i rri t i v trri v i v i t i v i v i i v i v rrrr S O N D J F M PERIOD OF OPERATION Graph does not include power reductions for ro u ti n e repairs, waterbox cleaning, or required repairs.
ST .lTIE 2 Operational l'eriod August 1, Through Sepleinher 12, 1995 -
1 2 .
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m N t 5
2 60-
- 1. On February II, 1995, the unit tripped as a result of low steam p generator water level. The condition was the result of a feedwater regulating valve closure after a steam generator water level control Z level transaltter failed high. The transmitter was replaced and the i y an 21U- unit was returned to service on February 25.
V 2. On August 1. 1995, the unit was shutdown as a result of Hurricane '
N Erin. It was restarted on August 4, 1995 but.
cL 20 - i I
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A S 0 N D J F M A -M J J A S i PERIOD OF OPERATION Graph does not. include power reduelions for routine repairs,' wa t e rbox clearting,
.. .. ... . : .. , ,i .... .... : .. -
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SITE INTEGRATION MATRIX BY DATE St. Lucie I SFA sEc APPARENT CAUSE I COMMENTS DATE , TYPE SOURCE ; ID , PRIM , ITEM
~
3/15/96 LER IR 96-04 L PS Fish kill identified in intake (greater than 25 fish Excessive levels of sitt in water due (pending) and greater than 100 lbs). NRC notification to recent rough seas.
required per TS and EPP.
3/t 4/96 OTHER 1R 96-04 L PS Management change. A. Desoiza (human (pending) resources manager) ieplaced by Lynn Morgan (from TP) 3/13/96 WEAK IR 96-04 M O ' Unplanned start of 2C AFW Pump. Pump was Weakness in troubleshooting S
(pending) out-of-service for maintenance and control. Operations was unaware troubleshooting due to the failure of 1 of 2 steam of the efforts in progress.
admission valves to open on demand.
Troubleshooting resulted in valve openning and pump starting. .
3/1?/96 OTHER !R 96-04 O M Unit 2 standby charging pumps started / stopped Undeleimined.
S (pending) for no reason. Troubleshooting underway for standby pumps' start controllers.
3/10/96 OTHER IR 96-04 O Unit 1 downpowered to 97.5% due to hot leg Hot leg stratification.
L (pending) stratification and flow swirl which resulted in higher than actual indicated reactor power.
3/1/96 OTHER IR 96-04 L O Management Changes - T. Plunkett succeeds' G.
Goldberg, C. Wood replaces L Rogers as manager of SCE, C. Marple replaces C. Wood as Ops Supervisor, i
Page 1 of 11 18-Mar-96 FROM: 1/1/90 TO: 3/18/96
I SFA l TYPE SOURCE ID PRIM sEc ITEM APPARENT CAUSE / COMMENTS DATE ,
2/27/96 WEAK 1R 96-04 S M Inadvertent start of 1 A EDG occurred when I&C Poorwork planning. Personnel (pending) personnel installing a modification in an were not aware of the proximity of electrical cabinet bumped the EDG's actuation the subject relay and EDG was not relay. No load shedding was required, nor did it declared out-of-service and isolated cccur. electrically prior to the commencement of work.
2/24/96 WEAK IR 96-04 PS O Unit I containment radiation monitor found out- Failure to follow procedure on the l_
(pending) of-service due to isolation valve which was part of HP personnel, compounded closed for a containment entry and not returned by failure to identify condition by to the open position operators during rounds (the low flow condition of the detector was WEAK IR 96-04 Maintenance practices for Steam Bypass and Poor preventive maintenance and 2/24/96 n M work instructions (pending) Control System and Feedwater Regulating valves found weak in inspection following 2/22/96 Unit 1 trip Additional weakness found in the acceptance criteria specified for CEDM coil resistances.
2/22/96 EMERG IR 96-04 O Dropped CEA (due to SCR failure) leads to TS- Equipment Failure S
F5"N required shutdown and declaration of NOUE.
Failure of air supply to FRV leads to operators tripping reactor from 26%. Good operator performance throughout.
2/17/96 OTHER IR 96-01 N M PS Work on I A ECCS suction header through-wall Personnel Work Practices ,
leak revealed strong FME, but poor HP work practices observed regarding contamination control.
2/17/96 NEG IR96-01 M Freeze seal procedure lacked objective criteria ProceduralWeakness N
defining when a freeze seal existed.
Page 2 of 11 18-Mar-96 conna 1rsion Tn 3:18/96
SFA SOURCE ID PRIM sEc ITEM APPARENT CAUSE / COMMENTS DATE TYPE ,
2/17/96 POS IR 96-01 N M Noted improvements in housekeeping and material conditions.
