IR 05000335/1996003
| ML20137R340 | |
| Person / Time | |
|---|---|
| Site: | Saint Lucie  |
| Issue date: | 03/08/1996 |
| From: | Ebneter S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20137R112 | List: |
| References | |
| FOIA-96-485 NUDOCS 9704140096 | |
| Download: ML20137R340 (400) | |
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InThe Matter Of: 1 !
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' INRE: STLUCIE PLANTNRC
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PROCEEDINGS BEFORE MR. STEWART D. EBNETER ' March 8,1996 , l BROWN REPORTING, INC.
ATLANTA, AUGUSTA, CARROLLTON ROME \ 1100 SPRING STREET SUITE 750 ATLANTA, GA USA 30309
, (404) 8768979 or (800) 637-0293 i
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..- PROCEEDINGS BEFORE MR. STEWART D EBNETER IN RE: ST. LIJCIE PLANT NRC March 8,1996
e . Page 1 Page 2 (1) . UNfTED STATES NUCLEAR REGULATORY COMMISSION p) On behes et the Nudeer RepAntory Commsekn REGION li pl S. Ebneter, Cheerman pl T. Peebine
pl J. Johnson p] IN RE: ) M. Miser ST. L.UCIE PLANT NFC ) fel C. Canto (5) INSPECTION REPORT NOS ) 50-33rA6-03 ered ) B. Uryc tel 50 30696-03 ) (s) J.Jeudon (7) L Watson Isl is] J. Bel pl C. Evans po) PROCEEDINGS BEFORE J, Norris
[a p t} MR. STEWART D. EBNETER CHAIRMAN (s} Onbehof of the St.Lacto Ptert: [12) March 8.1996 p] E. Weinkam 11 31 1190 asn.
D.J Derwar 3 41 po; W.H.BoNke 101 Martena Street T. Plunken (1 61 Alterna. George in1) J. Scarole ps) P. Honeysett pa pri F. Cone ps) H. Hotzmacher
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* Page 3 il a l pi MR. EBNETER: Let's get started. I want 121 to welcome Florida Power & Light here this morning.
pi l'm Stu Ebneter, Regional Administrator for the el Nuclear Regulatory Commission Region 11 office, ts) Region 11 has cognizance and jurisdiction over tai nuclear power plants in the southeast,and Florida in Power & Light Company of course is licensed by us.
- , '. ta) This morning we will conduct a L ! p) pre-decisional enforcement conference between the ipol Nuclear Regulatory Commission and Florida Pewer &
I pil Light.This will be a closed enforcement ip21 conference,and Mr.Uryc will discuss that with you It tsi in just a minute.
jp4) The focus of the meeting this morning is l psi on an event related to operational control of St.
! psi Lucie I related to the reactor coolant system boron n,
{pa dilution event that occurred onJanuary 23rd,1996.
- psi The agenda for the conference is shown on 1 3pel the viewgraph here.Following my brief opening poi remarks, rll turn it over to Bruno Uryc,who is the
!pil director of our enforcement investigation staff here ip21 at Region II. Basically,Bruno will discuss agency ! psi policy with you.Then I'll turn it en f to Al Ip41 Gibson,who is to my immediate right. Al is the lps) director of the division of reactor safety here in BROWN REPORTING, INC. (404) 876-8979 Min-U-Scripts (3) Page 1 - Page i
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PROF'FFDINGS BEFORE MR. STEWART D. EBNETER .
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March 8,1996 IN RE: ST. LUCIE PLANT NRC , Page 4 Page 6 p1 Region H,and he will essentially conduct the pj just a brief summary of some of the incidents that ' m conference and discuss the apparent violations with pl are related to control and operations.1 am quite p1 you.Then we will turn the rnecting over to you, p) concerned and the agency's concerned about these p; grve you an opportunity to respond. pi incidents and the inattention of the operators to
, (si I assume you have the basic inspection tsj what's going on in that power plant.There's n report and you understand the issue 9.
m nothing more important to the agency, and I'm sure m MR. PLUNKETT: Yes.
m your company, nothing more important than to have m MR. EBNETER: And we would expect you. is; discipline and control of that reactor and those m th;n,to respond to those, m safety systems at St.Lucie.
pq The pre-decisional enforcernent pq My own personal opinion is you guys did pit conferences are our means of getting additional p,j not pay the degree of attention that you should have na information from you so that you can provide any pri paid to your duties in controlling.That's all I pai data that we may not have access to or recently psi want to say at this point.
pq discovered information that you may have or anything pq Bruno, do you want to discuss the - psi that would shed some light on the issues and would psi MR. URYC: Perhaps we should make pe; help us make an informed decision. ps; introductions.
pn The three apparent violations will be on MR. GlBSON: I think probably there are a pq discussed by Mr.Gibson.One of them is related to .pej lot of folks in the room that may not know one pq the operating procedures for the operation of St. pq another.
pq Lucie 1,and another one is related to Appendix B, ,pq MR. PEEBLES:I'mTom Peebles, branch p,1 criterion three, design and control,and that talks lp,j chief. operations.
n insically about the procedure for adding 'pri MR. JOHNSON:JohnJohnson, deputy pst demineralized water and boric acid to the system and psi director, reactor projects.
pq how it relates to the UTSAR.The third one relates MR.GIBSON: Al Gibson, director of tiie as psi to 50.59 review, and Al will cover those in some pst division of reactor safety.
Page5 Page 7 p) detail. pj MR. MILLER: Mark Miller, senior gi li! hke to cornment just quickly on the m resident.
pi operators.The operators did allow an unmonitored p; MR. URYC: Bruno Uryc. director of the pi rezctivity addition which caused Unit I to exceed p1 enforcement staff.
rsi 100 percent power. Probably just as important as [si MR. COSTA: Chuck Costa, engineering (6) that is our understanding that this was not promptly m brunch chief.
m reported to management. And part of that addition, 'm MR. HOLZMACHER: Hank Holzmacher. control m at least part of the evolution, was conducted in a
. pl operator.
m manner that was different from what was specified in !m MR. CONE: Frank Cone, control operator.
sq the UFSAR.These are related to the violations that pq MR. HONEYSETT: Pete Honeysett.
pq Al will discuss.
pil supervisor.St.Lucie 1.
na Based on that,we think,then, that the pri MR, SCAROLA: Jim Scarola plant general ps! operators apparently did not conduct themselves in
. psi manager, pq lull accord with either the expectations of the pq
^ MR. PLUNKETT: Tom Plunkrtt, president of
, psi licensee or the NRC.We license operators,and we ;ps the nucleardivision.
pq expect them to fully conform with the regulations lpm MR. BOHLKE: Bill Bohlke, St. Lucie site on and the conditions of the plant, including the UFSAR inn vice president.
pq procedures. Mr.Gibson will comment on current psi MR. DENVER: Dan Denver, engineering pa agency policy with regard to enforcement action ps) manager.
am related to licensed operators. pq MR. WEINKAM: Ed Weinkam. licensing 99' Just as an aside, there have been far too
{pij manager,St.Lucie.
n many - and this is my comment here directed to the :g2) MS. EVANS: Carolyn Evans, regional psi operators - far too many incidents throughout the in counsel.
- pq industry with regard to control and operations. pq MR.GiBSON: On the telephone we have psi Have you seen Zach Pate's paper,any of you? That's psi representatives from our headquarters office, Jim Page 4'- Page 7 (4) Min-U-Scripte BROWN REPORTING, INC. (404) 876-8979
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a PROCEEDINGS BEFORE MR. STEWART D. EBNETER IN RE: ST. LUCIE PEANT NBC March 8,1996 - C Pagea Page10 p1 Bell imm the office of enforcement and Jan Norris ni I should also note at this time that - m from NRR- m statements of views or expressions of opinion made . pl MR.URYC: Mr.Ebneter,we made some hard pl by the NRC staff at this conference or the lack p1 copy of the agenda.I'd like to take just a few . pj thereof are not intended to represent final agency pl minutes to go over the enforcement policy and 14 deterrmnations or beliefs regardmg this matter.-
. pi procedure that we're in right now. pi Following this pre-decisional enforcement m After an apparent violation is m conference,Mr.Ebneter,in conjunction with the NRC pi identined it's assessed in accordance with t'ne - pl office of enforcement, the regional staff,and other p1 commsesion's enforcen:ent policy which was recentlY pi headquarters offices will reach an enforcemet.t ne revised and became effectiveJune 30th,1995 The _
pq decision,and this process normally takes about four p q enforcernent policy is now published as NUREG 1600. On weeks to accomplish,and that's when you'll hear l pa The assessment of an apparent violation pa from us as to what we decide. j na involves categorizing the apparent violation into . psi As Mr.Ebneter said,this is a closed ] pq one of four severity levels based on safety and pq conference,and they normally are closed,but the pq regulatory significance. For cases where there is a -psi commission has implemented a trial program that .j
. pel potential for escalate d enf orcement acti on,thatis, og began inJuly of 1992 to allow certain enforcernent
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pn where the severity level of the apparent violation on conferences to be open to public observation,and psi is categorized at severity level one,two or three.
. lpel the recent change to the new enforcernent policy has pq a pre. decisional enforcernent conference is !pe continued this practice,and it's been extended for j pq conducted. lpm additional evaluation. ! 1- py There are three primary enforcement !py Finally,if the final enforcement action
' pa sanctions available to the NRC,and they are notices na involves a proposed civil penalty or an order,the ,
psi of violations, civil penalties and orders. Notices psi NRC will issue a press release 24 hours after the ! pq of violation and civil penalties are issued based on og enforcement action is issued.
pq ider.ified violations. Orders may be issued for ps) Do you have any questions? I'll be happy !
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Page 9 , Page 11 i to violations or,in the absence of a violation, l Di to answer them.That's allI have. l m because of a significant public health or safety lm MR. E8NETER:Just quickly,the .
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pr conference is being recorded; we have a court U pl concern. j
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p1 This pre-decisional enforcement pi reporter here. I want to remind the staff to keep p1 conference is essentially the last step of the ! m on the issues of the enforcement conference.lf we , ni inspection process before the staff makes its final i pl get into areas that are off the enforcement { m enforcement decision.The purpose of this i m conference,which we shouldn't,and you're not m conference here today is not to negotiate a l pi prepared to respond,you should say so rather than j pi sanction.Our purpose here today is to obtain { pi trying to formulate a response.So with that.Al?
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pq information that will assist us in determining the lpm MR. GIBSON: Thank you, Stu.
pq appropriate enforcement action.We would want to inn Hob,if you would put the proposed notice pa achieve a common understanding of the facts, root {pa of violation on the viewgraph.
psi causes and missed opponunities associated with the jp3j g d like to discuss the apparent ; pq' violations,a common understanding of the corrective 'pq violations as we see them at the outset of the psi action taken or planned, and a common understanding psi conference.As Mr.Ebneter mentioned.we have pq of the significance of the issues and the need for ipe identified what appear to be three violations,and on lasting comprehensive corrective action. 'on the first is four examples of failure to follow ;
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pm The apparent violations discussed at this .pq procedures which would be contrary to tech spec ;
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og conference are subject to further review,and they ing 681.
pm may be subject to change prior to any resulting I pq The first example is a failure to monitor
- py enforcement action.it is important to note that !pq the flow for demineralized water that was added to '
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. na the decision to' conduct this conference does not {pa the reactor coolant system and a failure to close psi meae that the NRC has determined that a violation ! pal the valve after the desired amount of water had been
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pq has occurred or that enforcement action will be !pq added,which appears to be a violation of the Unit 1 pin taken, -lps; operating procedure,0250020.The second example is
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PROCEEDINGS BEFORE MR. STEWART D. EBNETER , #' March C,1996 IN RE: ST. LUCIE PLANT NRC , Page 12 Page 14 in a violation of administative procedure 0010120 for pl The NUREG states that we will apply pi an inadequate turnover that did not include in the m enforcement against individuals in a closely pi status that a dilution was in progress.The third l pi controlled and judicious manner. it also says that pi example of failure to follow procedures is an ( pj an enforcemen' t action involving an individual will m apparent violation of Appendix M to that same l tsj normally be taken only when the NRC is satisfied m administrative procedure when the dilution was isj that the individual fully understood or should have m accomplished from memory and the procedure for the m understood his or her responsibility, knew or should isi dilution was not referred to as required,when this Is1 have known the r quired actions,and knowingly or m administrative procedure specifically required that m with careless disregard,i.e.more than mere pq the dilution not be accomplished,that the dilution poi negligence, failed to take tequired actions which pq procedure not be accomplished from memory.The 10 9 have actual or potential safety significance.
pai fourth example of failure to follow procedures was a lpa We reviewed the circumstances of the pa failure to notify the operations supervisor of l psi dilution event,and,as we understand them,we have 04 unplanned reactivity change as required by Appendix 'p41 concluded that operator failuras were due to psi E of the administrative procedure 0010120. psi negligence. Consequently, pursuant to our sq Those four examples represent one psi enforcement policy,we do not at this time plan to na apparent violation of tech spec 681. Da take enforcement action against individual per Next we have an apparent violation of ,pq operators.Nonetheless,you should understand that pq criterion three to Appendix il for tailure to 'po) your performance in this event did not meet our pq translate design basis information into pmcedures. ,pq expectations, we're disappointed in your performance pq There was a difference between the procedure that lpy in this event,and we hope and expect that you will tm was used at the station for dilution and the method :pa take affirmative action to do better in the future, um of dilution described in the UFSAR.Specifically, I would also like to advise you that if jpa pa the procedure permitted a manual control of addition ;py you'd like to meet separately with us and discuss ps of a water / boric acid mixture to the suction of the ! psi any aspect of this event that we will be happy to Page 13 l Page 15 pi charging pumps.The UFSAR described automatic ' pi stay over after this meeting and talk with you about m controlof addition of a water / boric acid mixture to , m it.
ni the volume control tank. pi That in summary is what we see as m Finally.there was an apparent violation pj proposed enforcement.Do you have any questions m of 5059, iO CFR 50.59,in that a procedure change tsi about what we've described? I believe it to be m that was issued the day atter the dilution event : Is) consistent with the inspection report.
m pmvided for a method of dilution that was different im MR. PLUNKETT: No. ; Ist fmm that described in the UFSAR,and there was not MR. GlBSON:If not, ril turn it over to ist l n a safety evahtation performed to evaluate the roi you.
pq consequences of this difference. poi MR. PLUNKETT: Thank you. Mr. Gibson. , on Those. m summary, are the violations 09 llefore we get started with our formal presentation, I pa that we have identified.the apparent violations na rd hke to make a few remarks of my own. Right up om thit we have identified that we would like to focus ;pa front I want to say that we agree with the apparent ny our attention on today.
'py siolations.But secondly,1 want to etnphasize that esi I would also like to speak to enforcement j ps) the dilution event is much more than an apparent ' pai regardmg the individual operators involved in this pel violation in our eyes.It's a very serious event ; pa event.The operators also apparently violated pq which I think reflects on some of the problems and po regulatory requirements. As I'm sure you're aware, ! pai cultural values that have surfaced at St. Lucie in : poj the NRC has full authority to take enforcement poi the last six months. l pq action agamst licensed opemtors, including notices poi I had the same feelings or thoughts,it 99 of violation, monetary penalties and revocation and
[pq sounds hke,that you folks may have had concerning rm suspension oflicenses.Our enforcement policy for 'pa the event,the reporting of the event.So shortly as action against operators is described in NUREG 1600, f pai after the event,a matter of a couple of days,I p4i and if you'll bear with me for a moment.rd like to lp41 commissioned an investigation by a rather senior
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Page 16 Page 18 j p) name is Murray Selman.Murray's a retired senior p) since 1964.l*ve been in the nuclear part of the i m vice president.He was the chief nuclear officer at m business since 1987, rye been licensed since pi Consolidated Edison.But much more than those p1 November of 1993.
el credecdals,Murray is a real practical operator,a p) MR. PLUNKETT: Thank you.
is: down-tocarth type fellow that you'd want to do this ist MR, SCAROLA: Good morning.AsTom had ,
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isi investigation for you. Isi mentioned,rm going to go through the sequence of m My number one priority was to make sure m events,the timeline of the event,but probably what n that this event was handled with the highest isi I consider to be more important is our response to m integrity,that there wasn't any hint of any m the event. rtl cover that in detail, and then I pq misactions or misrepresentations,and I asked him to pq win go forward and carry through on our corrective pq took at other things,too,while he was there. pq action program as a result of this event and what it na Murray's report back to me was that there were na told us about our management and operation at St.
psi absolutely no misactions or any incident to not 1 931 Lucie.
041 properly report these actions. pq To start out with,I want to talk bnefly ps) With that information,I then talked wM1 no about the sequence that occurred that night,you pq the operators and formed the same opinion,and I :pel have to have the right background,and I want to pn hope today, der you talk to them and listen to pn make sure you understand the St.Lucie manning , og them,that you come to that same conclusion,because ,pm procedures.For each of our control rooms we have um 1 feel very strongly that these are three people who ! poi two reactor control center operators that are um have the highest integrity. lpq licensed operators,we have an assistant nuclear pn Now,in our presentation, Jim Scarola pu plant supervisor that is the SRO on each unit,and , ] pm will start out the presentation.We're all familiar na we have a nuclear plant supervisor and a watch pst with the event,but Til just go briefly through the pai engineer that are also SROs that are shared between no timeline ofit. Jim will emphasize our corrective p41 the two units.
psi action which we have taken,which has been ' ps) The night of this event the unit was Page 17 Page 19 p1 extensive.We'll then turn it then over to Dan i vi operating at 100 percent power with steady state . g m Denver,who will cover the apparent violations with l m operation,no surveillances in progress,and no ,
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0 pi respect to violation 50.59,and Bill Bohlke will ! p) maintenance activities in progress. At this point pi have wrap-up comments on the improvement aspects. pi in the core life, dilutien is performed on a tsj That's our format for this morning. ' isj frequency of three to four times a shift or every im If there are no questions,we'll go ahead : tel two to three hours,a fairly routine operation for m with that.rd like to introduce the three i m the crew.in order to maintain 100 percent power.
isi operators to you at this time,ifI could,and theY isi Ed has up for us the control room layout m can tell you their positions with respect to the , m here,and I want to step you through as to where we om dilution event and give you a little background. !vm had each of the operators stationed, ] pn MR. HONEYSETT: Um Pete Honeysett, ivy Our board operator normally operates na nuclear plant supervisor for St. Lucie 1. rye been 'pa within this range of area.Our desk operatoris psi employed with FPL 15 years and at St.Lucie .pa normally stationed here.At the beginning of this pq since '82. Tve been a licensed operator since :py event the board ope 2 tor was in front of RTGB 105.
pq 1985, rye been a nuclear plant supervisor for the psi 105 is the board that has the CVCS control system.
pm past 15 months, prior to that I was assistant :pe The boron and dilution control valves are located on ,
* . pn nuclear plant supervisor for four and a half years, on this panel.
q pm and prior to that I was a control operator. > p ei The desk operator had left the control , J pm MR. CONE: My name is Frst i 'one.1 was Icel room to heat up his midshift meal and was back in i sq a desk operator the night of tne dilution event. 'pq the kitchen.The NPS had relieved the ANPS and was
;ry I ve been with Florida Power & Light in their pq located at this computer station here with the STA.
pa nuclear program since 1980.and Tve been a licensed -pa the shift technical adviser,in the control room, rn! operator for the past four years. pm The board operator commenced a dilution pq MR. HOLZMACHER: My name is Hank 'pq activity which, for that activity, requires the * psi Holzmacher.Tvc been with Florida Power & Light jpe manipulation of two valves.He has to open up two , O + BROWN REPORTING, INC. (404) 876-8979 Min-U-Scripte (7) Page 16 - Page IS ; 4 o
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March 8,1996 IN RE: ST. LUCIE PLANT NRC . Page 20 Page 22 in valves to have primary water flow through the vi you what his perspective was and what he believes to pl suction of the charging pump to dilute the primary, m be the things that may have distracted him from his a Shortly after he commenced that dilution he had pi focus on the dilution in progress.
81 received an alarm on RTGB 102.He went from this pj MR. GIBSON: Before we begin. Hank,let's is) location over to this area here to acknowledge the isi try to straighten this telephone situation out.
p1 alarm and proceeded to head back in this direction si (Discussion ensued off the record.)
m when the board RCO or the desk RCO had returned back m MR. GIBSON: Mr.Holzmacher was about to - p1 into the control room in this location.The board pl give his perspective.
pl RCO requested the desk RCO at that time to relieve m MR. SCAROLA: Let me start out again here pq him of his watch stand at the controls and proceeded pq so we'll get us back on track.I do want to mention ny to go back to the kitchen to heat up his meal. inn that in your handout you have a timeline that we've nel The desk RCO moved in to the control [p2j added in there that goes through basically the - psi panellocation between RTGB 103 and 102.He was ;nsi sequence as we have been able to recollect it.
pei located in this location at the time. Now, this is (p4j That's from the plant computer system,some of the psi where we have the primary pressure controls.The Insi information,and some of those times are estimates.
psi pressure levels as well as steam gencrutor levels lps; We are confident in the sequence.The times you na are located right in this corner here,so he had inn need to consider is approximate from the best we're om positioned himscif here to be at the control panel.
!ns} able to determine them.
pel Within approximately five minutes,as lvoj At this time,I'd like to ask Hank to ! pq best as we can estimate, the original board operator inq start out and give you a perspective from his board 29 then returned from the kitchen.He proceeded to 'py watch position as the board RCO that night.
teri place his meal down on this panel right here.As he (prj MR. HOLZMACHER:Again, my name is Hank psi did that, he recalled hearing the integrator that is l psi Holzmacher. I was the board control operator the p4) clicking primary water or counting the gallons of (,e night of the boron dilution event. Routinely we psi primary water on RTGB 105. He immediately psj have to add primary water to the RCS to maintain the Page 21 Page 23 pj recognized that he had left the dilution in p) temperature. Going to the timeline,I initiated a , l-m progress. He announced that dilution in progress to m boron dilution to the RCS and stepped away from the si the desk RCO and to the NPS,immediately moved to i p) boron dilution station after receiving an alarm on pi RTGB 105, terminated the dilution,and commenced a l pj another board.Following resetting and m tx) ration. l rsi investigating the alarm,I did not return to the si The NPS had issued a command to the ANPS, j p1 dilution station but rather asked for permission for m who was located back in the kitchen heating his meal l m a brief turnover to go to get my food.
m at the time.At this point in time the NPS gal Approximately five to ten minutes later i si commanded the ANWo return to the control room and l pj returned to the control room and went back to the sq provide direct oversight of the recovery
.pq desk area in front of RTGB 105. Upon placing my py activities.The ANs a came mto the control room, py plate down I heard a click on the integrator,and it pri and he provided oversight of the activities that pri lit off what had happened.I realized that I had px were gomg on with the boration and the NPS and the
, psi left a dilution to the RCS and immediately stopped p43 STA.When the NPS was assured that we had a stable v4] it while announcing to the control room what had
. psj condition, he proceeded to review the tech specs and psi happened.1 stopped the dilution and started om make the appropriate tech spec r ury into a two hour psi borating.and I waited there and watched the on LCO for exceeding 549 degrees.
nn parameters while waiting for further guidance.
pm What l'd like to do,because we do have psi MR. SCAROLA: Let me take the floor back ps! the advantage of having the people who were involved 'pei for a second from Hank here,too.One of the issues ym in the activ'ty with us,l'd like to take a moment pm that we have been dealing with through this event an and ask that each of them discuss a little bit about my was the turnover,and Hank mennoned the turnover in pr: their perspective during the event.
- pri order for him to go back to the kitchen and heat up pst I'd like to start you with Hank,if you psi his lunch. Frank had received that turnover as the p41 would. For this night Hank had the assignment as 'p41 desk RCO,and I'd like Frank to talk to us a little the board operator,and I'd like llank to share with ps) bit about the turnover and what he expected at that .
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_ Page 24 Page 26 el time on his shift- ! vi stable and returning back to 549,we reviewed the pi MR. CONE:1 was the desk operator the ! m tech specs and had determined that they should be al night of the dilution event.1 had returned from . pi entered because temperature exceeded 549 degrees.
81 the kitchen back into the control room when 11ank , pi We entered the 140 and tnade the appropriate log ist requested that he'd like to go get his meal.This j ts) entries.I'm sure the appropriate log entries of isi being a back shift,there's no maintenance,so therc } tai the event were logged in the chronologicallog.
m was at this time no maintenance in progress at the !m After the plant was stable, my concern tal control room, so it was a very controlled atmosphere ' ai t then was exactly what happened, exactly how did Hank m and quiet.Now, we turn over at eleven o' clock as asi lose track of this task.It was clear to me that om oncoming crew,so we take a full turnover of plant :pm IIank had started the dilution and had been in the ny status conditions and walk down the RTGBs.Being ivy room several minutes before he had gone to the pri the desk operator,I'm cognizant of where that plant !va kitchen,before he turned over to Frank and had gone na is as far as a generalized statement. Insi to the kitchen, so my focus was exactly how Hank had p41 When he requested to go to the kitchen. pai tost track of this task.
psi he just said.I'd like to go to the kitchen to get psi MR. SCAROLA: Pete's pointing out pel my food,1 acknowledged that, and I took command and pai something that I probably should have emphasized.
vn control of the reactor and moved up to the RTGBs. I .pn This task itself,they were expecting to shoot less pet didn't expect any more of a turnover because I felt og than 40 gallons into the primrt ad with one poi hke I knew where the plant was.We had a black . psi charging pump running that hd have been a task pq board, no alarms in, and at that point I felt I was pq that took 45 seconds.That helps emphasize exactly pu cognizant of where the plant was at and didn't pq where Pete's focus was at that time.
pa expect any more of a turnover. pa MR. HONEYSETT: At that point I asked the um MR, SCAROLA:I'll come back to that in a um STA to go ahead and initiate an in-house event , 04 little bit more detail.This is obviously one of :p41 report.1 asked them to write up a data sheet psi the areas that we've learned some things about that 'asi seven, which is an opentions problem report. I
Page 25 Page 27 pi can strengthen our practices in this area,but I did pi then returned to my office on Unit 2,and when I got m want to make sure you had the opportunity to hear : m back to my office I reviewed the criteria for m from frank directly what his expectation was. m notification. Basically,the criteria said that I pi MR. GIBSON: Did you hear the integrator pj was responsible for promptly notifying the ts) clicking? tsi operations supervisor under certain circumstances, tot MR. CONE: No, sir,I didn't. From where is) and an unplanned or unexplained reactivity change is m I was at to the integrator is about 12 or 14 feet, m one of those criteria.We knew it was explained tai somewhere in that area.lfI'd heard the integrator tal because we knew exactly what happened from the m clicking I'd have secured the dilution. toi onset.We knew that we didn't have any equipment vm MR. SCAROLA: I'd like to ask Pete to pq problems or incident problems.And as far as being on talk to you now.Pete had the command position at 'py planned. Hank had planned to water the primary to pa the time in the contml room, and I'd like for him .pa raise the temperature,but that plan went astray, ow to share with us his perspective both on the event pai and of course the temperature increased nine-tenths eq itself and his reaction to the event,and probably .py higher than it should have.
ps) more sigmficant is the communication aspect.He psi So I made a judgment at this point, om had the accountability for communication in this psi knowing that the event was over, knowmg that an pn event and the irnmediate actions following the on in-house event report was being written up,knowmg pai event.Pete,if you could share that with us. Del that I requested a data sheet seven to be wntten
, om MR. HONEYSETT: Of course my immediate not up,and also knowing that in approximately two hours pm concern was to assure that 'he dilution was mm the operations supervisor would be calling on his g,i terminated when frank brought this to our attenuon, pq way to work. He normally calls between 5:30 and pa which he did.They properly started ejecting boric pa 5:45 every morning, so I elected to inform him of pa acid to counteruct the effects of the dilution.1 pm the event when he called on the phone.
pm called the ANPS back into the room to take control pq So approximately two hours later, when I psi of the situation.When I saw that the plant was psi spoke to him on the phone,I related the event to _ BROWN REPORTING, INC. (404) 876-8979 Min-U-Scripts (9) Page 24 - Page 27 ,
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Page 28 Page 30 ' pj him, who was involved,what we had donc,how hi8h p1 through this? m the temperature had gotten,and when he came to work m MR. SCAROLA: Yes, sir.
pi at six o' clock he came straight to the control room, pl MR. EBNETER: So I shouldn't pick on pi so at that time I spoke to him face-to-face about vi them,1 should pick on you? m the event.1 also at that time had a copy of the si MR.SCAROLA: You have me and my n draft in-house event which I handed him, and I also isj attention, sir.This event goes far up the ladder, m informed him that the HPES coordinator had been m and I'll explain to you what we've learned up the m called and was on site over in Unit I control room m ladder, what I've personally learned as we go up the m at the time talking to Hank and Frank and getting m ladder.
Oq came more information on the event.
pq MR. GlBSON:I understand there was an pq MR.SCAROLA:Thank you,Pete, ny alarm that sounded somewhere in this scenario.When pri MR. EBNETER: You're the NPS? pri did that sound and what did you do in response? vm MR. HONEYSETT: Yes. par MR. HONEYSETT: Approximately 30 seconds pq MR. EBNETER: And your office is over in v41 after Hank had realized that he had overdiluted he psi Unit 2? - inq began the boration.The control bleedoff to the pq MR. HONEYSETT: Yes, sir.
!pe RCPs goes directly to the VCT,and what had happened pn MR, EBHETER: Who was the ANPS?
!pn was the level in the VCT increased approximately ten pm MR. HONEYSETT: Charlie Simkins. inn percent. As that occurred the pressure increased, om MR.SCAROLA: Do you want to explain your lpe which caused the back pressure for the control pm relief at that point,Pete?
jpq bleedoff to increase to its alarm set point.
pq MR, HONEYSETT: I routinely go back and lpy MR. SCAROLA: I'm not sure, Al,if we're pri forth between Unit I and Unit 2 throughout the !pri addressing the right one for you.That's the alarm n night. I had been over there earlier at _ ps; following Hank coming back into the room.What he pq approximately 11:30 or 12 00,and I had returned at pq recalls is that he did get the alarm on the VCT. If pq approximately 2:00 to 2:15 to collect data for my , psi Hank had not walked back into the room it would i Page 29 i Page 31 p} morning report. At that time Charlie asked me ifI { l p) have brought it to frank'S attention that something m would stay in the control room while he went to the m was occurring.
m kitchen to get his midday meal, so that's how I came ! p) i MR. GlBSON: For the record,1 understand j pi to be in Unit I control room at the time.
- pi you did not receive an alarm onT. cold being above m MR. EBNETER: You guys were pretty !
i is) 549 degrees. ; m hungry.
m MR. SCAROLA: That's correct, and I'll m MR. HONEYSETT:lt was 2:30 or so,and m address that also as we have our discussion.
m that's halfway through the shift.
m When we get to the second timeline in m MR. EBNETER:If I was that hungry I m your handout there, where Pete has left us is with pq would leave this conference right now and go get my pq the in-house event report being generated.He had 09 lunch, right? My duty is not to go eat my lunch, my on had discussions with the operations supervision and pri duty is to be here. I'm just dismayed that you're l na what I want to pick up from is in this time frame i pa so hungry on the shift that you leave in the middle .ps; between 6:30 and 7:40.
pq of your task to go get your lunch. pq Upon my arrival at the site,I review the po MR. SCAROLA: Certainly, Mr. Ebneter, ,;
,pm higs the first thing in the morning,and the crew pe; that's a key thing in Pete's focus in his ps) had done a very good job in ensuring that the '
0n discussions with Hank when he came back in,that an orj appropriate log entries were made.it was very ' sai event,an activity that is only to last 45 seconds.
pa) clear to me that we had had a dilution activity , em is not one we'd expect to turn over on,it's not one om throughout the night that we had not adequately n that Mr. Cone would be expected to be receiving a pm controlled. At 7:40 I had the in-house event in pq turnover on, and it's not our practice at St. l.ucie
:py hand,and we have a tr*utine phone call that we make na to turn over a dilution in progress.
pa with Turkey Point in our corporate management. At n MR. EBNETER: Did you set these guys up pa that same time I have my staff there including the pq for these types of events in the way you do your pq operations supervisor and the operations manager.
pq dilutions? Are )ou going to discuss that as you go ;ps) We discussed the in house event,and the information Page 28 Page 31 (10) Miss-U-Scripte BROWN REPORTING, INC. (404) 876-8979
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Page 32 Page 34 D1 at that time on the in house event had a power level p1 of alllicense duties.
pi that had gone to 100.2 percent power. Im Over the next several days Mr. Sager, our p) I assigned the ops supervisor the pi site vice president at the time,andJeff West,who p) accountability to find out what had broken down and pi was acting on my behalf at that time as the plant si what lessons we needed to learn and to complete the (si manager,had collected numerous corrective actions, si in-house event.The in-house event will have the l iej and there had been industry surveys performed to see m initial conditions,the event scenario,and,when it m what the standard practice was for those plants that si gets down to the root cause analysis and pi we considered to be top performers in regard to SRO pi countermeasures section of that,1 will assign that pl oversight of routine dilution activities, manual om out after I receive it in the morning to the om versus automatic operation of these activities at pq individual that I believe to be best accountable to en other CE units,and they had collected a series of pn carry through on those actions.At this particular lpa corrective actions that began to be put in place as on time that was assigned to the operations lpa early as the 23rd.
041 supervisor. :pq On the 30th,after we had had numerous psi Now,I want to point out that this is l psi reviews the previous week I had taken the in house psi within three hours of the event.From my own l psi event, which at this point had been revised to have on perspective,I had adequate information that 1 lpn all the corrective actions that we had come to date ' psi should have reacted to a dilution event that had not l pal with, and I reviewed that in detail. In reviewing poj been adequately controlled wnh a higher degree of ing that.1 was not convinced that we had yet learned am diligence,and I want to make sure that's very pq all there was to learn from this event,that we had pu clear,that that's my lesson in this particular pq a lot of corrective actions,but whether they were na scenario. . pa the right corrective actions and whether they were psi MR. EBNETER:Jeff West is the ops igai through a logical, methodical problem-solving py supervisor? pq method,it was not evident to sne.
psi MR. SCAROL A: He's the ops manager. psj On the rmrning of the 31st I relieved Page 33 Page 35 p1 Chuck Wood at this particular time was the ops i vi five people from their duties. I took some of our m supervisor. I m most senior people out of the organization and asked pi MR. EBNETER:And who was the op5 l pi them to form a root cause team and start from si technical supervisor? l p) scratch in looking at this event and make sure that si MR. SCAROLA: Charlie Marple. He's the i m we had captured all the right lessons.
si individual we've placed in Chuck Wood's position lp1 What I would like to do now is talk to m recently.We had both Mr.Marple as well as Mr. i m you fmm this point about the finding.s of that m Wood maintain their licenses and they're off shift. ! pl team. And also,following that,as Mr. Plunkett had m but Charlie will carry out his shifts as an NPS l m stated earlier,he had conunissioned Mr.Selman to pq periodically. He will stand watch as an NPS. jpg come in and take yet a third look at the event and pq From this point Mr. Marple was assigned !py at what this team had performed and provide na the accountability as the ops technical supervisor 'pa additionalinput to us in certain areas. And I'll psi to find out the details that led to this dilution ' psi tell you from my perspective this had some real good ny activity.He spent the day on the 22nd gathering !pq value,because he added some value up in the psi the information that had been put together in the insi management area to things that I had not adequately ~ ps) in house event report,the HPES report,the lpq addressed or the team had not adequately addressed pn information out of the logs. He talked to the crew :pn in their review.So I want to share with you our i pm that morning and talked to the relief crew Ily that !pm conclusions here.
pm afternoon he had recommend that Mr.Holzmacher bc : poi MR. EBNETER: Let me take you back one um removed from his license duties. ' poi second. I'm not sure I understood what you said.
raq The followmg morning.a meeting was pu You said on the 31st you relieved five people.That ga conducted with the crew to validate the information !aa was to say you relieved them to work on this task pai that had been transmitted in writing.There was a l psi force? pq meeting with Mr. Holzmacher, and at that time Mr. r MR. SCAROLA: Yes.
psi Holzmacher on the morning of the 23rd was relieved lpq psi MR. EBNETER: Who were they? __ BROWN REPORTING, INC. (404) 876-8979 Min U-scripte (11) Page 32 - Page 35
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PROCEEDINGS BEFORE MR. STEWART D. EBNETER , ! March 8,1996 IN RE: ST. LUCIE PLANT NRC Page 36 Page 38 g,; MR. SCAROLA:I'll give you a little bit ty intmduced to it.
m of their backgrounds.We have an individualin our m MR.SCAROLA: We had covered it to a ni licensing department, his name is Dick Dietz. He is pl certain extent in requal.
pi a former mechanical design engineer from Combustion pi MR. HOLZMACHER: No,I have not seen it.
rsi Engineering.He has a tremendous background and MR. EBNEVER: Have you ever been imolved rsi isi experience level.1 asked Mike Snyder, who formerly rei in a reactivity incident before? m headed up our STA group and works now in our system m MR. HOLZMACHER: No.
m and component group,to lead the effort because he tsj MR. CONE: No, sir,I have not.
m has recently been tnined in root cause analysis. m MR. HONEYSETT: No.
poi He had a course taught to several individuals on pg MR. EBNETER: Well,I can't fault you too pu site recently,and I asked Mi4e because he has most on much on that.1 had a similar experience. nu t I am pa recently trained in that to head up the methodical va constantly arnazed at this.We can't ever seem to i psi analysis that I wanted performed.The head training psi get it down to the level where the activity occurs.
! 04i instructor, larry Rich, who heads up our requal 04) As part of your investigation did you psi training program, was asked to join the team. , psi look at the requal tnining? To say you put it in psi Charlie Marple, w ho was our technical ops -um requal training and all they do is wave it around pn supervisor, wu ,,4ed to join the team.And we on doesn't do much with regard to training people.
j pai askedJirn Vorhees, who is an SRO certified QA psi MR. SCAROLA: I agree wholeheartedly.
poi inspector, he was also asked to join the team. pel What we did the week of the event,before the end of pq So with this group of individuals,I Prol that week we had met with every crew with the Zach pq asked them to take a fresh look at the eve'nt.We lpy Pate speech on their shift as they were relieved at pa broke out the event in two problem areas,and I 1 921 the relief meeting, and Jeff West, Bill Bohlke, Dave psi think it's important to go through both of those psi Sager and myself,various ones of us attended each laci areas. pai one of the s'hifts around the clock until we had psi The first one I think is very clear, 'ps1 discussed this with all licensed opetutors and gone Page 37 Page 39 1,9 because we had a reactivity evolution that was p1 through the detail and the key points of Zach Pate's I m initiated without adequate controls. And certainly, l m speech.
pi Mr.Ebneter,when you say that I'm the guy'you need p) MR. EBNETER: That report is an important pi to talk to,this is very clear.This routine boron : pi part.Let's hear the rest, ts) ddution,to maintam 100 percent power,was not l tsi MR. SCAROLA: The second problem that I pi treated with the same importance as other acactivity m think is equally as significant as the event itself i m management evolutions.
m is the recognition by myself and my staff that we is! MR. EBNETER: Let me ask you something. ! eji were slow in our response.The root cause of this m You had allof these incidents.right? I m problem was really a lack of a well-defined poi MR. SCAROLA: Yes.
poi threshold for recognizing the safety significance of py MR. EBNETER: And you have done something ;py this. As we looked at the dimensions of each of na wnh your staff to make them aware of those pa these problems,and both problems have the same ps) incidents:is that nght? lp3; dimensions, we have corrective actions in the p4i MR. SCAROLA: Yes.
-p4) personnel area, procedures, documents and policies.
psi MR. EBNETER: Did it not have any ;nsi
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MR. EBNETER: Let me stop you for a psi effect? That was one of th major things they osi minute,These are the two problerns that you pa talked about, reactivity it.udents.
.pn identtfied from doing your event analysis:is that rej MR. SCAROLA: It did not have adequate 10:1 right? , poi penetration down through the organization,and I poi MR. SCAROLA: Yes.
poi wuuld ask the itCOs to correct me if I'm wrong, but I poi
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MR. EBNETER: And that was your team, pq would say prior to this event they had not seen the lpy these five individuals.and independently Mr.
pa speech that was presented or had discussions on ;ma Plunkett had brought in Murray Selman.Was Murray pa thot.You guys correct me if I'm wrong. , psi Selman done at this point? p41 MR. CONE: I got to k>ok at it in p4; MR. PLUNKETT: No.
951 requalification, but I'd not been formally psi MR. EBNETER: I was really interested in Page 36 Page 39 (12) Min-U-Scripte BROWN REPORTING, INC. (404) 876-8979
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pi Murray Selman's analysis versus what your own m MR. EBNETER: Those 25 are in your pi internal team found. p1 performance improvement? p; MR. PLUNKETT: Let me just talk about pj MR. BOHLKE: Yes, sir, and I'm going to isi what I saw there.1 saw that team delving into the Isi be talking about that.
isj details,and Murray looked at it much more broadly is) MR.SCAROLA: Each of the problems broke m than that. Jim's got Murray's stuff. As he goes m down into these five areas. I'll tell you the is) thmugh the presentation,it's factored into the tai significance of that.When Mr.Plunkett spoke m whole thing. m earlier about this giving us some real insight into pq Murray was focusing more on Jhn and the pq our organization,you can see that the five areas pit operating chain,these things you're getting on, p,1 cover all aspects of our organization, and the team na quite frankly,what had they done to get the na did a good job in identifying the improvement ps; operators ready,this whole attitude of following pai opportunities in each of those areas.
pq procedures, and that's where he came at it from.It 04) I want to start out backwards here,on ps) wasn't the black and white,so to speak,that the psi the last area,and the reason for it is obvious.
pm team tended to focus on. Om This is the one that I consider to be the most on MR. EBNETER: Have you seen Murray's on significant in this event.
og report. jost First of all,the decision to operate the og MR. MILLER: No,1 haven't. Ipoi units at the tech spec level of 549.We had given pq MR, SCAROLA: He's factored into the ipe direction to the operators to maintain a T-cold at pt; problem report we have given you.Let me tell the j pij $49 degrees.The UFSAR description says normal pa you the difference in perspective.When the team ipri operation is at 549 degrees.This is,outside of psi had finished,their focus was on the procedures and ps) power,the only parameter that we operate at the pq policies that had not been adequately either p41 tech spec limit with no margin. And if you think psi reinforced or established,on Hank's individual
{ps) through the precision in which you perform dilutions Page di l Page 43 pi accountability as an RCO.What they did not capture i pl on a routine basis,the management decision to m was the lessons learned for myself and the j m opetate at 549 and not believe that we would be si management team. ni going periodically above 549 was not a reasonable si Murray sat down with me and said, Hey. p1 expectation.
m Jim, what lessons did you learn through this thing, im in fact,the second item here is the m I went through those with him,and he said the l ts) adjustment of aTcold alarm.We had an alarm on m team's product doesn't reflect that.The team, . m this unit that was set at 549 by its original m naturally because of the layer that they were in in ' s) i design.That particular alarm came off of two m the organization.they were not as adept at looking i m temperature elements.When the operators control, pq at management accountability through this,and the .pq they're looking at an average of,1 think it's on vil less(ms that I felt had been learned is where Murray 'p,) the order of eight temperature elements.What they pri steered me to say that's the important thing to ivri had identified through our normal operation is they pm capture in this event.lic helped us add that layer -pai were receiving nuisance alarms at 549 degrees.That pm of quality to the problem report. pq was the first indicator that we as management were no MR. EBNETER: Mark just pointed out to me psi bumping up against the tech spec limit routinely.
ps; that this document you just sent to us - and I lpe MR.PEEBLES: And calling it a nuisance pn apologtre,I have not seen this.1 just wanted to pn alarm.
ps) make sure that we knew what Murray was finding and pai MR. SCAROLA: Yes.This was recognized, psi so on. , poi and I believe the date is 1993.That alarm was pq MR. SCAROLA: That report has 25 1pq moved to 553 degrees.There were three degrees pu corrective actions listed in it.Now,I don't pil additional margin provided on that particular alarm, pr; mtend today to go through all 25.What I've picked pa obviously well above the tech spec limit and of no rm up are the ones that I consider to be the most psi value to the operators.
pq significant for our discussion today. But if there :py Today we're operating both units at 548 pq are any questions on any of those, we'd be happy to (psi to 548.5 degrees.We've done the 50.59 evaluation BROWN REPORTING, INC. (404) 876-8979 Miss-U-Scripts (13) Page 40 - Page 43
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Pagea6 ; in to support that in order to make the UFSAR change. pj. MR. SCAROLA: And that was the logic that !
m Uc have also today backed the alarm down to a m was used originally when it was moved to 553, that, i pi setting of 549.3,where that allows the equivalent 91 well, that's off of something different than what '
- si alarm point, when you look at the averages and the ,
pj the operators are controlling to.
m deha between the averages of the RTDs ahere the l sq MR. GIBSON: And I would want to look m glarm point comes out of 548.8 is when the alarm l lei closely to see if you have sufficient correlation m would come in from the operators by the instruments. j , m between that instrument set point and the tech spec - ist they'rr controlling due to the accuracies of both isj such that you can say with confidence that you're ; j ' m instruments involved.
' m remaining within the tech spec.
pq MR. JOHNSON: Can you read these that pq MR.SCAROLA: We do,and that's the 50.59 4 0y closely?, , ny evaluation we had our engineering staff perform, ! pa MR.SCAROLA: You can.Let rne explain to ,pri which ones fed the alarm set point, which ones were i psi you what we put in on both units now.We do have lps) the operators controlling to.That was part of the pq digital indicators where I can read down to the
'pq logic behind this.Now,the final alarm set point, psi tenth now.Now,an RTD, typically the 500 degree -psi l'Il tell you that we have just accomplished that.
pq RTDs, their accuracy is no better than two and a pet We got the final alarrps in yesterday We actually
- prj hilf degrees, and that is typical of what we have on .
pri moved those down yesterday and got them reset.
ps; all our protection channels.1 believe there's a ' ps) The other area in management lessons * pas margm of plus or minus two and a half degrees. pq learned that's worthy of talking about is the pq MR. JOHNSON: What is the reason that you
,pq expectations to the operating crews.1 mentioned we ;
gy operate so high? Why is that to an advantage to lpy did meet with each of the crews with Zach Pate's ( 4 pa being so close to that lirrut? pa memo.In addition to that, Bill Bohlke and myself 4 psi MR.SCAROLA: The advantage is really { par sent a memo to every licensed operator at his home ; ' p41 steam carryover in the secondary and the efficiency pq reinforcing our expectations for their role in '
- pq of the secondary operating plant.The lower you : psi reactor safety and their importang M protecting Page 45 i Page 47 p,1 operate at,the more steam carryover,the more l pi the public's health and safety.
m potential you have for blade damage and you will m MR. EBNETER: What did you do with it? , l pi drop megawatts as you drop temperature. l pi MR. CONE:It's still at my house.
si MR. JOHNSON: But you can operate at full ! pj
;
" MR. ESNETER:Is it on your refrigerator m power at 549 or 547, either one,it's not { isi or something? in prohibitmg you from- t sj
;
i MR. CONE:It's right on my counter.
m MR. SCAROLA: Initially when we [ lm MR. EBNETER:l'm just cunous.Did you ; m implemented this we backed the unit down because we tai not discuss it in face-to-face meetings? m did not have the 50.59 in place.so we backed down l
:m MR. SCAROLA: Yes.That was done first.
pq to 98 percent power,which was equivalent to 548.5 !
!nq That was the crew meetings that we had with all the pu on the old curves.Once we recalibrated all the {
[py operators.Following that we said.Let's funher pri instruments and engineering did the evahiation, we ;
;pri reinforce this in writing and make sure that every j pai came back to 100 percent reactor power at the new lp3) operator receives the document.
- pq temperature limit of $48. 'pq { pq MR. EBNETER: You know for a fact that s MR. GIBSON:It sounds to me like you . psi cach of them has discussed this? poi have an instrument problem.You have a tech spec . pq MR. SCAROLA: Yes.
pn which you're controlling to meet an averageT-cold { pri MR. EBNETER: Not like the requal change r pq number,and you have an instrument that's giving you ipsi that was just waved around? ! poi s.1 indication of something that's something other l os; MR. SCAROLA:I know for a fact that pq than the averageTcold.
pq pq every crew member had discussions on the importance MR.SCAROLA:The alarm comes off a
'
:py of control group conduct and the expectations of pa different point. pa that as described.
! pst MR. GIBSON:And because of this you're l
: MR. EBNETER: Let me lecture you just onc !
pq forced to $ct the alarm point at something other lpai ps) than the tech spec.
- . - ~. - -.-..
}py pst after nunute.1 this thing was at another happened.1 wentrnecting recently to the meeting of right i
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PROrFFDENGS BEFORE MR. STEWART D. EBNETER ! IN ret ST. LUCIE PLANT NRC March 8,1996 I I ..- Page 48 Page 50 ! pl their managers and they discussed you guys.They p1 Now,in addition to that.1 recognize ; pj discussed this dilution event in that meeting while p; that there is more experience to be obtained in this j
. pi ! was sitting in there.They picked it off of the pj organization than what we have at St.Lucie At el NRC wires,and they made a point to go and talk to ]
pj 7:40 each day we have a phone call we make with l tsi cvery one of their operators about the dilution tsj Turkey Point and with Mr. Plunkett and his staff. ! m event that happened at your plant.That's the type m These events are shared now and we're at a new level m of sensitivity that it carries. If you did all { m of detail and cornmunication in that phone call so is) these things, fine, but too frequently things are isi that I have at my access the collective experience toi done like this.Yes, we put it in the procedure and isi of the nuclear division management with the actions pq we told the managers to discuss it.The intensity pq that we're taking or,just as important or rnore pq of the discussion isn't always where it should be. lpy important, the actions that we're not taking. ; pri Do you know that all this was done? pa The second area that I want to talk about ' ps; MR. SCAROLA: I know that a!! of that has pal briefly is the personnel area, and I'll be brief on j v41 been done. Dave was involved in the meetings,I was p4) this, but I think that it's very important that we ps) involved Jeff West and Bill Bohlke.This was an psi coverit.To start out with,asTom had stated i poi important communication for us.There is no
,pej carlier,I'll tell you that any event like this pn question in my mind that that expectation for lpa cannot be adequately analyzed without the pai reactor safety for attention to this level of detail ' lpaj cooperation of the people involved. And I will tell poi is well known by each of the operators.I'll also lpe you that this operating crew,I have seen nothing pm tell you that I also recognize that it's not a one lug but a high level of honesty, integrity and !
pq shot deal. I'm not going to fool myself to think lpn accountability from the start of this event.At the pa that because we did it once that that's something lpa same time,I'll tell you that there is that level of pai that they'll have for their career. It has to be
! pal accountability that cannot go unrecognized in this p41 reinforced on a routine basis,and I still have that 94j event.
psi accountability in front of me to carry that psj Mr. Holzmacher has lost the ability to ! Page 49 1 Page 51 j pl through.
pi perform his license duties.We asked Mr.Holzmacher ni I want to talk a httle bit about the ! p1 to go and have an evaluation done by our medical s ni communication aspects of this from the management ! pl review officer,and the medical review officer has pi chain.We talked a little bit about Pete's { l p) found him fit to perform his license duties.We m communication to the ops supervisor,the in-house i Isi have developed a program for Mr.Holzmacher that { n event,the log entries.When Ilooked at it I still l Isj involves ten weeks standing in a training capacity m wasn't satisfied,and part of this comes back to the ' m on shift followed by a series of examinations on a ; isi same lecture, Mr. Ebneter, that you're pmviding isi simulator specifically designed to test attention to pi with me, that there's nothing like face-to-face el detail, continuity through events. Mr. Holzmacher
{
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om communication or direct communication. pq will have the opportunity to regain his license py I now have a policy in place on any su through that series of activities.
pri in house event that within one hour of the NPS being na MR. EBNETER: Let me tell you something.
tot relieved of his crew that he has direct , ps) This is what I tell operators,and you've pmbably ! pai communication with me on any shift. If we have an p4i heard this when I present the certificates. All of ps1 event on Pete's shift,1 expect during that shift or ps) this stuff, putting you through the simulators,you pm immediately within one hour to have a phone call pai probab? didn't need all that.When we grant you a on from the NPS describing from his perspective the on license we've ascertained that you have all of the
,
i se details of that event.Now,following that,at t!' pai aptitudes to run that plant,all of these things.
pq 7:M meeting that we have daily the NPS cor as down
:pg You can do the boost.1 don't have any doubt of cm to that meeting and he presents to us the plant l pq that at all.What we don't test and what your crew py natus,and at that meeting we will discuss the no testing doesn't test is your attitude.
pa in-house event with my staff.This is the NPS's pa A!! the tests and all the simulators in psi opportunity to provide firsthand information beyond
,
.p:1 the world,if you get hungry and you think it's p41 what is written in the report to his recollection of
'pq better to have a checsc biscuit than it is to watch psi the event.' i jusi your boards, our tests don't show that.So I hope '
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PROCEEDINGS BEFORE MR. STEWART D. EBNETER March 8,1996 IN RE: ST. LUCIE PIANT NRC , __ Page 52 Page 54 pl what you have done and what you get out of this is p1 that just going through the simulator doesn's m not to go back over and run through the simulators { m correct the distractions.
p1 Cgain but that your primary attention should be i p) MR. PEEBLES:I thought it was real pi rfJht there on that power plant in the control room, pi important when you said earlier that the evolution m your attitude.lf you get a little hunger pang. Isi wasn't considered as significant as what you want to a you'd better make sure the boards are correct before isl do,and I guess you're going to cover that.
m you go and artisfy your hunger pang. im MR. SCAROLA: Yes.As y su look through
,
i m Tm sort of picking on you guys because ts) our procedures and policies, this is really where we m you are the front line, but I want to taake it m capture that point.
pq clear.1 don't think Hank needs all the simulator pq When this activity was performed,it was on training.1 went through that.You know how to run pu performed by an RCO, assumed to be his na the plant,but you just have to make sure that that pri accountability and one which he was empowered by our pr is in your forefront all the time, even if you're om policies to perform independent of the remainder of p q dying of hunger pangs. And I don't suspect you were 04 the operating crew.When we took our industry data, na dying of hunger pangs,right? ps) we found this is not consistent with the top ' sei MR. HOLZMACHER: No. ps) performers out there There are many plants that do on MR. EBNETER: In fact,I was questioning inn it this way.However,we found the top perforyners pe, why you were going to eat only three hours into the !Ps) have SRO involvement in dilution and boration poi ahift, but that's none of my business.The lvoi activities.So we have changed our policies and pq regulation doesn't say anything about that.My [pq programs to where first the activity is announced my pr >blem really is that technical training is 'pq and the SRO acknowledges that this activity will pa probably not at fault here.You know what it is, gri proceed.
pm the accountability and the - lps) This second item we've really covered pq MR. SCAROLA: Mr. Ebneter, what we are
{py already in detail.This is not an activity that we ps focusing on is the distractability.There's l psi would expect to be turned over.Certainly 45 Page 53 Page 55 p1 numerous distractions that operators wd! be pj seconds of a dilution is never an activity that m confronted with.It's always important that they m should be turned over.likewise,we're expanding p1 first assure themselves that the activities in p; this to look at other evolutions, both licensed and la progress are adequately attended to in response to p) non-licensed,that also should not be turned over in m those alarms.