2/17/96 WEAK IR 96-01 O E Numerous deficiencies identified in instrument Procedura! inadequacy N
air system walkdowns including drawings accuracy ONOP adequacy, and annunciator response procedure accuracy 2/17/96 NEG IR 96-01 M Weakness identified in l&C calibration Procedural inadequacy L
procedure -lack of detail provided for safety related calibrations 2/15/96 NEG IR 96-01 O M Tours of ECCS rooms revealed several active Material Conc.aon N
leaks. Licensee could not explain how (if) FSAR
, assumptions cn ECCS leakage were satisfied.
. i 1/26/96 OTHER IR 96-01 O Inspection of corrective action program revealed Corrective Actions :
N limely action on the part of management, but weaknesses in plans for tracking progress on personnel performance and procedure quality improvement.
1/26/96 VIO IR 96 O Violation identified regarding temporary changes Procedure Control N
VIO 96-01-01 to procedure which changed intent and wt.ich were approved for use without prior FRG review.
VIO IR 96 O E Boron dilution everd due to operator leaving Operator Error 1/22/96 L EA 96-040 control panel while dilution was in progress. ~ ;
Weak command and control, procedural ,
adherence, and short-term tumover. '
Additionally, OP for borationMilution not consistent with FSAR and no 50.59 performed.
Page 3 of 11 18- Mar-96 FROM: 1/1/90 TO: 3/18/96
' I I
SFA SOURCE ID PRIM sEC ITEM APPARENT CAUSE I COMMENTS DATE TYPE ,
1/7/96 N O SALP CYCLE 12 BEGINS 115/96 NEG IR 95-22 O Several procedural deficiencies and inadequate Procedure Review and N
calculational errors identified in reload physics Execution test procedule.
NCV IR 95 O PS Several delicient.ses m prodecure change Failure to Property implement I!509 N NCV 95 process implementation identified Expired or Procedures 01 cancelled TCs found in control rooms and hot shutdo,vn panel WEAK IR 95-22 O M U2 manual RX trip on high generator H2 temp Temp Ccntrol Valve Failure 1/5/96 L oue !9 failure of temp control valve. Operator awareness of RPS status post-trip poor.
Inspection of post-trip twiew(for current trip as i weII as past trips) indicated weaknesses in the rigor of post-trip reviews NEG IR 95-22 O E FRG meeting suffered / items deferred due to Lack of Attendance at FRG 12/27/95 S -
lack of OPS /Eng*g attendance at meeting.
Major issues at meeting affected OPS /Eng'g.
RX vessel flange inner O-ring groove pitting Pitting - Localized Corrosion 12/20/95 OTHER 1R 95-22 s M resulted in cooldown and head removal for ,
repair.
2A2 RCP sea! pkg lower seal destaged due to Filling RCS Before Coupling RCP 12/9/95 OTHER 1R 95-22 L M reverse pressure across seal.
Page 4 of 11 18-Mar-96 FROM: 1/1/90 TO: 3/18/96
' ' l SFA SOURCE ID PRIM sEc , ITEM , APPARENT CAUSE / COMMENTS DATE TYPE 12/5/95 WEAK IR 95-22 O M ESFAS cabinet doors found unlocked following Poor Logkeeping/ Attn to Detail N
maintenance work - l&C errut. Log entries associated with work were not complete.
12/1/95 NEG IR 95-21 O Operators unable to effectively obtain l&C Inadequate Oparatar Training N
setpoints from computer after hard copies were removed from control room.
IR 95-21 Rad survey results unavailable for B hot leg Failure to Document RAD Survey 12/1/95 NEG N PS work. Surveys performed but not documented.
NEG IR 95-21 O Unit 2 procedures and valve deviation log used Valve Position Administrative 12/1/95 N to cycle Unit 1 cross connect valves. Controls SDC procedure contained conflicting values for Procedural Weakness / Inadequate 12/1/95 WEAK IR 95-21 N O RX cavity level requirements. Procedure had Review been approved since emphasis on accuracy stressed.
WEAK IR 95-21 O CCW sample valve showed dualindication FTF Procedure 12/1/95 N without corrective action documentation initiated.
IR 95-21 O Clearance in place to isolate N2 from CST to Poor Corrective Actions 12/1/95 WEAK N facilitate pressure switch replacement for nine days without work order being written.
Page 5 of 11 18-Mar-96 FROM: 1/1/90 TO: 3/18/96
_ _ _ - _ _ _ ___m______._______-_.-_.__mm_____-___. , - _ _ _ . . _ _ _ _ .-_.__..-_-.__..________-__-_.__._._______.--________.___.._________--_.__..-_____.__.___.____-.__-m._-_-_.____m.-_m-m..________-___.__.--.___.______-__._._._____--__.,,_.__.___m-t .=u____.. .-_
SFA SOURCE ID PRIM sEc ITEM APPARENT CAUSE I COMMENTS DATE TYPE ,
12/1/95 NEG IR 95-21 N O Recurrent non-valid alarms when starting fire FTF Procedure pumps were not documented as operator workarounds. Voltage dips associated with such stants were contributors to a trip previously.
12/1/95 WEAK IR 95-21 N O Followup to previous inspection findings Corrective Actions indicated a weakness in followthrough in addressing deficiencies 12/1/95 NEG IR 95-21 O SDC Procedure required natural circ-related Procedural Inadequacy N
surveillance prior to establishing RCS pressure boundary Natural circ not possible without pressurization, 11/27/95 VIO IR 95 O Missed RCS Boron sample surveillance - Personnel Error L
VIO 95-21-03 Repeat from IR 95-18.
11/21/95 NCV IR 95 O Failure to maintain Penetration Log. FTF Procedure L
NCV 95 04 Light socket failure during lamp replacement Equipment Failure 11/21/95 OTHER IR 95-21 s O results in loss cooling to 1 A Main Transformer.
Unit downpower to -60%.
VIO IR 95 O Valve discovered Closed vice Locked Closed as FTF Procedure 11/20/95 N -
VIO 95-21-01 specified on Equipment Clearance Order. !
Page 6 of 11 18-Mar-96 FROM: 1/1/90 TO: 3/18!96
> SFA DATE TYPE SOURCE ID PRIM sEC ITEM APPARENT CAUSE I COMMENTS 11/16/95 OTHER IR 95-21 s O M Unit 1 manually tripped when 1B MFRV locked Long-Standing Equipment Problem in 50% position. Rool cause - degraded power supply, compounded by voltage dip on starting both station fire pumps.
11/11/95 VIO IR 95 N O Tech. Spec. equipment not specified for IV on FTF Procedure VIO 95-21-02 Equipment clearance Order.
t 11/6/95 OTHER 1R 95-21 s M Failure of EDG 2A relay sockets Potential Equipment Failure common mode failure.
11/ t/95 NCV IR 95 S M ICI wiring erroriluring RX head installation last Personnel Error NCV 95 RFO.
05 10/19/95 NCV IR 95 3 O Missed shift CEA position indication surveillance. Personnel Error NCV 95 06 10/18/95 NCV IR 95 L O Missed RCS Boron sample surveillance. Personnel Error NCV 95 07 10/17/95 WEAK IR 95-18 O Lack of attention to task resulted in overfilling' Personnel Error S
RCB lower cavity during flood up.
FROM: 111/90 TO: 3/18/96 Page 7 of 11 18-Mar-96
I SFA DATE TYPE SOURCE ID PRIM sEc ITEM APPARENT CAUSE I COMMENTS 10/12/95 VIO IR 95 S E Inserting CIAS signal during safeguards test Design Error VIO 95-18-04 shifted EDG 2A to isochronous mode while EDG i paratteled with offsite power.
10/9/95 LER LER 95-502 L PS Potential route for unauthonzed access to Personnel Error protected area. CW water piping.
10/7/95 VIO IR 95 N O Did not enter bypass key position in deviation Failure to Follow Procedures VIO 95-18-01 log 10/5/95 OTHER 1R 95-18 S M DG 18 developed FO leak at threaded Equipment Failure connection during surveillance run.
9/30/95 VIO IR 95 O Did not enter bypass key position in deviation Failure 10 Follow Procedures N
VIO 95-18-02 log.
9/28/95 OTHER 1R 95-18 S E Leaking PZR SVs extended forced outage - Equipment. Failure problems with lailpipe alignment.
9/20/95 OTHER 1R 95-18 M EDG 1 A/1B govemor control problems resulted Equipment Failure S
in load oscillations.
9/15/95 VIO IR 95 S O M Main / Ops did not provide clearance for work on Failure to Follow Procedures
- VIO 95-18-03 condenser waterbox cover. When cover pulled closed, severed worker's finger.
Page 8 of 11 18-Mar-96 i FROM: 1/1/90 TO: 3/18/96
I SFA DATE TYPE SOURCE ID PRIM sEc ITEM . APPARENT CAUSEICOMMENTS 9/14/95 WEAK LER U1/U2 L PS Security failed to take correct compensatory Failure to Follow Procedure 95-S01 action on computer tailure 9/10/95 WEAK IR 95-18 S O SG blowdown sent to incorrect system on RAB Failure to Use Correct Procedrue tool. Operator used wrong procedure. When identified did not back out ut procedure correctly.