, m progress,and we're idenufying those in the conduct p1 Now,Ilank has told us and we believe that j [si of ops so that we have clear expectations for all m we do not know exactly what distracted him. I can't m our operators.
m tell you that the fact that he went to respond to an 'm MR. EBNETER: I think that's good.1 m alarm is what caused him to lose his focus on the to) would like in our next meeting with you guys for you em dilution activity in progress, but Til also be om to tell me what that is.
p y confident in telling you that it is not flank's pq MR. SCAROLA: We'll be happy to share cri practice or any other operator's in the middle of a _ ri that with you.
p na dilunon activity to plan on going and eating their :pa The short term turnover process is also py lunch.We had lost focus of this event long before om one that we've had some discussion about.1 would no he had left that control room.
1pq like to share with you that over our preparations est MR.EBNETER:Well,1 understand that.
'psj for this meeting we have continued to revise the pn And Hank,1 appreciate these remarks that you do lpn short term turnover process.This again was an area pe) have the highest levels of honesty, integrity and
,ps: that we've taken corrective actions on immediately pet accountability,and I know we all get distracted.1
'p,; at the time.but we've rnade some adjustments to am get distracted,but the results of my distraction pq this.In fact this crew through their 99 are a lot less consequential than you people being .99 accountability has helped rewnte what the sa distracted. I might be distracted by Mr.Gibson,
.pa appropriate turnover process is.
pa but I don't have a big machine here.That has very pm Now,the turnover,and rd like to ask mi senous consequences.That's good that you went inq perhaps Frank to cover that with us here,the 99 through this process.Tm just going to let it go l psi current expectation for turnovers from the boarti and Page 52 - Page 55 (16) Min-U.Scripte BROWN REPORHNG, INC. (404) 876-8979 _-- - __ - ____-_____-__-_ - __-- -_____- -__ _---
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Page56 Page 58 m the desk RCO, ni procedure was revised for Umt 2 we had implemented pi MR. CONE: At this time operators that : m the verbatim compliance expectation while we were in p; have control of the plant,the actual shift holders, ! pi the Unit 2 outage.The initial focus was on the pi being the desk and board RCOs.they must verbalize , pi Unit 2 procedures and to make sure we had revised ist and functionally acknowledge back the fact of the ! tsi the procedures adequately for the operators to is; general status of the plant,any abnormal trends and ! tai return Unit 2 to service.In doing that,the Unit 1 m any evolutions in progress.lf anyone comes f m pmcedure was identified for upgrade and was put in Isi outside,from outside being an actual watch stander i (s) the upgrade progmm, but it was not immediately sq to relieve either of us,it must go through a fuel p) upgraded when we revised Unit 2.
pq turnover,which is a functional walkdown of every ,pq MR.GIBSON: What I'm really searching etj RTGII,revolume oflocks and abnormal trend data, Ipil for with my comments is if you had procedures in va night orders.That's where we stand right now. :pa place that maybe are difficult to follow or cannot pa; MR. MILLER: How does that differ from 'pa) be followed, even in some cases,and you know that 941 what was in place to begin with? , 1041 but don't change that,the fact that you say that paj MR.SCAROLA: What was in place to begin los) pet with, Mark,is that we had a policy out there that lps;hollowyou expectation expect verbatim compliance if you tolerate leaving is really a rat pri did not distinguish between watch standers and 'on pmcedures in place.
pai non-watch standers coming to take a relief and l psi MR. SCAROLA: And we have with ot.r pq turnover.What Frank is pointing out here is the 'per improvement plan been trying to change that cultural poi distinction between the desk operator has already lpq expectation.1 think that all the operators,and pii performed the entire board walkdown at the beginning lp,j these gentlemen can certainly attest to this or pa of his shift.,He is cognizant of the plant's !pri correct me ifI'm wrong, but I don't think there's psi status.What he is not cognizant of is the ! psi any question as to what verbatim compliance is , p41 evolutions in progress.So their efforts have been lp4) requested now of them. As we have performed this, pq how do we focus in on what's the key ifI'm moving lp3; g ll tell you that in the past this has been looked Pago 57 Page 59 , pl (mm the desk position over to the board, what is l 01 at as a skillof the trade evolution,and you know m the critical information that should be transferred pi through your inspection that we did not have that p1 to me,and how are we going to assure that transfer pi procedure out and were not following that pl ofinformation. ; p) procedure.It was a matter of maneuvenng two (q So it's incumbent, first of all upon the (si valves.They had always performed this evolution in im board operator,to verbalize cach of those three ' tai that same practice.
, m areas.The desk operator has to perform the repeat ,m That's why the discrepancy and the 1s1 back of him on those same three areas.So we've p1 stand-down said Hey,we can't verbatim comply with m formali7ed now the specific areas of turnover that is) this,and it was because we had not gone through and om they have to conduct between those two individuals- pq pulled the procedure and said Hey,we have a nii MR. GIBSON: So the procedure that was in on procedure for this evolution.do we comply with it.
Da place required a comprehensive turnover for all :prj That's just to acknowledge you're correct,and we've ps; situations.Was station management aware that the pai taken actions to address that. And we have a ways na comprehensive turnover was not taking place? pq in front of us to go yet in procedures to continue psi MR. SCAROLA: I have to acknowledge that psi to work through that.We've added three people to pq we enher were aware or should have been aware that om our procedure rewrite in the last month,and we're pq that was not occurnng.I certainly have been in on continuing to focus on the ops procedures as our pel the control room - psi highest priority right now, pq MR. GIBSON: This is similar to the fact : poi The last area that I want to cover on the pq that you had made changes, perhaps improvements,in 'pm procedures and policies is an area that we picked up
;29 the Umt 2 dilution procedure but had not made those try fromTurkey Point.We still have this procedure in na same changes to Unit 1 and must nave known that the :gr) a dmft format. However, we are implementing it '
psi Unit I procedure was not being closely followed. , psi stillin the draft format,and that is an event 94) MR. SCAROLA: Personally,1 did not know :p4) response team.We found that the event response psi gve had that discrepancy.At the time that the lps) teams down atTurkey Point have ensured a timely and BROWN REPORTING, INC, (404) 876-8979 ' Min-U-Scripts (17) Page 56 - Page 59
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IN llE: ST. LUCIE FING NRC , Page 60 Page 62 pi thorough analysis of the events there,and we're p) QA will assist us in this area in looking m taking that lesson fmmTudccy Point and we're gj at the industry events and our corrective actions a bringing it up to St.Lucie for implementation- pi associated with those events,and we will continue pr The next area,and I'll be brief on this, p) to put some emphasis and strength in this particular isi D the equipment area.This again presented an tsj area.
esi cpponunity for us to focus in on the dark boards. Isj The last item I want to talk about m the importance of the dark boards on all the a briefly is the safety significance of this event, iaj annunciator panels to the opetutors.We had an taj and I'll go through some of the numbers here for m annunciator that did distract the operators at that m you.As far as the reactive power,the peak power pq time.it was a nuisance alarm.They did write the sq that we had reached is 101.13 percent,the cold leg on work order and initiate the right activity to on temperature,and this is the max indicated na correct that when it came in,but nonetheless we paj temperature.There was one RTD that we had that usi took this opportunity to brmg our engineering ps) actually read above this, but what the operator's 04) manager in. Dan Denver came up to the control room p4j controlled by,the max was 549.75 degrees.The tech pq cad our maintenance manager and we had a meeting in pq spec limit for this particular parameter fort-cold ps; the control room to discuss the nuisance alarms and pel and consideration of DNB is 549.The LCO is that na the importance of responding quickly to climinate on you have to return below 549 within two hours.In poi eny nuisance alarms on the operators. And I think pai this particular event we exceeded 549 for a total of poi that we will continue to give that the highest IcVel poi 50 minutes.In addition,the UFSAR analysis for pq of attention.
pq this event,it does cover dilution events in Chapter 99 The second area is automatic versus * !py 15.The discussion in Chapter 15 assumes a dilution pa manual mode of operation. From day one St. Lucie pa of primary water directly to the suction of three par has been operated in a manual mode of operation.We ps) running charging pumps, which puts you at 32 gallons p4; took the opportunity here to readdress that with our
,p41 perminuteinjection.
pq other CE units that have similar CVCS control
! psi The UFSAR goes on further to discuss that Page 61 !
Page 63 01 systems.We found that it is common practice that vi this event would be called to the operator's pi the dilution and boration systems are operated in m attention by VC * alarms, both pressure and level, pi manual. Now, the reason for that is to maintain p1 and if the operators did not take the appropriate ni reactivity comnol always in the control of the si action to terminate a dilution event at that rate at gi operator.We will contmue to operate the system in (si that time, then the thermal margin low pressure and isi manual, although we are looking at the auto features
; rei variable high power reactor trips would be taken m as a potential backup to that operator.We want the
' m into account and shut the reactor down, protecting m operator to maintain his hands-on control of inj DNB limits.In contrast to this event, we did have m reactivity additions in this power plant, so we'll m one charging pump running,and that put us at 38 pq continue with that philosophy.We do have a 50.59 pq gallons per minute injection,and it was direct 09 th:t was put in place that ensures this was inn primary water to the suction of the charges pump as em consistent with the analysis in the UFSAR.
'pa opposed to the analysis of 132 gpm. Again,in this ps; in the traimng and quality assurance pai event the operators responded prior to recerving any 04; area, we talked about this being a snapshot in time, p4; alarms and immediately terminated the event in nu makmg sure we don't lose these lessons.The pq progress.
net importance of including them in the continuing .ps: The last point that I want to make is en trairung is how well we're able to sustain these
;pa that we did look at this from a PSA standpoint,and ps lessons in the long run.We have incorporated this (0:1 in terms of core damage this event shows no no: into our continumg training program. And then also ,
; psi significance.This event did not affect any of the a a lesson learned out of this is the effectiveness of
:po: mitigating systems that would affect core damage.
99 our corrective action pmgram. Clearly these events lpy We did assume in this analysis that this event went pa h:d occurred elsewhere in the industry, clearly they ;pa through a reactor trip,that the operators did not am had occurred atTurkey Point,and there were !asi take action, and that it was terminated with a p4} correcuve actions put in that we at St.Lucic lpo thermal margin low pressure reactor trip and that it
- <q should have learned better from and did not. lpst did not increase the core damage frequency making Page 60 - Page 63 08) Min-U-Script @ BROWN REPORTING, INC. (404) 876-8979
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pj do,and I hope you that can increase their m Unless there's some questions that I can m sensitivity.More than the fact that you're talking ! pi address, ril turn this over to Dan Denver.
p1 to the NRC, our company's assets are on die line, p1 MR. EBNETER: So I should conclude, then, p1 your careers on the line.
ts; that I shouldn't worry about this? tsj MR. CONE:Yes, sir,rm aware of that rei MR SCAROLA:No, sir.
rei and have been aware of that.
m MR. PLUNKETT: You should conclude that m MR.JAUDON: As Mr.Ebneter has made ; is the safety significance was not very large,but rei clear, we hold management accountable for carrying rei cverybody knows that.That's not the point.The ' m out the responsibility of getting that information pq point is it's a very senous event,the operators' pm to you.
py actions,our actions from management,the whole ball ny MR. SCAROLA: And I accept that the na of wax.1 don't want you to think we're not taking . pa accountability,I acknowledge that accountability, og this very seriously. pq and I assure you we're followmg through with it.
04j MR. EBNETER: rm just making sure I MR. EBNETER: You need to reinforce what psi wasn't getting the wmng message. lpq ps Frank does.
pq MR.SCAROLA:IfIleft you with that Ipm MR. SCAROLA: Mr. Cone can certainly on message, Mr. Ebneter, then I missed the whole point lpa assist management in carrying that expectation out, em of my presentatien.This incident was very serious lom but management has that accountability, poi in terms of St.l.ucie and where we're not on our om MR. EBNETER:It does have a big impact pq get-well plan and where we are.We learned a lot pq on your peers when you guys can talk with ther pq about out organization's effectiveness,about our my directly.
pa communication expectations to the operators and fpa MR. SCAROLA: And I assure you that we p3) where we are in relation to our operational Ipsi will take advantage of Mr. Cone's communication pq standards with others out there.We recognize we lpg skills with the rest of his crews, pq have a lot of work in front of us and don't intend {ps MR. EBNETER: Thank you.That's good, Page 65 ! Page 67 pi to close the book on our improvement plan,but this ! n; Frank.1 appreciate that.
m certainly aids us in ensuring that the right things
{m MR. DENVER: My name is Dan Denver,and ni are in that improvement plan.From that standpoint ! p; Tm the engineering manager.
p) it is very significant to us.
lp) MR. EBNETER: And you're here to tell me rsi MR. C:ME: May I say something sir? rsi not to worry,right? n MR.EBNETER: Sure. tej MR. DENVER: No.Um here to tell you m MR. CONE: Um well aware of the m how we screwed up, rd like to talk to you this a responsibility that's on my shoulders having a l tal morning about apparent violations B and C. Apparent m license to operate this facility,and Tm just as ! m violation B is for inadequate design control,and pq keenly aware of what the consequences of my poor
{pm apparent violation C is related to inadequate 10 CFR pq judgment and poor operating practices may have for ivy 50.59 evaluation. Apparent violation B says that na all of us.My sensitivity to this has been really lpa design control was inadequate in that pmcedures for om tuned up.and I can tell you right now and assure inai adding demineralized water and boric acid to the RCS pq you that when I go back to our plant,St.Lucie,all inn did not implement the method in Chapter 15.
psi my peers will also know that directly from me to 'o si Our assessment of this particular om them. Ipsi pmposed violation is that we concur with that on MR. EDNETER:Well.that's good. because
.pn apparent violation in that the UFSAR describes ps: I would expect your sensiuvity to be tuned up. lf om automatic mode as being the normal mode of operating pa it isn t there's something wrung with you.But insi the plant for the CVCS.and that dGes not conform to pq you're the only ones here, you three guys.How many 'pm plant practice, nor has it conformed to plant :29 others are sitting back at the plant who are your 99 practice for many years.
pa peers? pa After reviewing that, our conclusions psj MR. CONE:I will speak directly to lpa that we would find on that is that it definitely pq them.
lpy does not desenbe in the UFSAR exactly how we psi MR. EBNETER: That's good.1 hope you just operate the plant and that this inconsistency is BROWN REPORTING, INC. (404) 876-8979 Min-U-Scripte (19) Page 64 - Page 67
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ages'ch 8,1996 ' ' IN RE: ST. LUCIE PIANT NBC . , .
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Pagese -Page70 pl only one of a number of inconaamrencies in the tu wait until the following one.On Unit I we will be gi UFSAR, and we've established a plan to climinate - A making the corrections in time to make it with the p these inconsistencies.For this specific concern, si normal report we give six months after the fuel si the inconsistency with the CVCS system,we have el outage,which will be in approximately December of
: til completed a safety evaluatba,and we have put the tsi this year,the refueling outage to start in late (or UPSAR chang information itioutlibraryor catalog m April.
- m ofinformation that will be updated in the next m MR. JOHNSON: This is a one time review? pi UFSAR update. pj MR. DENVER: Yes,it is.
ml To go further than that, we have taken a pi MR. JOHNSON:Now, things go on all the og very hard look at our UFSAR, which is a total of 29. pq time, activities,and you have systems and on volumes,between the two units.We put together a on procedures that you're supposed to implement to make pri team of ten individuals that were senior na sure that whatever you do doesn't change the safety psi multidisciplined individuals ranging from licensing ps) basis as described in documents like the UFSAR. Do pq to engineering and operations backgrounds,and they : pq you have a plant safety review comnuttee? ns) in a period of a week and a half to two weeks did a psi MR. DENVER: Yes.
pai review of what was roughly a total of a third of the pq MR. JOHNSON: Do they know what's in the un UFSARs.They roughly reviewed somewhere over 50 on UFSAR before they're qualified to serve on that og percent of the text section of the UFSAR and a par committee? pq relatively smaller portion of the tables and the poi MR. DENVER:They have a general am charts that are in there. Ipq knowledge of the UFSAR,but I don't think that you pq MR. ESNETER: There were ten people on !py could count on them havmg a level of detailed pa that team? I pa knowledge of all 29 volumes of the UFSAR.
pai MR. DENVER: Yes, sir.
pai MR. JOHNSON:When people come to them pq MR. EBNETER: Did they include some pq and say,We want to do this procedure, we want to
: psi operators?
psi make this modification,they're the ones that have i Page 69 Page 71 (9 ' MR. DENVER: There were operations p1 to say it doesn't violate any of the bases in the
. p1 personnelinot current operators on shift,but i m UFSAR,so how can they do that without knowing pt people that held ROs or sos in the past.That was ' pl what's in there?
p1 very key to our review, because obviously we needed MR. PLUNKETT: I don't know what chapter si Isl to make sure we captured the ways the plant is ; tsj to go to to look for a specific system or something ter operated,both as m procedure as in practice. I m like that.With an SRO background I have some m The conclusion of the effort that we : m knowledge,and that's what I would expect from these tai undertook was in fact that there are a fairly large l Is) peopic.Nobody in God's world is going to know p1 number of inconsistencies in the UFSAR.The l pl what's in all the volumes.
om majority of those are internalinconsistencies or 'pq MR. DENVER: If I started stacking them pq editonal type problems. However,there was a inn here for you it's going to go this high.But you're na fraction of the problems that wete identified that lpa absolutely correct.There has to be a process and pai were m fact inconsistencies relative to the lps that process failed us.
99 procedures or operation of the plant or design !py MR. JOHNSON: That's what I'm asking.
psi questions.Hased on the review that was completed. (psi MR. DENVER: Our process failed us. And poi we've assessed what the total scope is that we 'pq if you'll bear with me a second I'll get to that.
pn believe the effort to correct the UFSARs will be, I MR. PEEBLES:It appears that you're
- pa! and we have initiated that effort at this time.
pg
.!nn vel saying you've got to change the UFSAR.Were there our plans are to complete the review of
!pe any instances where you've got to change the plant pq the mconsistencies and to establish the change
.pm procedures bec,ime the UFSAR was indeed right?
pn informauon necessary for the UFSAR far Unit 2 by ' inn MR. DENYUl: No, not changing plant pa September of this year,and we'll be providing a :pa procedures nor have we found in our review so far pa some report or submittal to the NRC.Our normal six
'ast that would result in an unreviewed safety question.
ps st;onth update following an outage will occur before ipy
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MR. CASTO: What number are we talking psi that,but we'll makc a special report 30 we don't { psi about? Page 681 Page 71 ' (20)_ Rgle-U-Scsipes BROWN REPORTING, INC. (404) 876-8979
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Page 74 19 MR. DENVER:In roughly a third of the pj Again,we concurwith the violation.And ' pi UFSAR we found 650 totalinconsistencies.Of those. pi again,the fundamental proble'm is that the UFSAR tsi approximately 500 were editorial or spelling, things pi description is just not consistent with the way we Mi of that nature.About 150 or 160 were things where pi operre the plant,and we've been operating the ' m we found an inconsistency between pmetice in the tsi plant with these practices since 1976.
- el plant.Our extrapolation based on the type of a rt.GissoN: Well,that's part of the m population that we did look at would tell us that we m problem.The other part of the problem is that you m expect we're probably going to see about 300 of isi made that procedure change last month and did not go m those total that we're going to have to look at very ; m back to check the UFSAR in the process of making the poi hard and make suse we don't have anything of noi change.
pu sigmficance in there by the tiene we're done. pq MR. DENVER: That's exactly correct, and pri MR. GIBSON: There's one comment I want pri that's the essence of violation C,the comparison t'st to make before we leave this subject aitc,gether, pai that was made by comparison to what was there in pq The UFSAR,as I recall, describes this automatic pq time,not back to the mot document.And of course pH control feature as a safety feature presumably to psi the screening that was done for this particular ps) prevent just the sort of event that occurred here, lps) temporary change doesn't support the conclusions un and I hope that your review is very careful before lpn that were made, which were that this wotdd not eq you decide that that's not the right way to go, !psj affect the UFSAR,and,as a result,the UFSAR or poi because it would appear, had you done it the way it ipei procedures screening process very definitely needs not was described in the UFSAR, that it might hase poi to be improved.We're developing procedural changes pq prevented this event, pq and we're improving the screening process for pri MR. SCAROLA: Let me address that.1 pai procedures to approve the process such that the ' pai think last year one of the units was operating in pai screener that does the evaluation will be required pq auto and the auto cut out, had failed,and they had inq to identify the sections of the UFSAR,the technical psi a dilution event as a result of that.1 think the l psi specifications that have been reviewed.This will i Page 73 l Page 75 pi proper thing would end up being a combination.Ilut l p) be a part of the process.It will be documented m from my perspective the operator in the lead,1 j m along with the screening.
. p) don't want his attention off of that,1 want him ipi We are at the present time conducting pi accountable to stop it and maybe use the auto { pi some training for those persons that do the pl features as a backup to that.We have to work
! sii screening of procedures to provide a special
! a further on that,and we may be the lead unit doing tai emphasis on the meaning of the procedures as m it that way, but to me logic-wise that may be the m described in the UFSAR.We're also intending to Isi right end result.
laj provide more cicar screening criteria directly n MR. DENVER:1fI could move along. tai associated with the screening procedures,and this pq pmcess-wise,in addition to actually correcting the poi is related to the identification of the technical ny UFSAR,which as you point out is going to be a pr, specification and UFSAR sections that will be pri one time shot,we're going to improve the process by pri requested for them to identify.
pal which we continue to nuintain the UFSAR so we will ps) To make this process easier,while we're poi not have this kmd of discrepancy creeping in m the pq going through the assessment that we talked about pu future, psi earlier in the UFSAR, which will be to essentiMiy poi l'Il claborate on that a little bit . psi require a thorough review of the entire UFSAR and pn further after I finish discussing apparent violation on touch every page, we'll be identifying those poi C because they're really intimately tied. Apparent esi sections of the UFSAR that in tact have procedurcs vej violation C is for a 50.59 cvaluation that wa*
. poi associated with them and providinga poi inadequate in that the licensee made a change to the poi cross-referenced set ofinfornution to make the job pu Unit I bortm dilution procedure to allow my easier for the person sitting there at two or three rm demineralized water in nunual and direcrjy to the M oilock in tlm morning trying to screen a temporary gni suction of the charging pumps that was different ,ps) procedure.We're going to take the information fmm pq frum the method stated in the UFSAR, Chapter 15 and psi without preparing a 50,59 safety evaluation.
. . _ _ _ _ _ _ lpq psi that thewill result of that,and will be referenced,they thebecome sections a of the UFSAR
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m procedure,in the body of the procedure,so,when g MR.JAUDON: One question.What are you pi he's sitting there in the middle of the night,at a pi comparing inconsistencies with? pi minimum he'!! know where to go to the UFSAR. He inay pi MR. DENVER:What are we comparing - is; have additional things he wants to look at, but it (sj MR.JAUDON: You said you're identifying n will make that pmcess casier. pi inconsistencies.What standatti are you comparing m The net result we believe that we'll end m the UFSAR to? Is) up with by the time we complete our corrective si MR. DFNVER: To the design basis for the si actions for these two violations is that we will pi plant either identified in the fuller context of pq have improved the UFSAR and brought it up-to-date pq design documents or the plant obviously has been on with current plant practice and procedures with the pq changed by change packages occurring over the year.
pri way we use the plant,and we will have put in place prj The physical modifications of the plant have been psi a process which we believe will prevent us from psi captured very well because there was a very clear pq causing this ' kind of discrepancy to occur in the pq process for changing the UFSAR.The biggest atras psifuture. ' osi that are ripe for having inconsistencies is where ; psi Now,if there aren't any further pai procedures have changed, where systems are operating on questions- nn somewhat differently than described. Really, when pra MR. ESNETER: When are you going to do ps: you get down to it,the esser.cc was describing a pet all this? poi method as normal that we don't any longer use as pq MR. DENVER: Mid September for Unit 2 and pq part of normal operation.
pq December for Unit 1.The procedural changes,we lpy MR.JAUDON: So operations is a big l pri haven't set specific dates now, but I can assure you lari vulnerability, variations in operation.
psi we'll have them in place within the next few weeks (psi MR. SCAROLA: Operational practices.
ra to a month. ! rey MR.JAUDON: What about technical psi MR. EBNETER: That would be, r.ay, April !ps1 specifications, license amendments, things like Page 77 i Page 79 p 10th? p) that? pi MR. B0HLKE: March 31st. pi MR. DENVER: All those have been captured pi MR. DENVER: That sounds good to me.
pi fairly well.The process was pretty well put in pj We've already concluded some of these corrective p) place for capturing those kind of things.
isi actions as we were preparing for these meetings, and pi MR. SCAROLA: The license amendments and i inj we haven't actually dragged the rest of the pi the plant modifications,I think that we're in l n orgainzauon along with these dates.
' m fairly good shape in terms of the UFSAR.In terms y MR. EBNETER: What about your screening isi of operational practices and some inconsistencies in m critena?
' si the UFSAR itself.where it has something in Chapter pq MR. DENVER: It will be enhanced as part '
pq 15 and Chapter 8 may not have those same un of the identtfying- ,04 descriptions in there,or.if you look at the j pri MR. EBNETER: March 31st? pri drawings.the drawings may show all the paths for psi MR. DENVER: Yes.
jos) normal and manual but the only description is for
-
pq MR. PLUNKETT: We're meeting with you on
.py auto and it has three different modes of operation usi Apnl 1st.so wc*ll tell you by then. insi that are all shown on the drawing, all discussed and pq MR. EBNETER:I'm not pushing you. ps bound by the Chapter 15 analysis, but when you get ( .p n MR. 80HLKE: The trainmg that Dan's on to the operating descnption in Chapter 8 there's
! pq talking about is already being done.
l ; psi only one of them described,it's those types of poi MR. DENVER: That's being done as part of inei thing tnat is Dan's pickmg up on.
pq the requal on our STAS,and we had the second week .pq MR. DENVER: The wnteup in the m yesterday; g2i l:21 enforcement letter we received was correct.These MR. EBNETER: And the last one would :p21 are on pages that had never been touched.and
- pm pmbably be in conjunction with your UFSAR review; l psi obviously that's one of the areas we have our pai is that right?
pq greatest focus on now to make sure that there are ' ps
-..MR. DENVER: The cross-references won't - - -
asi things that have not gotten out of kilter.
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l , PROCEEDINGS BEFORE MR. STEWART D. EBNETER ] IN RE: ST, LUCIE PLANT NRC March 8,1996 l l l 7 Page 80 Page 82 l In MR.JAUDON: We are finding examples of pi that,you know,there's a pretty big gap between _ pi where the technical spedfication limits, comparing gi what goes on in this building and what goes on in j p1 those to the UFSAR,if you'd complied with what was p; the rest of plant.Well,that's not real good news p; in the UFSAR you may have violated technical 81 for management, but at Icast it's honest and ; 19 specifications;forexample,a coreoffload. rsi actionable,and we've been trying to bridge this ! is) MR. DENVER: Those kinds of things is) gap.What Frank was telling us was that even after l m typically have gotten much more clearly updated when m several weeks of working on it we haven't made 1:1 changes have occurred. Is) enough progress.When we talk about management's pi MR. SCAROLA:I think in this case the p) expectations,we ned to talk about how we i sq UFSAR described normal operation at 549. pq communicate them, implement, monitor and reinforce og MR. DENVER: 549,that had always been on them.
Da there,and the basis of the thermal trip had always pri Jim spent a lot of time on operations and ! pa had the lowerlimit at 549.That was always ps) what's in it. Again, we were talking with the pq inherently a part,and rd assume that was a flaw in pq operators,and they pointed out that our anticipated pq the documentation from day one. !t was written that ps! requirements for short term turnover in the board , n way. pm RCO and desk RCO turnover on the peak shift probably on. If there are no further questions,then Inn wasn't a reasonable expectation.1 think at that set Mr.Bohlke will conclude. 'pq point the light bulb went on and said it doesn't pel MR. BOHLKE:Actually, Tom has some poi make a lot of sense to communicate an expectation pq closing temarks,and rm goi% to try to set him up lpq that isn't achievable.Now, we have revised the 99 in a pccitive sense. pn conduct of operations at least once since this 1 pa As Bruno was reading thmugh the overall pa event,and we're planning to revise it again at the rnt structure,it occurred to me that what I was talkin8 pa end of the month,but we want to take a little pq about was actually described in the regs.It's a py different twist on it.
pq common understanding of the significance ofissues (psi First of all,Pete Honeysett suggested I
Page 81 * Page 83 pi and the need for lasting comprehensive action. ! pi that all we ever did was add to it and didn't take gi That's pretty much the theme of what I intend to fa anything out ofit,and so we want to open it up for
.
pi talk about be afternoon. Another way of putting a pi feedback from the operations department and then el theme on my talk is thinking ofit as an answer to pj work on achieving a common understanding and Isi the question:Can the boron dilution incident be the . is) acceptance of what's in there.And then,instead of m watershed event that catalyzes the final cultural is) a conduct of operations,it really becomes more of a m change that we need here at the St.Lucie plant. m contract for operations, a bilateral contract m rm going to talk about five categories. , tal between management and the operators.1 think that m They're different,but they overlap the categories j m will be a significant improvement.
pq that were inJim's presentation.It's pretty !pq Jim and I have been pushing really hard pq obvious from the way we structured this that, !nq in communications with the whole plant staff,not na starting with managernent and ending with management. iva just the operations staff,and we've been hitting om because although Hank precipitated the mcident by :pm areas of accountability, attention to detail, en leaving his station,the material we reviewed this
!py housekeeping,and we got a little extra help with psi morning certainly suggests that we did a lot to set Lusi housekeeping a little while ago, repetitive pq him up for failure,and therefore we can't effect ;ps! equipment failures and personnel safety, and we need on permanent corrective action or permanent cultural :pa to continue to do that.But it doesn't do us any sq change unless rnanagement owns up to its lpu good to talk about it.we've got to figure out how pai responsibilities,and that's what I want to talk Josi wellit's being received,and when we get back down wg about.
- pq to the end, management performance,rll talk about 94 Startmg with managernent. in ;aeparing :py that,
,
pa for this meeting we were working in my conference Ipa To wrap up the management expectations
;r:; room at the plant and we were tniking about various {pa thing, what we're really trying to do is make sure pi l ir, sues,and Frank volunteered. As you probably '
we figured out, Frank can do that. Frank volunteered lpq psi itwe set forth positively whenthe proper we see expected it being behavior, reinfo accomplished,and
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Page 84 Page86 pi take corrective actions when we see that it's not. pl of management expectations we put out there, m The second major area I want to talk m whatever we think is going on with the operating ni about is programs and procedures. As we've gone p) experience feedback prograrn,if we're not using n through this presentation, Jim and Dan have pointed pi training to convey those messages and lessons, we're tsj to some programs that took some pretty big hits,and ist missing the boat.When we looked at it, we a one is the UFSAR update book. Another is the p1 determined we needed to change the tuining.We m operating expenence feedback program.You can ask m need tuining to be turning out world-class ' pi whether the FRG was effective when it approved a (si opentors,not turmng out operators who've passed te change which led the Tc alarm further awa" from the si licensing exams.There's a pretty substantial pq tech spec limit.Some work needs to be done on pq difference in focus when you look at it that way, pu programs.and we've outlined the UFSAR conformance I.et me give you some exampics.Zach v4 na review upgrade.That's going to send the right 02) Pate's memo is eight or nine pages long. It is very psi signal through the site,although it's one heck of a v31 focused and very clear.There are some other good na lot of work.Then we've got to make some tough 04) things out there that can help us think about psi management decisions on what level of resource, both psi improving human performance.We need to use psi numbers and talent wise, we need to make that an pq training to reinforce the expectations of management on effective program.
lpa or to rearticulate them if they have not been psi The event response team of course is a {pai appropriately conveyed.We need to use training to pq new approach arising from a program atTurkey ' poi pmmote the desired result or desired conduct when pq Point. Procedures took a hit this morning.We pq we talk about changes in command and control, when su talked about procedures when we were up here on the lpu we talk about changes in the way we approach and pa 8th of February. At that point we said we've got a prj conduct routine operations, which was pointed out so rai lot of work left to go on procedures just on the ps) succinctly.
pq shear standpoint of volume,and we continue to take p) We need to make sure we're getting the pst hits on the procedures almost every day when we go psi right conduct in the simulator such that when we go 1-Page 85 I Page 87
;q out to do work and find they're not adequate,not pj out to the plant we are reinforcing that conduct by m because we're not trying as hard as we can but ; m the ANPSs and the NPS and the ops supervisors and ni because there are so many procedures and the level p) the managers.We need taining to be sure it's n of detail that pervades all of them. pj helping the operators learn and be refreshed in mi And not to be redundant to what we said f ist their learning through their requal cycles. And l pr on the 8th of February,but the important things on , p) piubably most importantly,we need training to bc m the quality of procedure are the ability to be l ! m willingly and aggressively accepting feedback from '
is) executed,UFSAR conformance and clarity,and we also l pi operations at our plant and Turkey Point and out in p! look for consistency in the level of detail between ! p) the industry, making sure that that is put into the om and amcmg the procedures and making sure,as you pq lesson plan. j pq pomted out,that when you upgrade a Unit 2 ;py Coincidentally,I happened to be ' nn pmcedure you ought to be upgrading the Unit 1 pri observing a training class,and it was on the om procedure at the same time so the people can bring 'osi control element dnve mechanism.1 would tell you pq the nght level of focus and attention to the p41 that the operators were absolutely fascinated with psi operation.
- psi the discussion.It was a very acuve exchange psi We report on procedures every month in !per between the in a uctor, who was extremely competent pn our monthly indicator book and in a meeting we have, lpa and very knowledgeable,and the operators because pq and we'll continue to do that as well with any new l l psi they wanted to know what was going on and what the j
poi indicators developed, such as the quality of the 'pei differences were,and that was extremely effective.
am procedures being produced by virtue of being able to ) pq Why was it effective? Because h was really current ' au gauge the numbcr of errors or returns for rewrites.
- py with the condition gomg on in the plant,so they pri The third area is traming.The borun pa had and interest.We need to bnng that level to as dilution event was a wake-up call for us on ;pai more of what we do,and that will help the operato:
p41 trammg, a real wake up call.When we started !p41 get :hrash those weeks that sometimes I think they psipoking at it,we could see that whatever the level jpsi don't neceverily look forward to.
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,, Page. 88 Page 90 1 pi The fourth area is personnel vi of fertile ground for us to work on,but we can't m performance.We also talked e put that on the 8th.
f m stop there,and with Tom's approval we're going to pi and at that time we said getting sophisticated i ts) go into a mttch broader self assessment effort that p1 indicators to give us examples of personnel p) we expect tc produce a report on in about the July 151 performance is a major effort for us and continues is) time frame that's going to track our investigation l Is) to be,but there are some things we need to do,and , m of the way we do operations,and it will ultimately j m we'll be talking about them on the 15th and again on ! m be reflected of course in the revised conduct of l m the ist.It seems appropriate for us that { inj operations,but also to point to other areas where j
- m sedvities conducted 24 hours a day are monitored l Is) we may be enemaching upon a tech spec limit or a l pq periodically 24 hours a day so that we can see the 'pq design basis limit of some rype, places where we set I pq way expectations and procedures are consistently 09 the operators up to fail,much as we set Hank and ;
pa applied.or perhaps more important, inconsistently ,pri Frank up to fail by runningTcold at the tech spec l pai applied and to see how various sets of personnel !pai limit.
04: respond to the situations that come up- [p41 There are other areas of the plant that ! - pst I think we need to take a look at HPES l psi wouldn't say are necessarily equal to a diteu poi and see if we're getting our money's wonh out of lps) impact to nuclear safety, but they could eventually ) < pn it, not that the HPES individual or individuals Inn wind up there in the way we do our preventative ' pq aren't doing their job. but the way we're using the {pel maintenance processes and the way we account for the pm information to help us manage the plant.We need to ipei fact that St.Lucie is now 20 years old.These are i pq be doing a better job analyzing and trending the !pq the kinds of things that we need to be looking at in pq informatson.We've got 24 or 25 in-house events as ipn our self-assessment as weU as,again,the { pa of this morning for this year,and that's a nice Ipa commitment to look at management self-cntically.
- rn; number to take a look at. It's not too many and yn Talking with the crews down atTurkey Point has been pq st's not a few. p4i good for our crews,and we understand they enjoy psi We need to get some sense of how thinM ps) talking to our crews as well. Making sure that we ' Page 89 Page 91 pi are going and do the events taking place reflect ! p) have the appropriate questioning attitude and that m things we have presumably fixed or do they point to ! m we can count on that being present in the whole , ni things we haven't yet undertaken and that we need to I p1 management corps every day is really important, such (q take a look at,and we need feedback from these i pi as why are we running aT-cold at 549 and why are we ts; events to take a look at the performance of our ' m bumping the limit up.Something broke down.
[6) operators and other individuals in safety-related isi llasically,we talk about the 25 m spots.So we need to be doing some work on that i m corrective actions and the problem report that we io; because we talk about personnel performance in our j m provided you a copy of and the additionalitems that m monthly meeting,and that seems to be a good forum igj we are going to identify in the self assessment " pq to both report and discuss on these issues. 'pq that's going to go over the next four or five pq Last but not least, management pq months.Our commament is we want to bring those pa perfornunce. Jim has owned up that he's learned a !pri into the forum for discussion in our monthly l pm lot from this from the standpoint of being able to 'us) indicator meetings or monthly status meetings that l sq resp (md to events that cross the defined threshold 941 Tom and representatives from Turkey Point will ps; for safety significance and the appropriateness of psi attend, so we've got a pretty open discussion of pai management response.1 want to take it from a ps) what we're finding and where we arc.
pn dtfferent standpoint. pn in addition to that. I've asked the pai This event is another example of a less ipo company nuc! car review board to take an oversight pm than adequate self-assessment program because we : poi role in terms of constituting a semor review team, pm didn't take the opportunity to go out and find out 'pq and they'll have to augment their resources with an
,
an whether the conduct of operations was bemg pq external person who's pretty knowledgeable and gri followed.That's a pretty major hit,and that's an <pa bmadly based in the operations area so we get the pm area that we have to really, really improve on. As lpa; right focus on this thing so that at the end of the in it stands right now, Jim's root cause team that he :p4) day we've extracted the maximum benefit from this
;rsi established on the 31st ofJanuary uncovered a lot
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PROCFRDINGS BEFORE MR. STEWART D. EBNETER March 8,1996 IN RE: ST. WCIE P1. ANT'NRC . Page 92 Page 94 pr St. Lucie instead of wiping our brows and saying pj MR. PLUNKETT: No.But my initial-p1 thank God that has passed.Those are our intentions pi MR. EBNETER: You heard it, right, Frank? pi with respect to what we're going to do and how we're pj MR. CONE: I heard it, yes.
p1 going to report out the results both internally to pi MR.PLUNKETT:Just a quick comment herc ! isi ourselves and in a form to report to you. pi at the end.We have and are taking very extensive isi Are there any questions? pi corrective action,and the reason we put the safety m MR.EBNETER: Staff? m significance up there is because that's part of how pi MR. CASTO: You talked aboutTurkey pi you folks consider enforcement action. or at least si Point, and Jim,I think you talked about you and pi your policy says that.But once again,I want to
, pq Turkey Point have a conference call now, Do the pq make absolutely sure that you don't think that we're 0g Turkey Point operators get a letterin their ny underestinuting this event at all.We are not, and na mailbox? pri I hope it's clear now after today that we've taken psi IV A. SCAROLA: I can't tell you that Don vai this about as seriously as you can. It's much, much 04) hr s implemented that.They may have taken similar v41 broader than the safety significance that we had up psi actions previously. , psi there.
pq MR. PLUNKETT: If Ellis was here I know I pq Concerning the UFSAR,the UFSAR is a on would have gotten the question about why we had the jun regulatory contract we have with you folks.Our psi event at Turkey Point in 1993 and then up there. lpai contactors, they meet the contract, and we have an pa The corrective actions taken in 1993 at Turkey Point l poi obligation to meet the contract there also.1 think pq were very extensive.They don't need a letter. kam almost every plant in the country is going through an They've got that under control.The question is why {py some exercise now to try and match up plant design na wasn't this relayed up north,and it wasn't,and n with the UFSAR,and we will meet the action as Dan pa l've taken that as my responsibility.We've already pai indicated on his schedule.
p4i had discussion that we've been pretty much operating p41 That concludes our presentation, Mr.
psi ts two separate companies, and that's just not the ps) Ebneter.lf you have any questions we're Page 93 Page 95 pi way we are doing business anymore, so the ball was ! p) available.
(a put in my court a couple of weeks ago to make sure lpi MR. EBNETER: Questions? pl we're sharing everything,and we are.We're shanng . pi MS. WATSON: I have a few points,ifI pi it every morning.We also have other ways of l p) could.The 50.59 evaluation on manual mode of pi shinng it now because both sites will use condition j ist dilution and boration I assume has been completed isi reports and we're both going to be operating the ' l pi according to your problem report. Did you conclude m same way.Does that answer your questiot4? m that it was okay to use manual dilution boration is) MR. CASTO: Yes.
p1 directly to the suction and charging pumps?
. pi MR. PLUNKETT: Stu I'll just take a MR. DENVER: Yes, we did.
si pq mmute here.1 want to address something Mr Gibson inq MS, WATSON: Do you have a copy of that? pu mentioned on the integrator.1 had the same jpg MR. DENVER: I do.I can let you have pa reaction almost instantly, Unfortunately,it isn't ,pri that if you like.
Um that audible and that clear in their control room, ipsi MS, WATSON: I would.On the skill of p4) so that is on the corrective actions,one of the 25 p41 the craft versus procedural use,you said that you psi or so.
. psi would review that in the control room.and I was poi MR. GIBSON: That was a pmblem at Turkey pq wondering tf you had identified any other procedures sq Pomt,wasn't it? jpn that were being done, skill of the craft when the pai MR. PLUNKETT: No.We thought we were [pq procedure required them the procedure to be in hand, pq re:lly smart.What we did was the integrator wasn't .pq MR. SCAROLA:As part of our upgrade? pq wurking.it was a high maintenance item,and so we pq MS. WATSON: Yes.as part of the py replaced it with a high tech digital with no !py corrective actions.
pri audible,which was the wtung thing to do,so we went pa MR.SCAROLA: We have an ongoing pa back to the old one.
l pal improvement activity right now that's going through p4i MR. EBNETEA, I just thought that Frank
'p41 all our procedures,and that is part of the element psi had better heanng than the other fellow, psi that we're trying to sort through,what is a skill Page 92 - Page 95 (26) Min-U-Scripte BROWN REPORTING, INC. (404) 876-8979
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, PROrFFDINGS BEFORE MR. STEW /RT D. EMNETER ' IN RE: ST. LUCIE PIANT NRC MarchGb 1996 . Page 96 Page 98 pl of the craft activity versus what is an actual oj believe a total of ten RTDs between safety channel m unique specific direction to perform that activity, m temperature detectors and control channel si It's requiring the addition of some procedures,and p1 tempenture detectors that give us cold leg pj we're finding the deletion of some procedures also p1 temperatures.One of those multitude of temperature isi through that but we're not complete with that effort , tsi elements read the 550.8.So when we went back and isi yet, pi looked at the computer data we had one element that m MR. GISSON: I guess linda's question is m read that, isj that you have previouslyidentified which procedures MS. WATSON: You say that the licensed isi ! M you expected to be skill of the craft and which you m condition of maximum steady state thermal power was sq would use as reference procedures.Do you believe pq not violated during the event.What steady state pq the crews are currently following your previous pq thermal power did you reach? pa direction,or was this an isolated case? pri MR. SCAROLA: We went to 101.18 percent.
pa MR. EBNETER:Would you like him to pai The guidance on the 100 percent power- there is v41 rephrase that? :041 some guidance out.1 think it was an early letter psi MR. SCAROLA: No,I understand the Insi in 1980 that talks about the average power over a poi question.1 don't believe this to be an isolated 'pei period of time.
On case.1 believe that there are other opportunities on MS. WATSON: So you intend that to mean psi out there that we have still not identified.I'm ,ps! you didn't exceed the NRC guidance? psi not uncomfortable with where we're at in the cotitrol lpui MR. SCAROLA: That's correct.
pm room.Outside the control room and the field : MS. WATSON: That's all I have.
pH operators,I think we still have more opportunities lpm MR. EBNETER:Anything else? pa out there,or a higher number of opportunities with !py pa MR. GIBSON:I would like to remind the as the field operators certainly.Now,we have l psi operators again that if they wish to stay after the p41 insututed, and I'll mention this to you,we have a p41 meeting we'll be happy to talk with them.
psi management observation program that we have put in psj MR. EBNETER:It doesn't sound like the Pago97 Page 99 pi place to specifically assess our operating practices el staff has any other questions, so at this point in m versus our procedural requirements.We've been :ri the proceeding we normally take a break if the staff pi through the first round of that.We're still making pi needs one to caucus and see if we need to pursue si adjustments to get more spectfic. p1 anything else with you.Does the staff feel the isi Now, Turkey Point has implemented this m necessity to take a short caucus? m for quite son,c time.We took that from them,and is) MR. PEEBLES: No.I thought it was m we're making adjustments to where I assign to my m pretty complete.
m managers specific sections out of conduct of ops and pl MR. EBNETER: Jim Bell? m conduct of maintenance to go out and observe the im M2. BELL: No.
pq practice in the field and provide that delta so we ipoi MR. EBNETER:Jan? 09 can start addressing those deltas.but the deltas !ny MS. NORRIS: Not here.
pa still exist. 'pri MR. EBNETER: Does anybody want to take a pm MR. EBNETER: Does that answer your ps1 break and meet on this issue? pai question. Linda? !p4) ~ MR. GIBSON: I don't think there's any psi MS. WATSON: I think so. it sounds like pst disagreement.
pai you don't have an answer yet. ! psi MR. EBNETER:With that,then we thank pn MR.SCAROLA:We're still in the lon you for coming in and appreciate your candor, ps) assessment phase.! can't tell you how many there 'os) gentlemen.1 hope you've got something out of this pet are.
ipsj also.1 appreciate the time you put into the pq MS. WATSON: A couple of minor points. 'pm preparution.There were some commitments that you pq in your presentation >nu said you reached a cold le8 ,an made in here - and when I say commitments, pa temperature of 549.75,and in your report you used lpa committt.cnts have no meaning unless they're in
~~ pai the number 550.8. nsj writing, but we think - well, you know your dates.
pq MR. SCAROLA:If you look in the report, p41 They'll be on the record,but we can discuss those psi the 550.8 is the single point maximum.There is I ps! with you later.We'll close this meeting,and I _ BROWN REPORTING,INC. (404) 876 8979 Min-U-Scripte (27) Page 96 - Page 99
*
i PMFntNGS BEFORE MR. STEWART D, EBNETER - ' 1' March 8,1996 IN RE: ST. LUCIE PLANT NRC - j
!
Page 100 pl want to remind you that this meeting,this { pi pre <iccisional conference,is exactly that,it's pi pre <iecisional,and we still have to go through ' pi other steps in the final procedure. I r; I need to remind you of two qualifiers. . ; a First,the apparent violations we have discussed,
;
. m cnd there were three of them in this particular I tel meeting,are subject to further review and may be
!
pl subject to change prior to us developing a final pq enforcement action. Secondly,the statements or . 99 views or expressions of opinion made here by the pri staff or even the lack thereof don't represent any psi final agency position.With that, we'll just close 041 the conference and we'll get back with you within psi four weeks,when we would hope to have the nel cnforcement process finished, and let you know the prj results.
I pai Again, thank you for much for coming in.
poi 1 eppreciate it. ' rmi (Proceedings concluded at 1:10 p.m.)
on , pri R31 R41 R61 Page 101 pl l Iri pt CERTIFICATE 141 mi STATE OF GEORGIA: isi COUNTY OF FULTON: m I hereby certify that the foregoing ist proceedings were taken down,as stated in si the caption.and reduced to typewriting under poi my direction,and that the foregoing pages 1 ! Oy through 100 represent a true, complete, prr and correct transcript of said proceedings. , ps; This,the 18th day of March 1995. I pal i , 06l l pei . Keith A.Wilkerson CCR B-1381 My comnussion expires on the on 30th day of May,1999 > ps) - poi trol - try i
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pal !' i P31 tul 041
!
Page 100 - Page 101 (28) Min-U.Scripte BROWN REPORTING, INC. (404) 876-8979 - a
. . - . ! < . Lawyer's Notes i
s
,
e , O
e
(.f
. PROCEEDINGS BEFORE MR. STEWART D. EBNETER IN RE: ST. LUCIE PLANT NRC March 8,1996
2:30 29:7
"
actual 14:11; 56:3,8; , g A *:2 allows 44:3 aimosi 84:25;93:iz; , 0010120 12:1,15 3 ability 50:25,85:7 actually 46:16;62:13; 73:10;76:1;77:6;80:19.