IR 95-15 teak on SV 1201 !!ange extended outage, Weakness in Work Screening and 9/9/95 WEAK S M identified one month earlier but not worked Planning IR 95-15 Unit 2 Main Generator overpressurized while Personnel Error / Inoperable
'J/7/95 WEAK L O filling with H2. Inattention by operators. Equipment /OWA 9/2/95 VIO IR 95 O Weaknesses identified in logs relating to Personnel Error N
VIO 95-15-03 abnormal equipment conditions and out of service equipment not logged (mulitple examples).
8/31/95 OTHER 1R 95-15 M Damaged cylinder and head on 1B EDG due to Personnel Error S
loose fash adjustment.
WEAK lR 95-15 PS Containment closure walkdowns by Management and QC Weaknesses 8/30/95 N management were inadequate and depended heavity on QC involvement to identify .
deficiencies.
Page 9 of 11 18-Mar-96 FROM: 1/1/90 TO: 3/18/96
I SFA DATE TYPE SOURCE ID PRIM sEc ITEM APPARENT CAUSE I COMMENTS 8/30/95 WEAK IR 95-15 N M Maintenance personnel not using procedures for Supervisory Oversight and Worker work in progress. Altitude 8/29/95 VIO IR 95-15 ' N M Maintenance joumeyman not signing off Procedure Use VIO 95-15-06 procedure steps as work completed (previously identified as a weakness in May 1995).
S/29/95 VIO IR 95 O Started 18 LPSI pump with suction valve Personnel Error t
VIO 95-15-04 closed. (No damage 1o pump) 8/23/95 WEAK IR 95-15 M 2A HDP trip due to relay failure. Eight HDP trips Equipment Failutelinadequate S
in past year. Engineering solution available but Corrective Action not implemented.
8/22/95 VIO IR 95-15 y PS QA failed to document a deficiency on Personnel Error containtnent spray valve surveillance identified in an audit.
8/19/95 WEAK IR 95-15 O Overfill of PWT. Spilled approx.10K gallons on Operator Error / Operator 3
ground inside RCA. Operator work around on Workaround level control system and inattention to filling process by operator caused error.
8/18/95 WEAK IR 95-15 M Procedural weakness involving supervisory Procedural Weakness N
oversight and joumeyman qualif'cation. .
Page 10 of 11 18-Mar-96 FROM: 1/1/90 TO: 3/18/96
SFA ID PRIM sEc ITEM APPARENT CAUSE / COMMENTS DATE TYPE SOURCE B/17/95 VIO LER UI 95- O Spraydown of Unit 1 containment. STAR ProceduralInadequacy and 3
007 - VIO 95- process did not assign accountability for Weskness/ Operator-Work-Around 15 corrective action. Valve surveillance prelube not documented on STAR.
VIO IR 95 Inoperable Unit 1 PORVs due lo maintenance Maintenance / Testing Errors 8/9/95 L M LER U195- error / testing inadequacies. (Valves assembled 005 - EA 95- incorrectly) (Used acoustic data only) 180 VIO LER U195- E Lifting of Unit 1 SDC thermal relief due to Corrective Action / Procedural Bi6/95 S 006 - VIO 95- procedural revision from previous corrective Weakness 20-01 action Inopetable equipment not logged.
LER U195- O 1 A2 RCP seal failure due 10 " restaging" at high Procedural Weakness / Failure to 8/2/95 VIO L 004 - VIO 95- temperature. Follow Procedures 15-02 LER U195- O Operater failed to block MSIS actuation during Operator E'ror.
r 8/2/95 VIO 3 04 - VIO 95- cooldown.
15-01 SALP Functional Areas: ID Code:
E ENGINEERING L LICENSEE M MAINTENANCE N NRC 0 OPERATIONS S. SELF-REVEALED PS PLANT SUPPORT sA SAFETY ASSESSMENT & QV Page 11 of 11 18-Mar-96 conu- S riton To: 3/18/96
PREDECISIONAL j I
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SSA 02/16/95 LERf 33595001 50.72#: 28400 PWR HIST POWER OPERATIONS AT 1001 DESC : WN!LE RESTORING A SAFETT SUS TO A NORMAL LINEUP FOLLOWING RELAT REPLACEMENT. THE SUS WAS DEENERGIZED. THE EMERGENCY O!ESEL STARTED AND LOADED ONTO THE SUS. .)
i PI EVENTS FOR 95-2 1 NONE i
l PI EVENTS FOR 95-3 l
SCRAM 07/0s/95 LER8 33595003 50.728 29039 PWR H!sT: POWER OPERATIONS AT 1001 DESC : THE REACTOR TRIPPED ON HIGN PRESSURIZER PRESSURE VMEN THE MAIN TURS!NE GOVERNOR AS INTERCEPf VALVES WENT CLOSED DURING TESTING. THIS EVENT WAS CAUSED ST AN OPERATOR OMITTING A TEST PROGDURE STEP.