94:20 along 73:9;75:2;77:7 1 0250020 I1:25 able 22:13,18; 61:17; 24 already 54:24; 56:20, 30 30-13 85:20;89:13 add 22:25;41:13;831 77:4,18;92:23 2:8 added 71:21,24; 22:12;
} abnormal 56.6,11 although 61:6;81:13; 8:10; 3W 35:14;59:15 above 31:4;43:3,22; 84:13 31st 34:25;35:21;77:2, , 62:13 adding 4:22:67:13 altogether 72:13 1 3:16;4:20;5:4;7:11; 12;89:25 addition 5:4,7; 12:24; absence 9:1 always 48:11; 53:2;59.5; absolutely 16:13;71:12; 13:2;46:22;50:1;62:19; 61:4;80:11,12,13 8 0:1; 38629 87:14;94:10 73:10;91:17;9& 3 amazed 38:12 73:21;76'21;85:12 accept 66:11 additional 4:11;10:20; amendments 78:25; 10 13:5;67:10 100 5:5;19:1,7;37:5; k acceptance 83:5 35:12;43:21;76:5;91:8 additions 61:9 79;5 45:33; pg.33 accepting 87:7 amonc 85:10 ss 3 9:13; 100.2 32:2 40 26:18 access 4:13: 50.8 , amount 11:23
101,13 62:10 45 26:20;29:18;54:25 accomplish 10:11 { analysis 32.8,36:9,13; accomplished 12:7,10, . '" 3 '
! 39:17;40:2;60:1;61:12; 101*18 98:12 11:46:15;83:25 l addressing 30:22;9711 l 62:19;63:12,21;79:16
'33 j adopt 41:9 i ac::ord 5:14 i analyzed 50:17 103 20:13 ! adequate 32:17;37:2, t accordance 8 8 i analyzing 88:20 105 19:14,15;20.25; 50 62:19;68:17 l according 95:6 l 18;85:1;89.19 announced 21:2;54:20 21:4;23:10 ! adequately 31:19;32:19; l 50.59 4:25;13:5.5;17:3; I account 63:7;90:18 ! announcing 23:14 10th 77.1 I 35:15,16;40:24;50-17; 43:25;45:9;46:10;61:10; ! accountability 25:16; ' annunciator 60:8,9 11:30 28 24 67:11:73:19,25;95 4 32:4:33:12;41:1,10, 53:4;58:5 12 25:7 500 44.15;72:3 48:25;50:21,23;52:23;
'
j adjustment 43:6 25:24;28:17 12:00 28:24 54745:5 53:19:54:12;55:21; adjustments 55:19; 548 43:24;45:14 97:4,7
,
MPSs 87:2 132 63:12 l 66:12,12,18,83:13 accountable 32:11; 66.8, administrative 12:1,6,9, anticipated 82:14 14 25.7 548.5 43:25;45:10 73:4 15 anybody 99:12 15 17:13,16;62:21,21; 548.8 44:6 accuracles 44:8 Administrator 3:3 anymore 93:1 67.14;73:24:79:10,16 549 21:17;26:1,3;31:5; 42:19,21,22;43:2,3,7, accuracy 44:16 advantage 21:19,44:21, anyone 56:7 150 72:4 13;45:5;62:16,17,18; achievable 82:20 23;66:23 apologize 41:17 q 15th 88.7 80:10,11,13;91:4 achieve 9:12 advise 14:23 j apparent 4:2,17;8.7,12, 160 72~ 4 13,17;9:18,11:13;12:5,
.
549.3 44:3 achieving 83 4 adviser 19:22
,
549,75 62 14;97:72 acid 4:23;12:25;13:2; affect 63:19,20;74:18 3 g 550.8 97:23,25;98 5 25:23;67:13 affirmative 14:22 1980 17.22;98:15 73:17,18;100 6 553 43:20;462 acknowledge 20:5;56:5; afternoon 33:19;81:3 1984 18 1 57:15;59.12;66:12 apparently 5:13;13:17 5:30 27:21 again 22:9,22;52:3; l 1985IM 5 1987 18:2 5:45 27:22 acknowWged 24:16 55:17A5;63:12 74:1,2; 76:1 l pu ga acknowledges 54:21 82:13,22;88 7;90.21; I9.1 > 94:9;98.23;100:18 l appears 11:24;71:17 1993 18 3;43 19;92:18, !
;
f acting 34:4 I action 5:19;8:16;9.11, ! against 13:20,23;14:2,
PPendix 4:20; 12.5,14 I9 17;43:15 15'17,21,24;10:21,24; i 1995 8.10 165G 72:2 , APPlied 88:12,13 33 20,23;14:4,17,22; agency 3:22; 5:19,6 6; l 1996 3 17 i 681 11:19;12:17 16:25,18:11;61:21;63:4, l 10 4;100:13 apply 14:1 J 1:10 100 20 1 6:30 31:13 l 21,81:1,17;94:6,8,22; 1 appreciate 53:17;67:1; 1st 77:15,88 8 l 100.10 l agency's 6:3 agenda 3:18;8.4 ! 99 I7' I9; I I* I
{ y ; actionable 82:5 f aggressively 87:7
' actions 14.8,10;16:14; i ago 83:15; 93:2
' 8Pproach 84:19,86 21 aPProprise 9.11; 21:16, l
2 l i 25.17,32:12;34 5,12,17, i i 26:4,5,31:17;55:22,63:3; l 7:1549 19 , 21,22;39 13,41:21:50 9, agme 15:13; 38.18 gg_g;93:n 2 27 1;28.15,22,57.21; 7:40 31:13,20;50.4 l 11:5518,59:13;61:24; ahead 17:6; 26.23 1 appropriately 86:18 58 1,3,4,6,9,69:21; 62.2,64:11,11;76 9;77:5; aids 65:2 appropriateness 89:15 )
'6 20,85:11 20 90.19 g 84:1;91:7;92.15.19,
, 93 14;95:21 A13:23,24:4:25;5.11; approval 90.2 l I active 87:15
; 6:24;i1:9;30 21 alarm 20 4. 6; 23:3,5'-
,p p,,yg .g 1 22nd 3314 ,
' 8 79.10,1' ' activities 19:3:21:11,12; ! 30 11,20,22,24;31:4; approved 84:8 23rd 3:17; 33:25 34:13 24 10.23,88 9,10,21 , 82 17;14 ; 34 9,30;53;gi;53:3; 43 6,6,8.17,19,21: 44:2, , 8PProximate 2217 i 8th 84:22,85.6;88:2 54:19;70.10;88 9 I 4,6,6;45:21.24;46:12, approximately 20.19; 1 2[ 22;42:2;88.21; l activity19.24,24;2i:20, f 14;53 9,6010,84:9 23 8;27:19,24;28.24,25; 29 68 10;70:22 p ' 29.18,31:18,33:14; 38 13;53 10,13:54:10, i alarms 24:20,43:13; 46:16:53:5;60.16,18; 30 13,17;70 4;72:3
! April 70.6;76:25,77:15 2:00 28:25 20,21,24;55:1;60:11; 63:2,14 i aptitudes 51:18 2:15 28 25 98 45:10 95:23;96 1,2 allow 5 3:10:16;73:21 l area 19.12;20 5;2310; BROWN REPORUNG, INC. (404) 876-8979 Min-U-scripts (1) 0010120 area
.
PROCEEDINGS BEFORE MR. STEWART D. EBNETER March C41996 ~ IN RE: ST. I,UCIE PIAlvr hRC ,
* bloodeft 30:15,20 came 21:11;28:2,3; 29:3, channel 98:1,2 ,
4; 2'13- 'B board 19:11,14,15,23; 17;40:14;43:8;45:13; ' channels 44:18 55:17;59:19,20h60:4,5* 60:12,14 20:7.8,20;21:25;22:20, Chapter 62:20,21;67:14; 21;61:14;62.1,5;84:2; 21,23:23:4:24:20;55:25; can 4:12;17:9;20:20; B 4:20; 12:19;67:8,9,11 71:4;73:24;79:9,10,16,
#5:22;88:1;89:23;91:22 56:4,21:57:1,6;82:15; 25:1:42:10;44:10,12,14; back 16:12; 19:19; 20:6, 17 areas 11:6; 24:25; 35:12' M8 W&8; 51:19;58:21; , H; 21:7; 22:10; 23 9, charges 63:11 36 22,24;42:7.10,13; boards 51:25; 52:6;60:6, 64:2;65:13;66:1,16,20; 18,22;24 4,6,23;25:24 charging 13:1; 2&2; 57,7,8.9,78 14;79:23; 7 71:2;76:22;81:5,25;84:7; 26:1;27:2;28:21:29:17' 26:19;62:23;63:9;73:23; '
30:19,23,25;35:19; 85:2,13;86:14;88:10; boat 86:5 95:3
*d'I"9 84 I9 ' 45:13;49:7;52;2;56:5; 91:2;94:13;95:11;97:11; cround 38:16,24;47:18'
Bob 1IlI 99:24 Charlie 28:18:29:!;33:5, 57:8;65:14,21;74:9,14; 83:19;93:23;98:5;100:14 body 76:2 9;36:16 arrivel 31:14 candor 99:17 backed 44:2;45:8,9 16,16;173; charts 68:20 ascertained 51:17 capacity 51:6 i 2 223835; check 74:9 background 17:10; capture 41:1,13; 54:9 aside 5:21 18:16;36:5;71:6 ' ') cheese 51:24 aspect 14:25;25:15 6;85 17 captured 35:5;69:5; aspects 17:4;42:1:;49:3 boost 51:19 68 I ** " "
** **** D backup 61:7,73:5 borating 23:16 assessed 8 SMI6 backwards 42:14 boration 21:5,13; 30:15 assessment 8:12,67:15; 54:18,61:2;95:5,'7 ca w s chances 1C12; 75.14;97:18 beuRil 93 1 careful 72:17 27:5 '
boric M32R 67M " ' assets 66 3 69:15;72.6;91:22 boron 3:16;19:16;22:24; as;ign 32:9;97:7 23:2,3;37:4;73:21;81:5; a%n 22 de% 818 bases 71:1 carries 48.7 class 87:12 cocigned 32:3,13;33:11 85:22 basic 4:5 carry 18:10; 32:12; 33:9; clear 26:9:31:18;32:21; both 25:13;33:7;36.23; astnment 21:24 Basically 3:22; 4:22'. 48:25 36.25;37:4;52:10;55:6; C:Cist 910;62:1;66:17 22:12;27:3;91:6 39:12,43:24 44:8,13; 55:3;63:2;69.6;84:15; carrying 66:8,17 66:8;75:8;78:13;86:13; CO:istant 17:16;18 20 ' basis 12.20;43:1:48:24 '
' 70:13;78.8;80:12;90:10 89:10,92.4;93:5,6 l carryover 44:24;45.1 ; 93:13;94:12 associated 9:13;62'3'. l came80:9;90:12,17 Clearly 61:21,22;80:7 75 9,19 bear 13:24;71:16 bound 79:16 :
l cases 8:15;$8:13 11 branch 6:20,7:6 l clica 23: as:ume 4:5;63:21 became 8:10 breek 99:2,13 ! CASTO 71:24;92:8;93:8 clicking 20:24: 25:5,9 i 80 14;95:5 become 75:25 bridge 82:5 i catalog 68.6 l clock 38:24 as!umed 54:1I becomes 83:6 , close ;44:22;65:1; brief 3:19;6:1;23:7; i catalyzes 81:6 as!umes 62.21 began 10:16;30:15; categories 81:8,9
'
50:13;60:4 Cccumptions 641 34:12 * **d 3 II;IEI3'I4 begin 22.4; 56:14,15 briefly l6:23;18:14; categorized 8:18 me urance61:13 50:33;62.7 categorizing 8:13 c 102;RHM&6; cc:ure 25:20,53 3;57:3, , beginning 19:13; 56.21
" 8: ; l '.aucus 99:3,5 65.13;66.13,22,76:22 behalf 34 4 1 closing 80:20 8 2 as ured 21:14 f behavior 83:24 l cause 32.8;35:3;36:9; f cognizance 3:5 39 8,89:24 astray 27;12 behind 46:14 ,
"'
atmosphere 24 8 , beliefs 10:5 r 9 9 I#
caused 5:4;30:19,53:9
[82 23 attend 91:15 believe 15:5,32:11;43:2, 19,44:18,53 6;69:17; y 40 6; 91:22 36 22,42 6;91:5 causes 9:13 causing 7614 CobM 8m cold 62:10;97:2198 3 attended 38 23;53 4 j broken $2:4 76 7,13;96:10.16,17; CE 34:11; 60.25 cttention 6:11; 1314', ,
j brought 25:21;31:1;
"M2 25 21;30 6.31:1;48 l8' ' 98 I center 18.19 ;
il 8.52 3;60 20,63.2, believes 22:1 l 39.22,76:10 certain 10:16,27.5* ! Bell 81:99 8,9 ' brows 92.1 35:12;38 3 collective 50 8
'3 3.83 13.85 14 Bruno 3 20,22,614;7:3; Certainly 2915,37.2; combination 73:1 Cttest 58 21 below 62.17 8& 22 54:25;57.17,58.21;65:2; ; Combustion 36:4 cttitude 40,13; 51:21; benefit 91:24 52 5,91:1 building 82.2 66:16;81:15,9& 23 coming 30.23; 56:18, best 20 20,22.17; 32:11 99:17;100:18 cudible 9313,22 better 14:22,44:16; ' bulb 82:18 ' certificates 51:14 ,
certified 36.18 , command 21:6;24:16; cugment 91:20 51:24;52 6,61:25;88.20, : bumping 4315;91:5 93:25 l business 18.2.52.19, i CFR 13:5;67:10 25% H&20 futhority 1319 , commanded 21:9 ? r Cuto 616 '2.24.24, beyond 49 23 ' 93 I chain 40.11;49 4
"34;7914 -I change 9:20; 10:18; ; commenced 19.23;2&3; big 53 23,6619;78 21; i ) 21:4 tutomatic 131:34 10, , 82.1;84:5 i biggest 78:14 ( ; a2;M;13:5 M 6, R l; i 47:17:58:14.19;68 6; , comment 5:2,18,22; 60 21;6:18.72.14 cv;ilable 8 22,'8 I;95.I bilsterel 83.7 C 67 8' ' I9' I; """'" "
I ' U' "'I average 43.10,45.17,20* Bill 7:16; 17.3; 38.22' 74 12 U1:' ,18,84:9; 86-6; 100 9 j Commission 3:4,10, ' I 98 15 f 46 22 4815 5 4 , 10:15 t biscuit 51:24 l changed 54:19;78:11, , cverages 44:4,5 ,4 '
= Cwere 13.18,37I12, bit 21:21: 23-25; 24:24; ! called 25:24;2?:23:28.8, I henges 57:20,22; I commissioned !5:24; 57.13,16,16;65.7.10'- 36'l:401 4 3:16 63:1 '
66.5,6 black 2$;s9;40:15 calling 27:20;43:16 away 23 2;84:9 blade 45:2 calle 27.21 changing 71:21;78:14 : as cas . Commitment (2) f
_
~ . - - .- - . - . . - _ ..- ,-.. - - .. - _ . - . . - . . ~ _ . - _ . - - . PROCFFDINGS BEFORE MR. STEWART D. EBNETER
, IN REs ST. LUGE PLANT NRC March 8,1996 ' l' h connitmente 99:20,21, confidence 46.8 80:5 Den 7:18;17:1;60:14; detailed 70:21 1 l* ;22 confident 22:16; 53:11 corner }0:17 64:3;67:2;84:4;94:22 details 33:13;40:6;49:18
'
committee 70:14,18 conform 5:16;67:19 Don's 77:17;79:19 corporate 31:22 detectors 98:2,3
. common 9:12,14,15;
' contormance 84:11; corps 91:3 dark 60:6.7 determinations '10:5 61:1;80:25;83.4 , 85.8 ' correcting 73:10 date 4:13:26:24:27:18; determine 22:18
- communicate 82
- 10,19 conformed 67:20 corrections 70:2 28:25;54:14:56:11;98 6 determined 9:23;26:2;
" "
! confr need 53:2 corrective 9:14,17; dele 34:17;43:19 86:6
-
6 5 10' , !4;50.7;64:22;66:23 conjunction 10.7;77:23 16:24;I8:10;34:5,12,17, deles 76:22;77:7;99:23 determining 9:10 consequences 13:'10, 21,22;39:13;41:21; Deve 38:22;48:14 developed 51:5;85:19 communications 83:11 l 53:24;65:10 55:18;61:21,24;62:2; day 13:6:33:14:50:4; developing 74:20;100:9 companies 92:25 l consequential 53:21 76:8;77:4;81:17;84:1; 60:22;80:15;84:25;88:9, + y 3.7;6:7; 15:25; i92:19;93:14;94:6; Dick 36:3 Cmquendy 105 g 30;93 3,24 Dietr 36:3 company's 66:3 consider 18:8;22:17; 3 41:23:42:16,94.8 correlation 46 6 comparing 78:3,4,6; deel 48:21 difference 12:21;13:10; 80:2 consideration 62:16
*
doeling 23:20 40.22;86:10
)
"**
comparison 74:12,13 ' considered 34:8.54:5 Decomtier 70:4:76:21 differences 40:1;87:19 competent 87:16 consistency 85:9 l decide 10:12;72:18 different 5:9;13:7;45:22; i completc 32:5;69:19*. consister't 15 6; 54:15; I" decision 4:16; 9 7,22; I 46:3;73:23;79:14;81:9; ' 76 8; %:5;99:7 61:12;74:3 l counkract 25:23 10:10;42:18:43:1 82:24;89:17 completed 68:5;69:15; consistently 88:11 l countermonsures 32:9 decisions 84:15 differently 78:17 95:5 Consolidated 16:3 mndng 20:24 dMcuh 58:12 defined 89:14 compliance 58.2,15,23 constantly 38:12 country 94:20 : digital 44:14;93:21 definitely 67:23;74:19 complied 80:3 constituting 91:19 couple 15:23;93:2;97:20 ! diligence 32:20 degree 6:11;32:19; comply 59.8,11 context 78:9 course 3:7;25:19;27:13; 44;g5 l dilute 20:2 component 36.8 , continue 59:14;60.19;
; 3 1 18W degrees 21:17; 26:3;
' 31:5:42:21,22:43: 13,20, f dilution 3:17;12.3,6j comprehensive 9.17; i 61:5,10;62:3;73:13; ! court 11:3;93:2
, 10,10,22,23;13:6,7; ST12,14;81:1 l 83:17;84:24;85:18 ! cover 4:25;17:2;18:9; ! 20,25;44:17,19;62:14 14:13;15:15;1110,20; l 19:4,16,23;20:3;21:1,2, computer 19:21; 22.14; i continued 10:19;55:16 l 42.11;50:15;54:6;55:24; I g g I 59:19;62:20 4;22:3,24:23:2,3,6,13, 98:6 continues 88.5 delta 44:5;97:10 covered 38:2; 54 23 15;24:3;25:9,20,23; concern 9 3; 25:20; 26;7; condnuing 59:17;61:16, deltes 97:11,11 26:10;29:22;31:18; 68.3 19 95% @M 32:18;33:13;34:9;37:5; credentiels 16:4 delving 40:5 concerned 6:3,3 continuity 51:9 48:2,5;53:10,13;54:18, concerning 15:21;94:16 contract 83:7,7;94:17, creeping 73:14 emineralized (23'.
11:21;67:13;73:22 55:1;57:21;61:2;62:20, conclude 64:4,7;80:18, 18,19 crew 19:7;24:10; 31:15; 21 63:4;72:25;73:21; 95 6 I 33:17,18,22;38 20; DMVM18m M' y 81:5;85:23;95:5,7 I9' dilutions 29.25;42:25 concluded 14:14;77.4; l contractors 94:18
*
contrary 11:18 l
'
; . 68:23; 69:1;70.8l 15, '19, 100 20 ' contreet 63:8 ! 71:10,15,21:72:1:73:9; i dimensions 39:11,13 concludes 94:24 f control 3:15;4:21;5:24; i 90 j 74:11;76:20,'7:3,10,13, i direct 21:10;49:10,13; conclusion 16:18; 69.7 '24'25 1 19,25;78 4,8,79:2.20, ' 63:10,90:15 6:2,8,7.7,9;12:24:13:2, i criktio 7; .3,7;75:8-conclusions 3518, ' 3;17:18;I8:18,19;19.8, 80.6,11;95:9.11 I directed 5.22
,7;9 67:22,74:16 l 15,16,18,22; 20.8,12, '
department 36:3;83:3 direction 20.6;42.20, 18,21 9,i1;22:23;23:9, c$e&n 4:21;12:19 concur 67:16;74:1 deputy 6.22 9&2,12 condition 21:15;87.21* 2H,8 R 2M2,2t MMW descritse 67:24 directly 25:3; 3016; 93,5,9g.9 28 3,8;29:2.4;30:15,19; cross 89:14 descritged l2:23;13:1, 8, 62:22;65:15,23;66:21;
' cross-referenced 75:20 conditions 5:17; 21:11; l 5( 5 25'-
23,25,15:5;47:22,70:13; l 73:22;75.8;95.8 32 ' 61:4,4,8;67:9,12';72515; , cr so references 77:25 72:20;75:7;78:17;79.18, l director 3:21,25;6:23, conduct 3 8; 4:1; 5:13; ' 86:20,87:13;92:21- ' culturell5:18,58:19; I 80:10.24 24;7:3 9 22,47.21,55:5;57:10, 93:13;95:15;96:19 20; 81:6,17 : descritpos 67:17;72:14 ! disagreement 99:15 82 21;83 6;86:19.22,25; 98.2 curious 47.7 descritning 4917;78.18 ' disappointed 14:20 i 87:1;89 21;90 7;97 8,9 ! controlled 14:3:24:8, I current 5:38;55:25;69:2; I description 42:21:74:3; . discipline 6.8 conducted 5 8.8.20, , 31:20.32:19;62:14 76:11;87;20 ?9.13,17 33 22;88 9 ' discovered 4:14 controlling 6:12;44 8; , currently 9&ll descriptions 79:11 ! discrepency 57:25; conducting 75 3 45.1*;46 4,13 curves 45.11 l design 4:21;12:20;36:4; I 59.7;73 14:76 14 CONE 7:9,9,17:19,19; i controla 2010,15;37:2 j cut?2:24 l 43:8;67.9,12;69:14;78.8, discuss 3:12,22; 4:2, 24 2,25 6,29:20,37:24; i convey 86:4 CVCS 19:15,60:25, i 10;90:10,94:21 5:11;6.14;11:13;14:24; 38 8,47;3,6,56:2;65 5,7' 67;19;68 4 designed 51:8 21:21;29:25;47:8;48:10,
.3; ,16,9(3 conveyed 86:18 convinced 34:19 cycles 87;5 desired ll:23; 86:19,19 49:21;60:16;62:25; * 89:10,99:24 desk 17:20,19;12,18; conference 3 9,12,18, iI coolant 3.16,!1:2*' i discussed 4:is;9:i8 4 2,8 19;9:5,8,19,22; cooperation 50.18 '
D 20.7,9,i2:2i:3;23:10 24;24:2,12;56:1,4,20' 31:25;38:25;47:15;48.1, 10 3,7.I4;11:3,5,7.15; coordinator 28.7 57:1,7;82:16 2,79:15;100.6 29:10;81:22;92,10, copy 8 4:28.5;91:8, daily 49:19 100 2,14 detail 5:1; 18:9,24:24; discussing 73:17 j 95:10 demoge 45:2;63:18,20, 34:18;39:1;48:18;50:7; Discussion 22.6;31:7; 4:11;10:17 I core 19 4;63:18,20,25; 25 $1:9: 54:24;83:13;85:4,9 41:24:48:11;55:14; BROWN REPORTING. INC. (404) 876-8979. Min-U-Scripte (3) connaltments - Discussion )
_ . . __ _ _ _ _. ._.
. PROCEEDINGS BEFORE MR. STEWART D. EBNETER , March 8,1996 IN RE: ST. LUCIE PLANT NRC , 62:21;87:15;91:12,15; eating 53:13 enhanced 77:10 evident 34:24 factored 40:8,20 92:24 ESNETER3:1,3;t8; enjoy 90:24 evolution 5 8;37:1; 54:t facts 9:12 discussions 2917; 8:3;10:7,13;11:2,15; enough 82:8 59:1,5,11 fall 90:11,12 31:11;37:22;47:20 28:12,14,17 29:5,9,15, evolutions 37;7; 55:3; ensued 22:6 failed 14:10;71:13,15; dismayed 29.12 23;30:3;32:23;33:3; 56:7,24 59:25 72:24 disregard I(9 35:19,25;37:3,8,11,15; exactly 26:8,8,13,20; M5,10; 39;3,15,20,25; e ree6111 failure 11:17,20,22; distinction %:20 27:8;53:7;67:24;7 011; 12.4,12,13,19;81:16 40:17;41:15:42:2;47:2. 4, ensuring 31:16;65:2 goo.2 distinguish %:17 7,14,17,23;49.8;51:12; entered 26:3,4 examinations 51,7 distract 6&9 52:17,24;53:16;55:8; entire %:21;75:16 * 64:4,14,17;65:6,17,25; example 11:20' 25; 12:4' distractability 52:25 entries 26:5,5;31:17; fa 16:22 66:7.14,19,25;67:4; 12;80-5;89:18 distracted 22:2; 53:7,19, 49:6 for 5:21,23;2013;27do; 68:21,20 76:18,25;77tl, examP los 11:17; 12:16,. 20 22 22 80:1;86:11;88:4 30.6;62:9;71:22 12,16,22;92:7;93:24 entry 21:16 distraction 53:20 equal 90:15 exams 86:9 94:2'25;95:2; %:13-distractions 53:1;502 97;33;98:21,25;9911,10, fault 38:10; 52:22 equally 39:6 exceed 5:4:98:18 div'zion 3:25;6:25;7:15; 12,16 exceeded 26:3;62:18 i feature 72:15,15 equipment 27:9;60.5; 5*9 Ed 7:20; 19.8 83:16 exceeding 21:17 features 61:6;73:5 DNB 62:16; 63.8 February 8t22;85:6 Edison 16:3 equivalent 44:3;45:10 exchange 87:15 doc mont 41:16;47;13; editorial 69:11;72:3 fed 46:12 errors 85:21 executed 85:8
- 4 effect 37:16;81:16 feedback 83:3;807; escalated 8:16 exercise 9021 docYnwn n 8&15 effective 8:10;8t8,17; 86:3,87.7;89.4 essence 7012;78 I8 exist 97:12 doctmented 75:1 g7:19,go expanding 55:2 feel 16:19;99:4 essentially 4:1;9:5; documents 3914; effectiveness 61:20; 70:13;78:10 75:15 expect 4 8; 5:16;1021; l feelings 15:20 6021 24:18,22;29:19;49:15; feet 25:7 establish 69:20 Don 92:13 effects 25:23 54:25;58:15;65:18,71:7; follow 16:5;93:25 established 40:25;68:2; done 28.1; 31:16; 37;l1; efficiency 44:24 72:8;90:4 felt 24:18,20; 41:11 89:25 39 23;40:12;43:25;47:9; effort 36 8; 69.7,17,18; 'M R 48 9,12,14;51:2;52:1; estimate 20:20 I fertile 9&1 88.5;90:3;96:5 48:17;55:25;58:2,16,20'
72.11,19;74:15;77:18, estimates 22:15 66:17;82:17,19 l few 8:4;15:12;76:23-19,84:10;95:17 l efforts %:24 i 88:24 913 i eight 43:11;86:12 expecens 5dt l field %:20'23;97:10
'
doubt 51:19 evaluation 10:20;13:9; 14:20;46:20,24;47:21;
* * 4E 4 25; 43:25;45:12;46:11:51:2; figure 83:18 down 20:22; 23:ll. 56:9;57:16;78:9
$5:6;64:22,82:9; 83:22; 24:11:32:4,8;37:19; .
67;11;68:5;73:19,25; 86:1,16;88:11 figured 81:25 38:13;41:4;42.7;44 2,14; l ejecting 25:22 7023;95:4 expected 23:25:29:20; final 9.6; 10:4,21:46:14, 45.8,9,46:17;49.19; ; elaborate 73:16 EVANS 7:22,22 83:24;96:9 , 16;81:6;100:4,9,13 59 25,63:7;78 18;83:19, ; elected 27:22 even 52:13: 58:13;82:6; : expecting 26:17 l Finally 10:21:13:4 90:23;91:5 element 87:13;95:24; 100:12 ' experience 36:6; 38:11; ; find 32:4;33:13;67:23; down-to-earth 16:5 l 98 6
'
event 3:15,17;13:6,17; 50:2,8;84:7;86:3 ; 85:1;89:20 draft 28 6; 59 22,23 elements 43:9,11;98:5 14:13,19,21,25;15:15, explain 28:19;30:7; . finding 41:18;80:1; dragged 77:6 16,22,22,23;16.8.23; l 91:16;96.4 ( eleven 24:9 drawing 79.15 ' eliminate 60:17;68:2 8 11,25; l 44:12 explained 27.7 , findings 35.7 drawinge 79.12,12 Ellis 92:16 l f9 fine 48.8 l 23:20;24:3;25:13,54,17, l expressions 10:2; drive 87:13 else 98:21;99 4 l 18:26 6,23;27:16,17,23, j 10&ll , finish 73:17 drop 45:3,3 ; elsewhere 61;22 i 25;28 5,6,10;29:18; extended 10:19 finished 40:23;100:16 due 1410 44.8 l emphasis 62.4;75 6 30.6;31:10,20,25;32:1, I extensive 17:1:92:20; ; first 11:17,20;31:15; during 21:22;49.15; ; emphasize 15:14;16:24; 6,6,7,16,18;33:16; j 94:5 ; 36:25;42:18:43:14:47:9; 98 to i 26:20 34:16,20,35 4,10;36:21, I extent 38.3 53:3;54.20,57:5;82:25; (*uties 612,33:20,34:l; ' emphasized 26:16 22;37:21:38:19;39:6,17; ! external 91:21 l 97:3;100 6 35 1;51:1,4 employed 17:13 , extra 83:14 , firsthand 49:23 1 8 , 0 duty 29.11,12 fit 51:4
,
empowered 5012 21,24;53:14:59-23,24; ( extracted 91:24 dying 5214,15 encroaching 90:9 62-7,18.20;63 1,4,8,13, extrapolation 72.6
.
five 2019 23 8;35:1,21;
,
end 38:19;73:1,8,76:7; ! 14,18,19,21 64:10, . 3 21327,10,81:8, extremely 87:16,19 E 82:23;83:20;91:23;91 5 72:16,21,25;81:6;82:22; eyes 15.16 8018,85.23;89.18; fixed 89.2 ending 81:12 , M2 dam 138w I p h 80u E 12:15 enforcement 3:9,II,21; ' events 18 7;29.24:50.6, 4:10;5:19,7:4;8:1,5,9' floor 23:18 each 1818. 21; 19.10, 51:9,60.1;61:21;62.2,3. Florida 3:2,6,10; 17:21, 11,16,19,21;9:4,7,11' 21 21:38 23.39.11:42 6, 20,88 21;89.1.5,14 21,24;10 6,8,9,16,18 fabric 91:25 25 13,46.21:47:15,48.19' eventually 90:16 21.24;11:5,6;13:15,19, ' face-to-face 28 4,47:8; { flow 11:21:20;1 1 50 t E6 i 22;I(2,4,16,17;15 4; every 19:5; 27;22; 38:20; 49.9 l focus 3:;4;13:13;22:3; ~ earl 6er 28.23:35 9,42.9, ! 79.21;908.100.10,16 46:23;47:12,20,48:5; 5016;504;7515 facility 65:9 ! 26:13,21:29:16;40:16, engineer 18:23;36:4 56:10;75:17;8t25; fact 43:5; 47d 4,19 23;53:9,I4;56.25;58:3; early 3013;98:14 engineering 7:5,18; 85:16;91:3;93:4;9020 59:17,60 6;79:24;85:14;
'
52:17;53.8;55:20;56:5; easier 7513,21;76:6 36:5:45:12;46:11;60:13; everybody 609 57:19,58 lt 66:2;69.8, 86:10;11:23 set 2911: 52.18 67:3:68:14 overything 93:3 13;75M;90:19 focused 86:13 discussions focused (4) Min-U-scripte BROWN REPORTING, INC. (404) 876-8979
- - . . -. . . . ~ . - -- .- - . - . - - _
- _ . ,
, PROCEEDINGS CEFORE MR. STEWART D. EBNETER IN RE: ST. LUCIE Pt. ANT NRC March 8,1996 focusing 40:10:52:25 future 14:22;73:15; 81:13;90:11 78:3,6,15;79:8
- l house 31:25;47:3 folks 6:18;15:21:94:8.17 76:15 Hank's 40:25;53:11 housekeeping 83:14,15 inconsistency 67:25;
l follow 11:17l 12:4,12; happened 23:12,15; HPES 28.7; 33:16;88:15, l 68:4;72:5 l 58:12 followed 51:7;57;23; 6 26.8J7:8:30:16:47:25; 48:6;87:11 17 ! inconsistently 88:12 j l human 86:15 ' incorporated 61:18 hePPy 10:25;14:25; ) gallons 20:24; 26:18'. ' hunger 52:5,7.14,15 incrosse 30:20,63:25; i Following 3:19;10:6; 41:25:55:11:98:24
~
62.23;63:10 hungry 29:6,9,13:51:23 66:1 23:4;25:17;30:23;33:21; hard 8.3;68:10;72:10; incrossed 27:13; 30:17, 35 8;40:13;47:11;49:18; gap 82:1,6 83:10;85:2 18 59'3.66:13,69:24;70:1; gathering 33:14 haven't 40:19;76:22; i incumbent 57:5 96:11 gouge 85:21 i 77:6;823;89:3 indeed 71:20 food 23:7;24:16 general 7:12; 56.6,70:19 head 20 6; 36:12,13 1.e 14:9 y A.:54:13 fool 48:21 generalised 24:13 ' headed 36.7 , identification 75:10 independently 39:21 force 35:23 generated 31:10 l headquarters 7:25;10:9 l identified 8:8,25;11:16; indicated 62:11:94:23 forced 45:24 generator 20:16 ; 13:12,13;39:17;43:12; i heads 36:14 ! indication 45:19 forefront 52:13 gentlemen's 15:25 5 ;9 9 health 9:2; 47:1 4 indicator 43:14;85:17; form 35:3;92:5 gentlemen 58:21;99.18 9 *
,
hear 10:11;25:2,4;39:4 91:13 formal 15:11 get-woll 64:20 heard 23:11;25:8;51:14; 99 i *" Y 4; 4 indicators 44:14;85:19; ! formalized 57:9 gets 32.8 88:4
! 94:2 3 formally 37:25 Gibson 3:24;4:18;5:18; I" d b hearing 20:23;93:25 ,5:17; 33;7 5 formet 17:5; 59:22,23 6:17,24,24;7:24;11:10'- : ' 17;15:25:32:11:33:6; '
15.8,10;22.4,7;25:4; heet 19:19,20:11; 23:22 i 11 3 :4,5,22;4:1 ! 36:2;40:25;88:17 formed 16:16 30:10;31:3;45:15,23; heating 21:7 I immediate 3:24; 25:17, l Individuals 14:2;36:10, former 36 4 46:5;53:22;57:11,19; heck 84:13 ! 19 ! 20;39:21;57:10;68:12, formerly 36.6 58:10,72:12;74:6;93:10-held 69:3 immediately 20:25;21:3; 13;88;17;89.6 formulate 11:9 16;96.7;98:22;99:14 help 4:16;83:14;86:14; 23:13;49:16;55:18;58.8; industry 5:24;34:6; forth 28.22;83:24 g von 40:21:42:19 87:23;88:19 63:14 54:14;61:22;62:2;87.9 forum 89:9,91:12 g ng 42% 45.18 ! helped 41:13:55:21 impact 66:19;90:16 inform 27:22 forward 18 10,87:25 God 92:2 l helping 87:4 implement 67:i4;70:11; information 4:12,14; found 40.3; 51:4; 54:15' 8 82:10 helps 26:20 l 9:10;12:20:16:15:22:15. j 17;59:24;61:1;71:22; t goes 22.12; 30 6,16; "" " '
'
40 7;62:25;82:2,2 Hey 41:4; 59.8' 10 72.2'5 . I implemented 10:15; : 33:15,17,22,49:23:57:2,
,
to s-34; go lo 3 3:37., Good 18:5;31:16;35:13; 28:1#21N20; I 45.8;58:1:92:14:97:5 4;66:9;68:6,7;69:21; . 12 16;17:17.23[19'5'. 42:12:53:24:55 8;65:17, 63 6;71:11:93:20 i l 75:20,23,88:19,21 implementing 59:22 91:10,100:15 25;66:25;77:3:79:7;82:3; high-tech 93:21 j informed 4:16: 28:7
, 83:18;86:13;89:9.90:24 higher 27:14:32:19, l ImPortance6:46:25: 37: inherently 80:14 fourth 12-12;88:1
. l 47:20;603,17;61:16 I gPm63:12 ; 96:22 initial 32.7; 58:3;94:1 FPL l7:13 i important s:5;6:6,7; W3
,
g m nt 6
'
h traction 69.12 ; 9:21;18.8,36.23;39 3; < initially 45:7 greatest 79.24 l8 l l frame 31;12;905 l 41:12;48:16:50:10,11, initiate 26:23;60:11 himself 20:18 14;53:2;54 4,85 6;88.12; initiated 23:1;37:2;69:18 Frank 7,9; 17:19; 23:23, { ground 90:1 I hint 16 9 ' 91:3 24;25:3 21;26 12;28 9 ! injection 62:24;63:10 55 24; Shl9,6615,67:1; l group 36:7,8,20,47:21 guess 54:6;96:7 hit 84:20; 89.22 Importantly 87:6 input 35.12 81:24,25,25;82 6,90.12, ' guidance 23:17;98:13, < hits 84:5,25 improve 73:12,89.23 93:21;94:2
,
insight 42:9 hitting 83:12
<
l14,18 improved 74:20;76:10
, hold 66 8 inspection 4:5;9.6; 15:6; frank'S 31 1 ! guy 37:3 Improvement 17:4:42.3- 59:2 frankly 4012 ! guys 6:10; 29 5,23; holders 56.3 ; 12;58:19,65:1,3;83 9, inspector 36:19 frequency 19 5.63 25 37 23;48:1;52.8;55 9, hollow 58:16 95 23 i 65.20,66.20 improvements 57:20 instances 71:19 frequently 48 8 . HOLZMACHER 73,7;
' 17:24,25;223,22,23; ; improving 74:21;86:15 9 fresh 36 2: ,
instead 83 5;921 818 i j H : 5:19,24,25;384,7; I 50:25;51:1,5,9;52:16 in-hou.e 26:23; 27.i7; i 28.6;31:10,20;32:1,6,6; ' insmuted 96.24 front 15:13;1914; 2310; , 48 25,52 9,59:14;64:25 ' home 46:23 33 16;34 15;49 5,12,22, instructor 36:14:87 16 i fvel 56 9; 70 3 l 6815 half 17:17; 44.17,19; honest 82:4 88:21 instrument 45:16, ls,
;
, honesty 50:20;5318 inadequate 12:2,67.9, 46.7 full 514; 1319: 24:10, i halfway 29.8
' HONEYSETT 7.10,10 10,12 0 3.20 instruments 44:7,9 49 4 hand 31:21;95:18 i 17:11,11;25:19;26:22l j inattention 6:4 , 45:12 fuller 78 9 , handed 28 6 28:13,16,18,21;29.7; i incident 16:13; 27:10, integrator 20:23; 23:11; fully 516,14 6, handled 16 8 ' 38 6;64 18;81:5,13 25 4,7,8;93 11,19 30:13:38:9,82:25 l functional 56 to handout 22.11:31:9 hope 14:21; 16:17; 51:25; incidents 5 23;61,4; integrity 16 9,20,50 20, I functionally 56 5 ; hands on 61:8 65 25,66 1;72:17;94:12; 37:9,13,17 53:38 fundamental 74:2 ! Hank 7 7;17:24;21:23, ' 99 18;300 15 ' include 12.2,68 24 intend 41:22,64.25; 81:2; turther 919; 23.17; 24,25;22.4,19,22;23:19, l hour 21:16;49.12,16 including 5:17;13.20, 98 37 47:11;62:25;68 9,73 6, 21:24 4:26 8,10,13; hours 10 23,19.6;27:19, 31:23;61:16 ; intended 10:4
!? 76:16;80.17;84:9, 27:11;28:9;29:17;30 14, 24;32;16;52:18;62:17; 100 8 inconsistencies 68:1,3; l Intending 75.7 23,25:52:10:53 6,17; 88 9,10 69:9,10,13,20,72:2; i intensity 48:10 BROWN REPORTING, INC. (404) 876-8979 Min-U-Scripte (5) focusing-intensity
.
. - - . ..-. - -. - . -. .- _ -
.
'
PRONJMNGS BEFORE MR. STEWART D. EBNETER March 8,1996
,
IN RE: ST. LUCIE PLANT NRC .
intentions 92:2 letter 79:21;92:11,20; low 63:5,24 may 4:13,14;6:18;8:25; interest 87:22 K 9824 iowe, u.25;80:23 9:20;i5:21:22:2;65:5,ii; i i interested 39:25- level 8:17,18;30:17; Lucie 3-16; 4:20; 6:9; 73:6,7;76:4;79:10,12; j internel 40:3;69:10 keenly 65:10 32:1;36:6;38:13;42:19; 7:11,16,21:15:18:17:12, 80:4:90:9.92:14:100:8 i internally 92.4 ' heep 11:4 8S6,20,22M9; 13;18:13,17;29:21;50:3; maybe 58:12;73:4 , 63:2;70:21;84:15;85:3,9, 60:3,22:61i2: 44:19- moel 19:19: 20:11,22;
{
- intimately 73:18 key 29:16;39:1; 56:25; I4,25;87:22 i 69:4 65:14;81:7;9i 19;92$1 21:7;24:5;29;3 Inte 8:13;11:6;12:20; levels 8:14; 20:16,16; l 20 8,21:11,16;24:4; killer 79.25 lunch 23:23;Mll, II mean 9:23;98:17 1 53:18 14;53:14 25:24:26:18;30:23,25; kind 73:14;76:14;79.4 meaning 73:6;99:22 l library 68 6 ; 40:5,8,20;42.7,9,52:18, kinds 80:6;90:20 license 5:15;33:20;34:1; """' '
'
61:19,63:7;87:9,90:3; kitchen 19:20; 20:11,21; 51:1,4,10,17;65:9; *** h*" * 91:12;99:19 21:7;23:22;24:4,!4,I5; 78:25;79:5 mechanism 87:13 l
.
Introduce 17:7 26:12,13;29:3 licensed 3:7;5:20;13:20; M 12:5 medical 51:2,3 introduced 38.1 know 14:7; 24:19;27;7,8, 17:14,22;18:2,20;38:25; meet 14:19, .4; 45.17; 46:23;55:3;98:8 machine 53 23 Introductions 6:16 9,43;3 g 46:21;94:18,19,22;99:13 , investigating 23:5 knowing 27:16,16,17, licensee 5:15;73:20 meeting 3:14;4:3;15:1; g 5 investigation 3:21; 19,71:2 licenses 13:22;33:8 33:21,2t 38:22 $ :24, 33:8;37:5;42:20;61:3,8; 15:24;16.6;38:14;90:5 knowingly 14:8 licensing 7:20;36:3; 25;48:2;49:19,20,21; ,
' ' 73 33 involved 13:16;21:19, knowledge 70:20,22; 13 86:9 '
l maintenance 19:3;24:6, , 28 24- ! 28:1;38:5;44:9;48:14,15; 71:7 7;60:15;90:18;93:20, k,xf i~ _ "le 87:17; Light 3:2,7,11; 4:15; 99:25,400:1,8 ! 08, 97;9 j ; 1 21 17:21,25;82:18 ' meetings 47:8,1o; + r 37:16;8t2; 88:5; 48:14;77:5;91:13,13 n es 8.13; 1&22; known l4:8,48:19;57:22 Likewise 55:2 lg
'
f knows 64:9 limit 42:24; 43:15,22;
, 44:22; 45:lt 62:15; l majority 69:10 mer'9er 47:20 '
involving 14:4 i 80:13;stlo;90:9, go,13; l makes 9:6 memo 46:22,23:86:12 ' isolated 96.12,16 ! 91:5 making 61:15;63:25; * memory 12:7,11 issue 10 23,99:13 l limits 63:8;80:2 64:14;70:2:74:9;85:10; l mention 22:10;%:24 " issued 8.24,25; 10:24; l 10.3; 39.9; 100:12 i ock 87:9;90:25;97:3,7 Linde 97:14 , 13 6.21:6 ' ledder 30 6,8,9 Linda's 9&7 "'"*8' 88 I9 2 21:46:20;93:11 is ues 4 6,15;9.16;11:5; large 64:8;69:8 line 52:9;66:3. 4 management 5.7;18:12; } ,3:g49 , 23:19;80:25;81:20 89:10 Larry 36:14 listed 41:21
'
l message 64:15,17 i ' item 43:5; 5023;62:6; last 9:5; 15:19; 29:18, f6 8 9 3; listen l6:17 50:9;5:13;64:11;66:8, messages 86:4 93:20 42:15;59:16,19,62.6; 63:16;72:23,74:8;77:22, lit 23:12 17,18,31:12,12,18,21; mot 38.20 items 91:8 little 17.10; 21:21; 23:24; 82:4;8.1:8,20,22;84:15; 89 II method 12:22;13:7; i itself 25:14;26:17;396; 2024;36:1;49:2,4:52:5; 86:1,it ;8931,16; 90:22; , 34:24;67:14;73:24;78:19 : 79.9 lasting 9.17;81:1 73.16;82:23;83:14,15 91:3;96 25
,
methodical 3t23;36:12 l l late 70:5 located 19.16,21;20:14, manage,9ertt's 82.8 Mid 76:20 j later 23:8.27:24;99:25 17;'21:7 manager 7:13,19,21; layer 41:8,13 ' midday 29 3 - location 20:5,8,13,14 31:24;32:25:305;60:14, :
{ layout 19 8
'
locks 56:11 15;67:3 l middle 29:13; 53:12,76:3 i J;n 81;99.10 l LCO 21:17;26:4;62:16 log 26:4,5,6; 31:17; 49 6 managers 48.1, lo;87: 3; j midshift 19:19 J:nuary 3'l7; H9 25 I lead 36 8;73:2,6 98 logged 26.6 J AUDON 66 7,78 2,5, l learn 32.5; 3020,41:5; rneneuvedng 5M l h W, u i 21,24;80 1 logic 46:1,14 ,
; 37:4 maniPulation 19:25 . MILLER 7:1,1;40:19; 1 Jeff 32.23:303:38 22, logic wise 73:7 learned 24:25; 30:7,8, ! logical 3023 **"" ' 9; I # 3 4M 15 4 34:19,41:2,11:46:19, l ! monning 18.17 m $
)
Jim 7:12,25,16 21,20 , 61:20,25: 6t20; 89:12 ' '3IN3W manuall2:2034:9, minimum W i 36 18,40.10,41:5.82.12, learning 87:5 ng 53:14 61:18,8612 minor 97:20
: 60:22,23;61.3,6;73 22; i 83 10;84 4,89.12,92:9; *
least 5.8.82.4,21;89:11; IOR9'I 78:I9 ' 79.13;95:4,7 minus 4t19 { 99 8 94 g ; look 16:11:3510; 36:21; ; many 5:22,23;5016, minute 3:13;39:16; 1 Jim's 40 7; 81:10,89:24 leave 29.10,13;72:13 l 37:2038.15;404;46.5; l 65.20;67:21;85:3;88.23; 47:24;62.24;63:10;93:10 l job 31:16,42.12;75.20; I 97:18 leaving 58.16; 81:14 f ,9 h minutes 8:5; 20:19; 23:8; I 88 18,20 08Clure 47:23; 49.8 l 8 :9;86:10;87:25;88:15 * *I John 6.22 $ led 3313;809 i 23;89 4 5;90:22;97:24 margin 42:24;43:21; misections 16:10,13 JOHNSON 6 22,22; 1 j g,,, 3 918,21:1; 23:13; ;6 M,24 misrepmsentadons looked 39:11; 40 6; 49:6; ; 44.10. 20: 45 4f'0 7.9, Mark ?:1:41:15:56:16 16 10 319,5315; 6t16; 8023 58 25;86 5,98 6 ,
'
leg 62.10; 97.21;98 3 looking 35 4; 41:9;43:10; Marple 33:5,7.11; 36:16 missed 9:13;6tl,
" * *
less 26.17; 53:21;89.18 61:6;62:1;85:25,90.20 match 9021 ' missing 86:5 judgment 27,15,65:11 lesson 32:21;60 2; ' lose 26:9;$3:9,61:15 meterial81:14 mitigating 63.20 l
'"'ICS I 61:20;87:10 I lost 26:14; 50:25; 53:14 metter IQ.5;15:23:59 4 mixture 12:25;13:2 )
July 1016;90 4 l loseons 32:5; 35;5;41:2 lot 6:18;34:21; 53:21; max 62.11, !4 , mode 60:22,23;67;18, 1 J m e 8.10 5,11;46:18;61:15,18; 6( 20,25;81:15;82:12, maximum 91:2097:25; i 18;95:4 i
, jurlediction 3 5 86-4 19;84 14,23;89:13,25 98:9 i modes 79:14 1 latentions - modes (6) main-thseripee BROWN REPORTING, INC. (404) 876-8979
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PROCEEDINGS BEFORE MR. STEWART D. EBNETER IN RE: ST. LUCIE PLANT NRC March 0,1996 modNicotion 70:25 negotiele 9.8 %:25 85:15
* outlined 84:11 modWicetions 78:12; not 76:7 observe 97:9 operational 3:15;64:23; outset 11:14 79:6 new 10:18; 45:13; 50.6; 78:23;79:8 observing 87:12 outside 15:25;42:22; moment 13:24;21:20 84:19;85:18 OPerstions 5:24;6:2,21; < 56 8,8;%:20 obtain 9:9 monetary 13:21 news 82:3 12:13;26:25;27:5,20, obtained 50:2 l over 3:5,20,23;4:3;8:5; money's 88:16 Next 12:18;34:2,55:9, obvious 42:15;81:11 '
monitor 11:20;82:10 60:4;68:7;76:23;91:10 obviously 24:24:43:22; 1 8-]l 21 2. j 8814, 3; monitored 88:9 nice 88:22 21;83:3.6,7,12;86:22; 29:19,22:34:2;52:2; 69 4;78:10;79:23 87:8;89:21;90:6,8;91:22 54:25;55:2,4,15;57:1; month 59:16:69 24; night 17:20:18:15,25; , occur 69:24;76:14 74 8,76:24;82:23;85:16 21:24;22:21,24;24:3; operator 7:8,9; 14:14; 64:3;68:17;78:11;91:10; cccurred 3:17;9:24; 16:4;17:14,18,20,23; 28:23,31:19;56:12,76:3 98:15 monthly 85:17; 89:9, 18:15;30:18;61:22,23; 19;l1,12,14,18,23; 91:12,13 nine 86:12 72:16;80:8,23 overall 80:22 20:20;21:25;22:23;24:2, months 15:19;17:16; nine tenths 27:13 occurring 31:2; 57:17; 12;46:23;47:13;56:20;
.