SSF 08/09/95 LER# 33595005 50.72#: 29178 PWR HIST: C3e! TION EXISTED IP ALL MODES UP TO 1001 POWER $!NCE 1994 GROUP : SAFETT AND RELIEF VALVES GRCRJP STSTEM : REACTOR COOLANT STSTEM l DESC : THE POWER OPERATED RELIEF VALVES WERE FOUND INOPERABLE DURING TESTING. THE MAIN DISC liUIDES WERE INSTALLED INCORRECTLY DURING THE 1994 REFUELING OUTAGE. )
l SSF 08/10/95 LERS 33595006 50.72#:
PWR HIST: EVENT OCCURRED IN COLD SHUTDOWN GROUP : RESIDUAL HEAT REMOVAL SYSTEMS GROUP STSTEM : RESIDUAL HEAT REMOVAL STITEM l DESC : SOTN TRAINS OF RESIDUAL HEAT REMOVAL WERE RENDERED IMOPERASLE AS A RESULT OF A FAILED OPEN SUCTIO l RELIEF VALVE. THE ROOT CAUSE WAS INADEQUATE DESIGN MARGIN SETWEEN THE RELIEF AND SLOm0bal SETPO A85 NORMAL STSTEM OPERATING PRESSURE.
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l PREDECISIENAL I
ST. LUCIE 2 ;
PI EVENTS FOR 95-1 PW HIST: POWER OPERATIONS AT 100% !
SCRAM 02/21/95 LERs 38995002 50.728: 28416 DESC : A REACTOR TRIP RESULTED FROM A LOW STEAM GENERATOR LEVEL AFTER A STCAM GENERATOR LEVEL INS j FAILED HIGM, CAUSING THE FEG REGULATING VALVE TO CLOSE.
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SSF 11/20/95 LERs 38995005 50.728: 29626 M m MIST: COWITION EXISTG FOR AN INDETERMINATE PERIts OF TIME GRt1JP : DERGENCY AC/DC POER STITDt3 GRCRJP J STITEM : EMAGENCT ONSITE POWER StPPLT SYSTEM )
DESC
- DEGRADD RELAT SOCET CONNECTIONS CAUSS THE FAILURE OF ONE EDG, AND THE POTENTIAL FAILLRE OF THE' OTHER. V!BRATION INDUCED FATIGUE CAUSED T8E SOCKET CONNECTION DEGRADATION. 3 i
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ST, LUCIE ENFORCEMENT IHSTORY Subject Severity Status EA NO. Inspection Date Level PORVs inoperable due to personnel error III Open 95-180 08/28/95 95-209 09/08/95 DOL case Phipps alleges discrimination. Open I PENDING 96-040 01/30/96 Overdilution event due to innattentive III board reactor operator and crew 6
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ST LUCIE MAJOR ASSESSMENTS DATE TYPE OF ASSESSMENT i
JULY 1995 INPO ASSESSMENT - CATEGORY l i
AUGUST 1995 DR. CHOU ANALYSIS BY REGION 11 TO IDENTIFY ROOT CAUSES OF THE RECENT DECLINE IN PERFORMANCE AND MULTIPLE EVENTS The team concluded that the predominant root cause for the events observed at St Lucie was insufficient detail and scope in site procrans and procedures. This causal factor i was found to result in recent events which demonstrated deficiencies in the following t
areas:
- job skills, work practices, and decision making;
- interface among organizations as evidenced by a lack of interface formality;.
- organizational authority for program implementation as evidenced by instances ;
of unclear responsibility and accountability.
t AUGUST 1995 LICENSEE SELF-ASSESSMENT: A SPECIAL TEAM PERFORMED AN ASSESSMENT OF OPERATIONAL PROBLEMS AND IDENTIFIED ROOT CAUSES: MANAGEMtNT AND STAFF COMPLACENCY - POOR PERFORMANCE, ACCEPTING LONGSTANDING EQUIPMENT PROBLEMS, AND NOT KEEPING UP WITH INDUSTRY IMPROVEMENTS.
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