overdiluted 30:14 70 3;91:11 Nobody 71:8 78:11 57.6,7;61:5,7,8;73:2 ' overlap 81:9 more 6:6,7;14:9;15:15; non-licensed 55:4 occurs 38:13 operator's 53:12;62:13; oversight 21:10,12'- 16:3;18.8;24:18,22,24; oM 11:6; 22:6; 23:12;33:8, 34;9;93 3g non-watch 56:18 63:1 25:15;28:10,40.6,10, 43:8;45:21;46:3;48:3; own 6:10; 15:12; 32:16-none 5219 operators 5:3,3,13,15, 45:1,I;50:2,10,66:2; 73 3 20,23;6:4;I3:16,17,20, 40:2 75.8;80.7,83 6;87:23; Nonetheless 14:18; oWice 3:4;7:25;8:1;10:8; 23;14:18;16:16;17:8; owned 89:12 88 12;96:21;97:4 A 27:1,2;28:14 n ,71:22 3 g:39,20; 19:10; 38:25; owns 81:18 rnorning 3:2.8 I4:17:5; o#icer 16:2; 51:3,3 40:13;42:20;43:9,23; ' I8 5;27:22;29:I;31:15'. n C 1M12; 32:10;33:18,21,25; 67:18;69.23;70 3;78.19, oMioed 80.5
l oMices 10: 44:7;46:4,13;47:11;48:5, 19; $1:13; 53:1:55:7;5& 2; p 34:25;67.8.75.22;81:15; , 20MiW W 19,93:23 58:5.20;60:8.9,I8;63 3, ; 81 20;88:22;93.4 normally 10.10,14;14:5; '! old 45:11;90: 13,22M10,22M2% most 35.2; 3611; 41:23; 1911,1 2W2 j Once 45:11:48:22 } P.m l00:20 82:21;94:9 69:2;82:lt 818M8,8, packages 7811 42.16,87:6 Norris 8:1;99:11 8 oncoming 24:10 * ' Page 75:17 move 73:9 north 92:22 * '
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t moved 20:12; 21:3; lI note 9.21;10: 1 One 4:18,20,24;6:18; ; Pages 79:22;86:12 8:14,18;I2:16;16:7; { opinion 6:10;10:2'. ' Paid 6:12 24:17;43:20;46:2,17 nothing 6.6,7; 49:9; 23:19;24:24;26:18;27.7; 50.19 l 29:19,19;30.22;35:19; i 16:16;100:11 i Panel 19:17;20:13,18 moving 56 25 . I ' 22 much 15:15;16.3;3811, ! notice 11:11 ! 36.25;37:16;38:24; g ,93 3'. 17;40.6;80.7;81:2;90.3, ! notices 8:22,23;I3:20 l 4 :16;45 5 47:23;48.5,
;g gg panels 60:8 i1;92:24;94:13,13; gg notification 27:3 '
100 18 1 notify 12:13 55 14;60:22;62:12;63:9, , 49:23;51:10;60:6,13,24; l pangs 52:14,15 68 1;70:1,7;72:12,23; j 89:20 ; paper 125 multi-disciplined 68.13 l notifying 27.4 l 77:22;78 2;79:18,23; j opposed 63:12 multitude 98 4 l parameter 42:23;62:15 l November 18 3 1 80:15;84:6,13;93:14,23; ' ops 32:3,23,25;33:1,3, Murrmy 16.1,4;39 22,22, NPS 19:20,21:3,6,8,13, 98 4,6;99.3 parameters 23:17 40.2,6,10;41:4,11,I8 12;36:16;49,5;55:6; 14;28:12;33.9,10;49:12, one-time 73:12 59:17;87:2;97.8 part 5:7,8;18:1; 38:14; Mutray's 16:1,12;40.7, 17,19;87:2 39 4;46:13;49,7;74:6,7, j ones 38:23; 41:23; 46:12, order 10:22; 19:7; 23:22, 17 NPS's 49:22 75:1;77:10,19;78:20; i 12;65:20;70:25 43:11:44:1;60:11 must 56.4,9,57.22 , 80.14;91:25;94:7,95:19, NRC 5:15;8.22;9:23; ongoing 95:22 orders 8:23,25;56.12 :20,24 myself 38 23;39 7,41:2; 10 3,7,23;13:19;14:5; 46.22;48 21 only 14:5; 29.18; 42.23; I organization 35.2; ! particular 32.12,21; 48.4;66:3;69.23;98:18 52.18,65:20,68 1;79:13, ) 37:19,41:9;42:10,i1; i 33:1;43:8.21;62.4,15, NRR82 ; 18 i 50 3;77:7 ! 18,67:15;74:15;100.7 N ;i Nuclear 346,10,7.1% j onset 27:9 16 2,17:12,15,17,22;
! organization's 64:21
'
passed 86 8,92:2
, open 10.17,19 25,83.2; past 17:16,23; 58:25; 18 1,20,22,50:9,90:16; ' 91:15 ! originally original 20.20,43.7 '
91 I8 46:2 69:3
"h , ,
' ;
' opening 3:19 I others 64:24:65 21 Pate 38.21 naturally 418 '
'10'16'18 Perate 42:18,23:43:2; ; ought 85:12 ' Pate's 5:25;39.1;46:21; nature 72.4 44:21:45:1,4;61:5;65:9; ' 86:12 number 16.7;45.18- 67;25;74:4 l 2'5 necessarily 87:25;90.15 , 68.1:69.9,71:24;85:21; " ' ' paths 7912 necessary 69 21 88.23;96 22.97:23 j operated 60 23;61:2; $0 2 Pay 6:11 L 69 6 15 324 0 5 necessity 99.5 < numbers 62.8,84:16 339, g 3,37,35 12; 36:22, peak 62 9,82:16 operates 1911 41:15;42:14;44 6;50.15 need 916. 22.17; 37:3; numerous 34:5,14;53:1 PEEBLES 6:20,20-i operating 4:19;11:25; 52:1:54:16:56:16,19, 43.16;54:3,71:17;99 6 51:16;66 14;81:1.7,82 9; j NUREG 811;13 23.25; i 19.1;40.11:43:24;44:25; I 59 3;61:20;64:24;66:9, k 83 16;84:16;86 7,15,18, > 14:1 *rs 65:15* 22 2L 87 3,6,22; 88 6,15, 46 20;50 19;54:14: 17;72:24;"3:11;'9 25; 65 11;67 I8,72:23;"4 4; 81:25;82 14;83:2,18 Penatties 8.23,'66 24;I3.21 20 19,25 89.3,4.';90.20
,
92 20,99 3;100 5 O i 78 16;79 i7;84:7,86:2; i 85 i,ii;86.i,7,8,i4.22; i pensity iO:22 l 87:1,8;88:16;89:20,20; : penetration 37.19
,
needed 32.5;69 4; 86 6 , l 92.24;93 6;97:1 operation 4:19,18:12; 92:4:96 18,22;97.8,9, i noods 52:10,74.19; t o' clock 24:9;28 3;75:22 l 19.2,6;34:10,42:22; } 98 14;99'18 ' people 16:19;21:19; 81:10,99 3 obligation 94:19 35:1,2,21:38:17;50:18; 43:12,60:22,23;69:14; outage 58 3,69:24;70.4, 53:21;59:15;68:21;69.3; negligence 14.10,15 observation 10.17; 78:20,22;79:14;80:10; 5 70:23;71:8;85:13 BROWN REPOR11NG, INC. (404) 876-8979 Min-U-scripts (7) modification - people t __ ___ _ _ _ - - _ _ - _ - _ _ _ _ - _ - - _ - _ - _ _ _ - _ - _ - - - - - - - - - - . - _ - - - - - - - - - - - - - - - . - - . -
- . - ~. - ~ .~ - . . .. . .- - . .
.'{
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PROTFFDINGS BEFORE DER. STEMRT I). EBNETER . : Marcia 8,1996 IN RE: ST. I.UCIE PIANT NRC - port 2:24;63:10 21;67:19,20,20,25;69:5, propering 73:25;77:5; 53:25;55:13,17,22; .85:7.19 percent 5:5;19:1,7; . 14;70:14;71:19,21:72:6; 81:21 71:12,13,15;73:12;74:9, questioning 52:17;91:1 . 30:18;32:2;37:5:45:10,' 74:4,5;76:11,12;78:9, present 51:14;75:3;91:2 19,21,22;75:1,13;76:6, quick 94:4 13;62.10;68:18;98 12,13 10,12;79:6;81:7,23; 13;78:14;79:3;100:16 presentation 15:11; quickly 5:2;11:2;60:17 perform 42.25;4611;. 82:3;83:11;87:1,8,21; 16:21,22;40:8;64:18- Process-wise 73:10 51:1,4;54:13;57;7.96:2 88:19;90:14;94:20,21 81:10;84:4;94:24;97$21 processes 90:18 Performance 14:19,20; plant's 56:22 " Presented 37:22;60:5. produce 90:4 42.3;83:20;86:15;88:2,5; Pl ante 3:6;34:7; 54:16 presents 49:20 produced 85:20 13:9;19.4;
' #
! t 34:6;35:11;36:13;54:10, N 4:7;7:14,I4; 15:7,10;I8:4;35:8; 39:2,'
(4) pecgram 10:15;17:22; press 10:23 18:11;36:15;51:5:58:8; raise 27;12 11;56:21:58:24;59:5 24;40:4;42:8;50:5;64:7'
; performers 34:8;54:16, 71:4;77:14;92:16;93:9, pressure 20:15,16; 61:19,21;84:7,17,19; range 19:12 ,
, 17 18;94:1.4 - 30:18,19;63:2,5,24 86:3;89:19; %:25 ranging 68:13 '
Perhaps 6:15,55:24; Pi us 44:19 Presumably 72:15;89:2 Programs 54:20;84:3,5 rete 63:4 ' 57:20;88:12 - Pretty 29:5;79:3;81:2, 11 rather 11:8;15:24; 23:6; point 6:13;19:3;21:8; ; period 68:15,98:16 24:20;26:22;27:15; 10;82:1;84:5;86:9;89:22; progress 12:3;19:2,3; 58:15 - periodically 33:10;43:3'. 28:20;30:20;31:22; 91:15,21;92:24;99.7 21:2,2;22:3;24:7;29:22; RCO 20:7,7,9,9,12;
'
88:1o 32:15;33:11:34:16;35:7; Pmvent 72:16;76:13 53:4,10;55:5;56:7,24; 21:3;22:21;23:24;41:1;
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39:23;44:4,6;45:22,24; preventative 90.17 63:15;82:8 54:11;56:1;82:16,16 permanent 81:17,17 permission 23 6 * **4 5 5; Prevented 72:21 Prohibiting 45:6 RCOs 37:20;56:4 ' permitted 12:24 previous 34:15;%:11 Projects 6:23 RCPs 30:16 1 ' 3 7*. person 75:21;91:21 73:11;82:18;84:20,22; Previously 92:15;96:8 promote 86:19 RCS 22:25;23:2,13; I personal 6:10 87;8,89:2;90:8,23;91:14; Primary 8:21; 20:1,2,15, Promptly 5:6;27:4 67:13 92:9,10,11,18,19;93:17; 24,25;22:25;26:18; proper 73:1;83:24 reach 10:9;98:11 personally 30.8; 57:24 -, 97:5.25;99:1 2111:52:3M2:22;63:11 properly 16:14: 25:22 personnel 39:14: 50:13; a l reached 62:10;97:21 69 2;83:16;88.1,4,13; Pointed 41:15;82:14; prior 9:20; 17:16,18; 84:4;85:11;86:22 37:21;63:13;100:9 i proposed 10:22:11:11; j reacted 32:18
!
39.g 15:4;67;16 , reaction 25:14;93:12 i persons 75:4 Peinting 26:15; $6:19 Priority 16:7; 59:18 protecting 46:25;63:7 l reactive 62:9 i perspective 21:22; 22:1, Points 39:1;95:3 97:20 Probably 5:5;6:17;18:7; protection 44:18 l reactivity 5:4;12:10 25:14;26:16;51:13,16; l 8,20,25:13;32:17;35:13; policles 39:14:40:24; provide 4:12;21:10; j 27:6;37:1,6,17;38:6; 54:8,13,19:59:20 - ;77:23;81:24; 40:22;49:17;73:2 Policy 3:23: 5:19; 8:5,9, e
:], 35:11:49:23;75:5.8;
, 97:10
, 61:4,9 reactor 3:16,25;6:8,23, pervades 85:4 i Problem 26:25;36:22; Pete 7:10,17:11; 25.10, i 11;10:18;13:22,25; : provided 13:7;21:12; 25;11:22;18:19;24:17; '
14 16 3 45:13;46:25;48:18;63:6, 11,18;28:11,20;31.9; 43:~21;91:8
- , 82
- 25 l po:or;49:11;56:16;94:9 65:10,11
.
i Providing 49.8,69:22; 7,22,24
;
91:7;93:16,95:6 l !- Pete*o 2615,21; 29.16; Population 72:7 ' 75:19 reed 44:10,14; 62:13; ! 49.4,15 portion 68:19 p,,gg 98:5,7
'* ' PSA 63:17 phase 97:18 philosophy 61:10 , position 22:21;25:11; : 33 6;57:1;100.13 fo9l[
69:11,12'12 l6
.
'
*
Public 9:2;10:17 Public's 47:1 meddmes 6&24 madng 8&22 g Phone 27:23,25; 31:21; , Positioned 20:18 : procedural 74:20;76:21; , published 8:ll medy 4&l3 49 16;50 4,7 ! positions 17:9 95:14;97:2 pulled 59:10 real16:4;35:13;42:9; ; Physical78.12 ' positive 80 21 8 *8
,
pump 20 2; 26:19,63:9, . pick 30 3.4; 31:12 positively 83:25 { 11:25;12:1.6,7,9.11,15, procedure 4:22;8 6; 11 ! realized 23:12:30:14 Picked 41:22; 48 3: 59.20 potential 8:16;14:ll; + 21.24:13 5;48 9;57:11, pumps 13:1;62:23; really 39.9,25: 44:23; ', picking 52.8."919 45:2;61:7 21.23:58 1,",59 3.4.10. 3:23;95.8 52:21:54:8.23:58:10.15; 4 Power 3:2,6. 7,10. 5:5; 11.16.21;69 6;70 24; n12218J8R 8M, place 20 22,34:12; 45.9; purpo,,9,7,9 4911; Sb I 4. I 5; 57. I 2, , 6:5;17:21,25;19:1,7; 73:21;74:8.75:23;76:2,2, 10,23;87:20;89:23,23; 14.58 12,1*;61:11- 32.1,2:37:5,42:23:45:5, 857,12.13:95.18.18; 91:3;93:19 76 12,23,79 4:89 I 97:1 10,13;52:4;61:9;62:9,9; 100 4 Pursue 99 3 i rearticulate 86:17 63 6;98 9,11,13,15 procedures 4:19; 518; Pushing 77:16; 83:10 reason 42:15;44:20, placed 33 6 ,
' places 90 to P 11:18,12.4,12.20;18:18; ; put 11:11:33:15:34:12; ,
61:3;94.6 - ~
! Practice racticall6.410:19: 29'21'-
14,23,54 8; 38:15;44:13:48 9,58.7; $ reasonable 43:3;82:17 lacin' 58:4,5,11,17;59:14,17, , 61:11,24;62:4;63:9,68.5, i mcaHbmbd 4511
.
Pl an 14:16;27:12,5313; 34:7;53 12;59 6;6l:1'
20;67:12;69.14;70:11; 11 76:12;79:3;86:1;87:9, j recall 72:14
.
u 19;64:20,65:1,3; 68:2; i .,'7:20,21;69 71:20,22;74:19,22;75:5 l 93:2;94:6;96:25;99:19 6:11:9110 6;7 25'- ,'
,
;
87.10 t 6,9,18;76:11;78:16; , puts 62:23 i meaHed 2a23 * Planned 9.15. 27:11, !! - P s 25 1 1;
, ,
84:3,20,21,23,25;85:3- l putting 51:15;813 recaHe 3&24 ; planning 82 22 ! 10,16,20;88 11;95:16, receive 31:4; 32:10 . ' lent ;";13: 4 22 21 8 :19
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17.12,15,17;18:21I22 P IPN*"d 8h Proceeded 20 6,10,21; receives 47:13 22 14;24:10.12,19,21] Precision 42:25 . ;.21:15 QA 36:18,62:1 receiving 23 3; 29.20- ' ' 25:25;26 7;34 4;44:25; { properation 99:20 proceeding 99:2 , quellfied70:17 . 43:13;63:13 48 6; 49 2R 51;18; 52:4, 3, properations 55:15 ' Proceedings 100:20 ; qualifiers 100:5 12, % 3,6;61:9;65 14, recent !als 5 propered 11:8 process 9:6:10:10; quality 41:14;61:13; * i-- - .", 4:13; 8:9; 33:7; P NN W Min-U4criste BROWN RFPOR11NG. TNC (404) R%RQ74
.. ._ _
, PROCEEDINGS EEFORE MR. STEWART D. EBNETER IN RE: ST. LUCIS PIANT NRC March C,1996 36:9,11.12;47:24 replaced 93:21 1 e;71:22;72:17;75:16; 18;31:23;37:6;39:12; September 69:22,76:20
recognition 39:7 report 4:6; 15:6; 16:12, 77:23;84:12;91:18,19; 49:8,50:22;57.8,22;59.6; sequence 18:6,15; recognize 48:20; 50:1; 14;26:24,25;27:17;29:1; 95:15;100.8 79:10;85:13;93:7.1I I 22:13,16 64:24 31:10;33:16,16;39.3; reviewed 14:12;26:1; sanction 9:9 l series 34:11;51:7.11 recognized 21:1;43:18 40:18,21:41:14,20; 27;2:34:18;68:17;74:25; sanctions 8:22 j serious 15:16; 53:24; 49:24;69:23,25;70:3; 81:14 sat 41:4 i 64:10,18 l recognizing 39:10 ' 85:16;89:10;90:4;91:7; reviewing 34:18;67:22 satisfied 14:5; 49:7 92:4,3;95:6;97:22,24 seriously 64:13;94:13 ) reviews 34:15 satisfy 52:7 serve 70:17 l rCPorted 5a revise 55:16;82:22 saw 25;25; 40:5, 5 recommend 33:19. i service 58.6 reporter 11:4 revised 8:10; 34:16; 58:1, saying 71:18;92:1 record 22:6; 31:3;99:24 f set 29:23;30:20;43:7; ' reporting 15:22 4,9;82:20;90:7 SCAROLA 7:12,12; I 45:24:46:7,12,14;75:20; ! reemded 11:3 reports 93:6 revocation 13;21 76:22;80:20;81:15; 16:21;18:5;22:9;23:18; l recovwy 21:10 represent 10:4;12:16; revolume 56:11 24:23:25:10;26:15; 83:24;90:10,11 redundant 85-5 100:12 rewrite 55:21; 59:16 28:11,19;29:15;30:2,5, sets 88:13 reference 761;96:10 representatives 7:25; rewrites 85:21 21;31:6;32:25;33:5; setting 44:3 i referenced 75:25 91:14 Rich 36:14
' seven 26:25; 27:18 referred 12:8 requal 36:14; 38 3,15, 2 9 94 i right 3:24; 8.6; 15:12; 41:20:42:6;43:18:44:12, l speral 2&llM2; reflect 41;7; 89:1 16;47:17;77:20,87:5 18:16;20:17,22;29:10, 23;45:7.21;46:1,10; l 36:10;82:7 reflected 90.7 requalification 37.25 : 11:30:22;34:22;35:5; 47;9,16,19;48:13;52.24; severity 8:14,17,18 reflects 1517 , requested 20:9;24:5,14; { 37:9,13;39:18;47:6,24; 54:7:55:11:56:15;57:15, shape 79:7
'! 27:18,58 24;75 12 52:4,15;56:12:59:18, 3 refreshed 87:4 24;58:18;64.6.16;66:11, share 21:25; 25:13,18; I
. 60:11;65:2,13;67:5; 16,22;72.22;78.23;79:5; refrigerator 47.4 require 75:16 35:17;55:11,15 l
71:20;72:18;73:8;77:24; 80:9;92:13;95:19,22; ' refueling 70.5 required l2:8,9,14; 84 12;85:14;86:25; shared 18:23:50:6 ' 96 15;97:17,24;98.12,19 regain 51:10 14:8,10,57,12,74:23; 89:24;91:23;94:2;95:23 scenario 30:11; 32:7.22 95 18 ripe 7815 , shear 84:24
- rd 5.19,24; 34 8; s hedule9 :23 g requirements 13:18, I role 46 24;91:19 ! shed 4:15
regarding 10:5;1316 room 6:18; 19.8,19,22; , l sheet 26:24;27:18 requires 19.24 35 4 Region 3:4.5,22;4:1 14 shift 19.5,22; 24:1,6; requiring 9&3 20 8;21:9'11;23:9'6:11;screen 75:22 24:4,8,25:12,24;2 ' 29.8,13;33 8,38:21; Regional 3:3;7:22; 10.8 reset 46:17 28:3,8;29:2.4;30:23,25; screener 74:23 1 49.14,15,15:51:7,52:19, regs 80:24 52:4;53:15:57:18,60:14, screening 74:15,19,21; I 56:3,22;69:2;82:16 resetting 23:4 regulation 52:20 16;81:23;93:13;95 15; 75:2,5,8,9;77:8 i shifts 33:9;38:24
regulations 5.16 IruidenM2 l 96:20,20
! ! resource 84:15 :
screwed 67:7 shoot 26:17 Regulatory 3 4,10,8.15; I resources 91:20 * ** i searching 58.10 short 55:13,17; 82:15; 13'18;94'17 I toot 9.12;32:8;35:3; resPed m3,9,92:3 second 11:25; 23:19, 99:5 reinforce 47:12;66:14; i 36:9,39 8;74:14;89:24 31:8;35:20,39:5:43:5; respond 4:4,9,11:8, i shortly 15:22;20:3 82:10,83.24;86:16 50:12;54:23;60:21; I 42t 53 8; 88M 8%14 l ROs 69.3 shot 48:21;73:12 reinforced 40.25; 48.24 l roughly 68.16,17,72:1 71:16;77:20,84:2 i reinforcing 46:24,87:1 r#Pon el3 secondary 44:24,25 related 315,16; 4:18,20; resPon ng 60:17 l round 97:3 l shouldn't shoulders 65:8 11:7; 30:3, I routine 19.6; 3121:34 9; secondly 15:14:100:10 5:10.20,6:2;27:25;67;10, es e1 37:4;4 :1;48 4;86:22 '! 64:5 seconds 26:20; 29:18; show 51:25;79:12 0 8; 5 ;59 4' ;
, ; 24;84.18;89:16 Routinely 22.24; 28:21: 30:13;55:I shown 3:18;79 15 l *
i responsibilities 81:19 4 5 * " * shows 63:18 relation 64:23 i RTD 44:15: 62.12 sections 74:24; 75:11, relative 6913
* * 3 8 " 3 ., [*3 g RTDs 44:5,16,98:1 18,24;97:8
relatively 6819
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responsible 27.4 ! RTGB 1914; 20:4,13,25; j secured 25 9 g relayed 92:22 I *** rest 39 4;66 24;77 6' 14:11:39 10;42.8;62.7; I release 10 23 l RTGBs 24:11,17 j seems 38 8;89:9 63:19,64.8;72;11;80:25; l 82:3 , I relief 28 20.3318,38.22; result 18 11;71:23; 89.15,94g,14
% I8 72:25,73 8,74:18,75 24, ,26:19,62.23; l running run E18,52.2, ; 90I3,21;91:9 L 61:18 i seSassessment 8m, significant 9.2,25:15; relieve 20 9. 56 9 76 7;86-19 63:9;90 12;91:4 I self-critically 90:22 39 6;41:24:42:17;54:5, ;
relieved 19 20,33 25 resulting 930 , Selman 16:l; 35 9,39 22, 65 4,83:9 34 25;35 21,22;38 21; 49.13 I results 53: 20;92.4;
' S I 23 simiiw 38 ii;5 i9.
90 37 . Selman's 40.2 60 25;92.14 remainder 54:13 similarities 40.1 remaining 46:9 f retired 16.1 ' safety 3 25;6.9,25;8.14; l send 84.12 return 21:9; 23:5; 58 6; 9.2;13:9,14:11;39.10; senim 11; 1124; 161, SMns 2818 remarks 3 20;15:12, 62:17 35:2.68 12,91:19
, 46:25;47.1;48.18;62;7; simulator 518. 5210.
5m 80 20 returned 20 ?,21; 23 9, 64 8.68 5,70 12,14; sense 80 21,82.19. 541;86 25 remind 11 4,98 22; 24.3;27:!;28.24 1 71:23;72:15,*3:25; , 88 25 simulators 51:15,22; 100.I,5 ! returning 261 ' 83 16;89.15,90.16,94 6, l sensitivity 48 7;6512, 52.2 removed 33 20 14,98:1 J 18;66:2
' returns 85:21 single 97:25 repeat 57;7 ! review 4:25;919,21:15; ! safety-related 89.6 I sent 41:16,46.23 site 7.16; 28 8; 31:14; repetitive 8315 j 31:14;35:17;51:3,3; j Saget 34:2; 38 23 separate 92:25 , 34 3;36:11;84:13 rephrase 9614 1 68.16;69:4,15,19;70:7, i same 12:5;15 20;16:16, separately 14:24 i sites 93:5 BROWN REPORTING, INC. (404) 876-8979 Min-U-Scripte (9) recognition - sites
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PROrFFDINGS BEFORE MR. STEWART D. EBNETER , j March C,1996 IN RE: ST. I.UCIE PLANT NRC
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citting 48:3;65:21;75:21; stocking 71:10 suggests 81:15 teems 59:25 44:2;94:12 76:3- staff 3:21;7:4:9.6;10:3, toch 11:18;12:17:21:15, summarias 13:25 together 33:15;68:11 Cituation 22:5; 25:25 8;11:4;31:23:37:12;39:7; 16;26:2;42:19,20 43:15, summary 6:1;13:11: told 18:12:48:10:53:6 cituations 57:13;88:14 46:11;49:22;50.5;83:11, 15:3 22;45:16,25;46:7,9; ] 12;92:7;99:1,2,4;100:12 tolerate 58:16 tix 15:19,28 3;69:23; supervision 31:11 62:14;84:10,90:9,12 Tom 6:20;7:14;18:5; i 70:3 stand 20:10;33:10; $6:12 technical 19:22;33:4,12; supervisor 7:11:12:13; 50:15;80:19;91:14 (kill 59.1;9513,17,25;' sund<fown 59.8 36:M;52:21;74:24; l 17:12.15,17;18:21,22; Tom's 90:2 96 9 standard 307;78:6 27:5,20;31:2 0 32:3,14, 75:10;78:24;80:2,4 ckills 66:24 standards 64:24 24;33:2,4,12;36:17;49:5 telephone 7:24;22:5 5014;60:13,24;84:5,20; slow 39:8 stander 568 supervisors 87:2 telling 53:11;82:6 97:6
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cmeller 68:19 standers 56:17,18 support 44:1;74:16 temperature 23:1;26:3; gap 34 g;34:t5, g7 cmart 93:19 standing 51:6 supposed 70:11 2 2 1,
, .' total 62:18;68:10,16; !
Cnapshot 61:14 standpoint 63:17,65:3; sure 6:6;13:18;16:7; 69:16;72:2,9;98:1 9g g Snyder 36:6 8t24;89:13,17 18:17;25:2;26:5;30:21; touch 75:17 - g something ;;516;31:1; stands 89:24 , ku 22 37.8.11;45.19,19,24; stort 16:22;18:14:21:23; h2 jt r ry74:16;75:22 61:15;6014:65:6;69:5; ten 23:8;30:17;51:6; tough 8t14 46.3:47,5;48:22;51:12; 12:9,20;35:3;42:14; 65 5,19,71:5;79 9;91:5; 70:12;72:10;79:20 68:12,21;98:1 tmck 22:10; 2&9,it Yl:15,21;70:5;97:13 , 93 10;99:18 83:23;85:10;86:24;87:3. tended 40:16 # stuted 3:1;15:11;23:15; 9;90:25;93:2;94:10 sometimes 87:24 25:22;26:10;71:10;85:24 tenth 4015 somewhat 78:17 surfaced 15:18 trained 36:9,12 Fa; N g 8h12,21 surveillances 19:2
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someWere J5.8; 30M , training 36:13,15;38:15, mas 77:20 surveys 306
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16,17;51:6;52:11,21; 68 U ~ I"888d 21:t 5: I; sophisik:sted 83 3 state 19:1;98:9,10 suspect $2:14 l l' 61:13,17,19;75:4;77:17;
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stated 35:9; 5015;73:24 suspension 13:22 n22,2W, O, M, sort 52.3; 72;16. 95:25 terms 63:18; 64:19;79:7, statement 24:13 18;87:3,6,12 sos 69:3 , sustain 61:17 7;91:19
,,g 3g statements 10:2,100:10 transfer 57:3 9gg system 3:16;4:23;i1:22; l test 51:8,20,21 states R1 2103&7;61:5; transferred 57:2 sounded 30-11 testing 51:21
;l translate 12:20 sounds 15:21:45:15; 77:3;97:15 ""5 Ifl3 8l f systems 6:9,61:1,2; theme 81:2,4 transmWed 33:23 stationed 19:10,13 63:20,70:10;78:16 treated 37:6 southeast 3:6 themselves 5:13;53:3 speak 13.15; 40;15; '"* ' tremendous 36:5
{'6 23 91l13 T therefore 81:16 trend 56:11 spec 11:18,12:17,21:16; stay 15:1; 29.2,98:23 tmndng 88:20 42:19,20 43:15,22; steady 19:1;98:9,10 thermal 63:5,24;80:12; T-cold 31:t 42:20; 43:6; trends 56:6 98:9,1 g 45 16,25;46 7,9;62.15; I steem 20:16;44:24;45:1 45:17,20;62:15;90:12; ~
8010;90:9,12 * 91:4 trip 63:22,2t 80:12 l they'll 99:24 48:23;91:20; special69 25;75 5 f stop steered9:5;19:941:12 ; tables 68:19
they're 33 8;43:10;4t8; hi Ps 634 specific $7.9,68.3;71:5; i stopped 23:2 i talent-wise 8016 17,25;73:18;81:9; try 22:5:80:20;9 021 7622;962,97:4,8 ! steps 100.4 I alk t 15:1:16:17;18:14; tpacifically 12:9,23; still 47:3; 48:24;49:6; I } 85:1;99:22 70: trying 11:9;58.19;75.22; 82:5;83:23;85.2;95:25 51.8;97;1 23:24;25:11;35:6;37:4; ' They've 92:21 59:21,23;96:18,21;97:3, 4&t 48.0 49:2; 5&l2; tuned 65:13,18 cpecification ?5-il;80:2 12,17;100 3 62:6;66.20,67:7;81:3, 4, thinking 81:4 8 third 4 2012:3;35:10'. i Turkey 31:22;50:5; ifications 74:25; stop 39.15;73:4;90.2
; - 8 2; [2b 9 9 6; 681M2:1;85:22 stopped 23:13,15 98 24 thorough 60:1;75:16 ; 8 23; It specified 5 9 straight 28.3 92.8.10,11,18,19;93:16; rpec3 21:15; 26.2 l talked 16:15;33:17,18, , thought 503;93:18,20 l 97 5 i straighten 22:5 37:17;49 4:61:14;75:14; 99.6 tpeech 37:22,38 214 strength 62:4 { 84:21;88 2;92.8,9 thoughts 15:20 ' turn 3:20,23;4:3;15:8, D2 l strengthen 25 I i 17:1;2t9; 29.19,22;64:3 cpolling 72.3 talking 28 9,42.5; 46:19; ! three t17,21;8:18,21; i turned 26:12;5t25;
' strongly 16.19 l 66:2.71:20 7"':18,80:23, 11:16;12:19,16 19;17,7; spent 33:108212 i 81:23;82:13;88:7;90:23, , 19:5,6;32:16:43:20; l
55:2A epoke 27 5;28042.8 ' structure 80 23 turning 86.7,8 structured 81:11 !,, CP C 89" !' Stu 3:3;11:10;93:9 93' g ' f2 2 5 5 I turnover 12:2; 23:7,21, SRO 18.21; 34 8; 36.18, 79;I4;100,7 21,23,25;2010,18,22;
. stuff 40.7; 51:15 : tan 133 >
2%21M 13. D,22,20
'54 I8,21;71:6 - task 26:9,14,17,19, threshold 39:10;89:14 s 91% 20J2:13; 56:10,19;57:9,12,1.4; i SROs IH 23 * 29:10 35.22 throughout 5:23; 28:22; 82.15,16
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St 315. 419,6 9,'ll, taught 3610 31 39 16,21;15:18;17:12,13; a nma 23
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tied 73:18 turnovers 55:25
> , substantial 86:9 Tc 84:9 twist 82:24 1H.I2,17; 29 21;50 3. timsHne 1&2018:7; team 35:3,8,11,16; 60 3,22,61.20 6t 19; succinctty 86:23 22:11:23:1;31:8 two 8:18; 18:19 2t 1 >.6'
36 15,17,19;39:20,40 3, 25,25;21:16:25 19,24; 65 14 81:7;90:19,92:1 suction 12:25; 20.2; e
' 5,46,22:41:3,7:42:11; : timely 59:25 STA 19 21:21:10 26:23; l 62:22;63:11;73:23;95.8 36:22;39:16:43.8;44:16, 59:24;68:12,22;8018; ; times 19:5;22:15,16 19;57:10; $9:4;62:17; '36 7 l sufficient 46 6 89:24;91:19 t today9.8,9;13:lt 68:11,15;75:21;76:9; stable 21:14:26:1.7 ! suggested 82:25 team's 41:7 ! 16:17:41:22,20 43:24; 92:25;100:5 l
titting - twe 00) Atle-U-Scripte BROWN REPORTING, INC. (404) 876 8979
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PROCFFnINGS BEFORE MR. STEWART D, EBNETER ; IN RE: ST. LUCIE PLANT NRC March 8,1996 type 16:5; 48.6;69:11; 90:9 17 write 26:24;60:10
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72.6;90:10 Uryc 3:12,20;6:15;7:3, l watchedi 23:16 writeup 79:20 ; types 29:24;79:18 3;83 water 4:23;11:21,23; writing 33:23;47:12;
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typical 44:17 use 73:4;76:12;78:19; 20:1,24,25;22:25;27:11; 99:23 I typically 44:15; 80.7 86:15,18;93:5,95:7.14; , 62.22;63:11:67:13:73:22 written 27:17,I8;49:24; I 9610 ! water / boric 12:25;13:2 80:15 U ""d '2:22 4e2s22 i .,e,shed 8i:6 wr g 37:20,23:58:22; using 8&3;88:18 6015;65:19;93:22 WATSON 95:3,10,13, j UFSAR 4:24; 5:10,17; 20;97:15,20;98:8.17,20 Y
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12.23;I3:1,8;42:21;44:1; wave 38:16 - Y l 1 61:12;62:19,25,67:17, waved 47:18 a 24;68:2.6,8,10,I8;69:9, validate 33:22 wax 64:12 year 69:22;70:5;72:23; } 21;70:13,17,20,22;71:2, value 35:14,14:43:23 78:11:88:22 way 27:21:29:24: 54:17; ; 18,20;72.2,14,20;73:11, 72:18,19;73:7;74:3; years 17:13,17,23; values 15:18 ! 76:12;80:16;81:3,11; 67:21;90:19 j 7 11,1 8 4 valve 11:23 76 4 10;77:23[78[7,14; valves 19:16,25; 20:1; , 86:10,21;88:11,16;90:6, yesterday 46:16,17; 59:5 l 17,18;93:1,7 77:21 79:7,9;80:3,4,10;84:6, ; l 11;85 8;94:16,16,22 variable 63:6 l ways 59:13;69:5;93:4 l UFSARs 68.17;69:17 variations 78.22 , week 34:15;38:19,20; i 68:15;77:20
! E I ultimately 90 6 various 38:23;81:23; l uncomfortable 96:19 88:13 , weeks 10:11:51:6;68:15; ' Zach 5:25:38:20;39:1; Oncovered 89:25 VCT 30:16,17,24:63:2 1 76:23;82:7;87:24;93:2; i 46:21;86:11 under 27:5;92:21 verbalize 56:4; 57:6 i 100:15
! WEINKA*A7:20,20 {;
underestimating 94:ll verbatim S8:2,15,23; understood 14:6,7; j 59:8 I welcome 3:2 35:20 versus 34:10;40:2; ! welldefined 39:9 ; l 60:21:95:14:96:1;97:2 ! West 32:23:34:3;38.22; > undertaken 89.3 undertook 69.8 i vice 7:17;16:2;34:3 48:15 unexplained 27:6 .' vi*w9faPh 3.19;11:12 l what's 6:5;56:25;70:16; l l I views 10 2;100:11 ! 71:3,9,82:13;83:5 ' l Unfortunately 93:12 unique 96:2 white 40:15 I j violate 71:1 Unit 5:4:11:24:18 21,25; ! violated 13:17;80:4; ! who's 91:21 l who've 86.8 l 27:1;28 8,15,22.22, , 98:10 29 4:43:7;45 8;57:21,22, violation 8:7.12,13,17, , whole 40:9,13;64:11,17; I 23;58.1,3,4,6,6,9; 24;9:1,23: 11:12,24; I 83:11;91:2 69.21;70 1;73 6,21; 12:1,5,17,18;13 4,21; wholeheartedly 38.18 i i 76:20,21;85:11,12 15:16;17:3;67:9,10,11, l w itingly 87:7 I units 18.24;34:11;42:19, 16,17;73:17,19;74:1,12 wind 90:17 43:24:44:13;60:25, violations 4:2,17; 5:10; ; 8:23,25;9:1,I4,18; wiping 92:1 68.11;72.23 ! Unless 64:2,81:18;99 22 H:14,16,13:11,12; , wires 48-4 , 8 9' ' * ' unmonitored 5:3 i, 100 6 ! within 19.12;20:19-I
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unplanned 12:14; 27.6 > 32:16;46:9;49:12,16;
! virtue 85:20 i unrecognized 50 23 t volume 13:3,84:24 l 62:17;76:1,23;100:14 l
unreswed 423 l Volumes 68:11;70:22; , without 37.2;50.17;71:2 ! up 1512; 19 8,19,25; , y 3 :9 73:25 20.11;23:22,24:17; i volunteered 81:24,29 l wondering 95:16 i 26 24;27:17.19;29 23; ' Wood 33:1,8 i 30 6,*.8,31:12,35 14; !i Vorhees 36:18 36 7,12,14;41:23;43: ! vulneraM3ty 78:22 , Wood,s 33 6 l 15; I 99 20.60 3,14;65:13,18; work 27:21; 28 2; 35:22, 6?';'31;768,7919, 80 20.81:16,18;83 2,22; l g Wl52H;64 25;73:5; 83:4;84:10,14,23;85:1;
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84:21;88 14;89 12; ! 89.7;90 I 90 11,12,l',91:5;92:18. ! wait 70.1 [ working 81:22;82:7; i 22,94:7,14,21 ,' waited 2316 ; 93:20 up-to-date 76:10 I waiting 23:17 ' works 36.7 update 68 8;69 24;84 6 wake-up 85 23,24 world 51:23;71:8 updated 68 7; 80.7 ! walk 24:11 world-class 86.7 upgrade 58:7. 8,84:12, I walkdown 56:10,21 worry 64:5;67:5 85:11;95:19 walked 30.25 l worth 88:16 ) upgraded 58.9 wants 76 5 worthy 46:19 I upgrading a5:12 watch 18:22; 20:10; I wrap Upon 2310,31:14; $7:5; 22:21;33:10:51:24;56.8, I wrapup83:22 17:4 BROWN REPORTING, INC. (404) 876-8979 Min-U-scripte (11) type Zach _
(-, t Lawyer's Notes
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UNITED STATES NUCLEAR REGULATORY 1 COMMISSION-REGION II'
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:3 -
,4' IN~RE:' )
~ST.'LUCIE PLANT NRC -) {
.5 . INSPECTION REPORT NOS. )
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i' 50-335/96-03 and ) 6- 50-389/96-03. )
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:. 8l
~9
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10 PROCEEDINGS BEFORE
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11' MR. STEWART D. EBNETER, CHAIRMAN e i 11 2 ' March 8, 1996 13 11:00 a.m.
! 14. '
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Suite 2900
101 Marietta Street ' Atlanta, Georgia
17 j 18 I p ' 19 q 20. ' s
Keith A. Wilkerson, CCR-B-1381, RPR l '
BROWN REPORTING, INC.
24 1100 SPRING STREET, SUITE 750 ATLANTA, GEORGIA 30309 25'
(404) 876-8979
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1 On behalf of the Nuclear Regulatory Commission: 2 S. Ebneter, Chairman T. Peebles 3 J. Johnson M. Miller 4 C. Casto B. Uryc 5 J. Jaudon L. Wstson 6 J. Bell C. Evans 7 J. Norris 8 On behalf of the St. Lucie Plant: 9 E. Weinkam D. J. Denver 10 W. H. Bohlke T. Plunkett 11 J. Scarola P. Honeysett 12 F. Cone H. Holzmacher
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1 MR. EBNETER: Let's get started. :I'want 2 to welcome Florida Power & Light here this morning.
3 I'm Stu Ebneter, Regional Administrator for the 4' Nuclear Regulatory Commission Region-II office.
5 ' Region-II has cognizance and jurisdiction'over
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t 6 nuclear power plants in the southeast, and Florida :
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7 Power-& Light Company of course is licensed by us.
8 This morning we will conduct a
:9 . pre-decisional enforcement conference between the 10 Nuclear Regulatory Commission and Florida Power &
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11 Light. This will be a closed enforcement , 12. conference, and Mr. Uryc will discuss that with you , 13 in just a minute.
14 The focus of the meeting this morning is
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15 on an event related to operational control of St.
16 Lucie 1 related to the reactor coolant system boron 17 dilution event that occurred on January 23rd, 1996.
18 The agenda for the conference is shown on 19 the viewgraph here. Following my brief opening ' 20 remarks, I'll turn it over to Bruno Uryc, who is the ; 21- director of our enforcement investigation staff here [ 22 at Region II. Basically, Bruno will discuss agency ; 23 policy.with you. Then I'll turn it over to Al ; l 24 Gibson, who is to my immediate right. Al in the 25 director of the division of reactor safety here in
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' l' .RegionLII,.and he.will essentially conduct the f 2 conference and discuss the apparent violations with
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3 you. Then we will' turn the meeting over to you, i 4- give.you an' opportunity'to respond. , 5 I. assume you have the basic inspection. i 61 report land you. understand the issues.
7 MR. PLUNKETT: Yes. !
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8; MR. EBNETER: And we would expect you, 9- then, to' respond to those. 'l 10. -The pre-decisional enforcement l
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11 conferences are our means of getting additional j i 13 information from you so that you can provide any j
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13 data that we may not have access to or recently I i 4 14 discovered information that you may have or anything }
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15 that would shed some light on the issues and would. t l 16 help us make an informed decision.
17 The three apparent violations will be !
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18 : discussed by Mr. Gibson. One of them is related to : 19 the' operating procedures for the operation of St. i r 20 Lucie 1, and another one is related to Appendix B, i
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21- lcriteri'on three, design and control, and that talks i
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24' h o w '4. t relates to the UFSAR. The third one relates , 25- Lto 50.59 review, and Al will cover those in some
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5 1 detail.
2 I'd like to comment just quickly on the 3- operators. The operators did allow an unmonitored 4 reactivity addition which caused Unit 1 to exceed 5 100 percent power. Probably just as important as 6 that is our understanding that this was not promptly 7 reported to management. And part of that addition, 8 at least part of the evolution, was conducted in a 9 manner that was different from what was specified in 10 the UFSAR. These are related to the violations that 11 Al will discuss.
12 Based on that, we think, then, that the 13 operators apparently did not conduct themselves in 14 full accord with either the expectations of the 15 licensee or the NRC. We license operators, and we 16 expect them to fully conform with the regulations l 17 and the conditions of the plant, including the UFSAR l 18 procedures. Mr. Gibson will comment on current 19 agency policy with regard to enforcement action 20 related to licensed operators.
21 Just as an aside, there have been far too 22 many -- and this is my comment here directed to the 23 operators -- far too many incidents throughout the j 24 industry with regard to control and operations. l
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25 Have you seen Zach Pate's paper, any of you? That's
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1 just a brief summary of some of the incidents that 2' are related to control and operations. I am quite f 3 concerned and the agency's concerned about these 4 incidents and the inattention of the operators to 5 what's going on in that power plant. There's 6 nothing more important to the agency, and I'm sure 7 your company, nothing more important than to have 8 discipline and control of that reactor and those 9 safety systems at St. Lucie.
10 My own personal opinion is you guys did 11 not pay the degree of attention that you should have 12 paid to your duties in controlling. That's all I 13 want to say at this point.
14 Bruno, do you want to discuss the -- 15 MR. URYC: Perhaps we should make 16 introductions.
17 MR. GIBSON: I think probably there are a 18 lot of folks in the room that may not know one j 19 another.
20 MR. PEEBLES: I'm Tom Peebles, branch
21 chief, operations.
22 MR. JOHNSON: John Johnson, deputy 23 director, reactor projects.
24 MR. GIBSON: Al Gibson, director of the ! i 25 division of reactor safety.
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1 MR. MILLER: Mark Miller, senior 2 resident.
3 MR. URYC: Bruno Uryc, director of the 4 enforcement staff.
P 5 MR. COSTA: Chuck Costa, engineering 6' branch' chief.
7 MR. HOLZMACHER: Hank Holzmacher, control 8 operator.
9. MR. CONE: Frank Cone, control operator.
10 MR. HONEYSETT: Pete Honeysett, 11 supervisor, St. Lucie 1.
' 12 MR. SCAROLA: Jim Scarola, plant general 13 manager.
, 14 MR. PLUNKETT:
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Tom Plunkett, president of 15 the nuclear division.
16 MR. BOHLKE: Bill Bohlke, St. Lucie site 17 vice president, i 18 MR. DENVER: Dan Denver, engineering 19 manager. l 20 MR. WEINKAM: 2 Ed Weinkam, licensing 21 manager, St. Lucie.
! 22 MS. EVANS: Carolyn Evans, regional
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23 counsel.
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24 MR. GIBSON: On the telephone we have
representatives from our headquarters office, Jim l
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1 Bell from the' office of enforcement and Jan Norris 2 from NRR. i J 3 MR. URYC: Mr. Ebneter, we made some hard. . 4 copyLof the. agenda. I'd like to take just a few
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.5 minut es . tcf go . over the enforcement policy and
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6 procedure that we're in right now.
i 7 After an apparent violation is 8' identified, it's assessed ir accordance with.the :
'9 ' commission's enforcement policy which was recently i
10 revised and became effective June 30th, 1995. The ' ' 11 enforcement policy is now published as NUREG 1600. .
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12 .The assessment of an apparent violation
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13 . involves categorizing the apparent violation into
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'14 one of four severity levels based on safety and i i
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-15 regulatory significance. For cases where there is a -
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. 16 potential for escalated enforcement action, that is, 17 where the severity level of the apparent violation i 18 is categorized at severity level one, two or three, . .
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19- a pre-decisional enforcement conference is .' ' 20
' ' conducted.
21 There are three primary enforcement I 22 . sanctions available to the NRC, and they are notices l
- 23 oo f violations, civil penalties and orders. Notices
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- 24- of1 violation and civil penalties are issued based on 25 ' identified violations. Orders may be issued for . l . : '
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1 violations or, in the absence of a violation, ! 2 'because of a significant public health or' safety
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3 concern.
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4 This pre-decisional enforcement H 5 conference.is essentially the last step of the ' '
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6 inspection process before-the staff makes its final
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L 1. 7 enforcement decision. The purpose of this ! $ 8- conference here today is not to negotiate a i t 9 sanction. Our purpose here today is to obtain i .
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- 10 information'that will assist us in determining the 11 appropriate enforcement action. We would want to i
12 achieve a common understanding of the facts, root ' 13 causes and missed opportunities associated with the . i o
14 violations, a common understanding of the corrective ;
- 15 action taken or planned, and a common understanding ;
' t 16 of the significance of the issues and the need for
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17 lasting comprehensive corrective action.
. 18 The apparent violations discussed at this
i conference are subject to further review, and they g . 20 may be subject to change p'rior to any resulting 21' enforcement action.
. It is important to note that. j 22 I . the decision to conduct this conference does not 1 23 ! .
'mean that the NRC has determined that a violation l
' 24 ! has occurred or that enforcement' action will be 25 taken. '
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1 I should also note at this time that 2 statements ot views or expressions of opinion made 3 by the NRC staff at this conference or the lack 4 thereof are not intended to represent final agency 5 determinations or beliefs regarding this matter.
6 Following this pre-decisional enforcement 7 conference, Mr. Ebneter, in conjunction with the NRC 8 office of enforcement, the regional staff, and other 9 headquarters offices will reach an enforcement 10 decision, and this process normally takes about four 11 weeks tc accomplish, and that's when you'll hear 12 from us as to what we decide.
13 As Mr. Ebneter said, this is a closed 14 conference, and they normally are closed, but the 15 commission has implemented a trial program that 16 began in July of 1992 to allow certain enforcement 17 conferences to be open to public observation, and 18 the recent change to the new enforcement policy has 19 continued this practice, and it's been extended for 20 additional evaluation.
. 21 Finally, if the final enforcement action 22 involves a proposed civil penalty or an order, the 23 NRC will issue a press release 24 hours after the 24 enforcement action is issued.
25 Do you have any questions? I'll be happy
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'l to answer them. That's all I have. *
l ' 2~ MR. EBNETER: Just quickly, the
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3- conference is being recorded; we have a court
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p i , i 4 reporter here. I want to remin'd i the staff to. keep ^ i
- 5 on the'issuesiof the enforcement conference. If we.
- 6. get into areas that are off the enforcement
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? ;7 conference, which~we shouldn't, and you're-not ; . ,
8: prepared to respond, you should say so rather than- *
9 trying to formulate a response. So'with that, Al? ! .
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10 MR. GIBSON: Thank you, Stu. j * 11: Bob, if you would put the proposed notice
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'121 of violation on the viewgraph.
' ' 13 I'd like to discuss the apparent ' i -
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14 violations as we see them at the outset of the ! i ! - 15 conference. As Mr. Ebneter mentioned, we have f
.16 q identified what appear to be three violations, and 17 the first is four examples of failure to follow !
18 procedures which would be contrary to tech spec !
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19 681.
.. y H2 0 . The first example is a failure to monitor : - t 21 the flow for demineralized water that was added to !
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the valve after the~ desired amount of water had been ' l ' 24 added, whi~ch appears to be a violation of the Unit 1 .
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L 25. -operating procedure, 0250020.
i The second example is )
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. l' a' violation of administrative procedure 0010120 for 2 an inadequate turnover that did not include in the - ; 3 status that a' dilution was in progress. The third
.4 example of failure to follow procedures is an
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5 apparent violation of Appendix M to that same , 6 administrative procedure when the dilution was 7 accomplished from memory and the procedure for the ' i e 8 dilution was not referred to-as required, when this , l . 9- administrative procedure specifically required that l 10 .the dilution not be accomplished, that the dilution > L 11 procedure not be accomplished from memory. The 12 fourth example of failure to follow procedures was a
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- 13 failure to notify the op4 rations supervisor of 14 unplanned reactivity change as required by Appendix 15 E of the administrative procedure 0010120. .
16 Those four examples represent one , 17 apparent violation of tech spec 681. i 18 Next we have an apparent violation of 19 criterion three to Appendix B for failure to 20 . translate design basis information into procedures.
21 There was'a difference between the procedure that ' 22 was used at the station for dilution and the method 23 of dilution described in the UFSAR. Specifically, , 24 the procedure permitted a manual control of addition ' 25 of a' water / boric. acid mixture to the suction of the l
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;1 charging pumps. The UFSAR described automatic 2 control of addition of a water / boric acid mixture to 3 the volume control. tank.
4 Finally, there was an apparent violation , i 5 of'50.59, 10.CFR 50.59, in that a' procedure changer e 6 that was issued the day after.the dilution event
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l 7 'provided for a method of dilution that was different j 8. from that-described in the UFSAR, and there was not t l9 a safety evaluation performed to evaluate the '
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10 consequences of this difference.
, 11 Those, in summary, are the violations
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12 that we have identified, the apparent violations 13 that we have identified that we would like to focus L 14 our attention on today.
- ,, t 15 I would also like to speak to enforcement
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16 regarding the individual operators involved in this l 17 event. The operators also apparently violated ; 18 regulatory requirements. As I'm sure you're aware, P
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19 the NRC has full authority to'take enforcement
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20 action,against licensed operators, including notices
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21 of violation, monetary penalties, and revocation and ! i 22 suspension 1of licenses. Our-enforcement policy for [
'23 action against operators is described in NUREG 1600, ,
! 24 and if you'll bear with me for a moment, I'd like to "- 25 summarize the policy as described in that NUREG.
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1 The NUREG states tht . we will apply.
! 2 -. enforcement against individualt; in a closely [
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3- ' controlled and judicious manner. It also says_that- ;
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4 an enforcement action involving an individual will : 5 normally be taken'only when the NRC is satisfied.
-6 that.th'e individual fully understood or should have !
7' understood his or her responsibility, knew or should ! 8 .have known the required actions, and knowingly or 'l
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t' 9. with careless disregard, i.e. more than mere
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10 negligence, failed to take required actions which !
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11 have actual or potential safety significance. j
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12 We reviewed the circumstances of the l.
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dilution event, and, as we understand them, we have : 14 concluded that operator failures ware due to 15 negligence. Consequently, pursuant to our 16 enforcement policy, we do not at this time plan to . 17 take enforcement action against individual ' 18 operators. Nonetheless, you should understand that , i 19 your performance in this event did not meet our 20 expectations, we're disappointed in your performance ! 21 in this event, and we hope and expect that you will ; 4'
~22 takeEaffirmative action to do better in the future.
.23 I would also like to advise you that if
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24 you'd:like to meet separately with-us and discuss ; 25 1 any aspect of this. event that we will be happy to
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3 That in. summary.is.what weisee as i h 41 proposed enf orcement .: Do you have any. questions; ; 5 Tabout what we've described?
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6 -consistent with the inspection report. ; t 7 MR. PLUNKETT: No. '
10 MR. GIBSON: If not, I'll turn it over.to i ,. , 9 you.. [ 10 MR. PLUNKETT: Thank you, Mr. Gibson. l i 11- Before.we get started with our formal presentation, ! 12~ I'd like to make a few remarks of my own. Right up 13 front I want to say that we agree with the apparent l l 14 violations. But secondly, I want to emphasize that
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i 15 the dilution event is much more than an apparent- . 16 violation.in our eyes. It's a very serious event i i 17 which I think reflects on some of the problems and i
! - 18 cultural values that have surfaced at St. Lucie in 19 the last six months.
20 I had the same feelings or thoughts, it
- 21; ' sounds 111ke, that you folks may-have had concerning - 22 the event,- the. reporting of the event. So shortly . 23 after the event, a matter.of a couple of days, I 24 commissioned'an investigation by a rather senior '
25, * individual outside of our company. The gentleman's 3
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1 name is Murray Selman. Murray's a retired senior 2 vice president. He was the chief nuclear officer at 3 Consolidated Edison. But much more than those 4 credentials, Murray is a real practical operator, a 5 down-to-earth type fellow that you'd want to do this 6 _ investigation for you.
7 My number one priority was to make sure 8 that this event was handled with the highest 9 integrity, that there wasn't any hint of any 10 misactions or misrepresentations, and I asked him to 11 look at other things, too, while he was there.
12 Murray's report back to me was that there were 13 absolutely no misactions or any incident to not 14 properly report these actions.
15 With that information, I then talked with 16 the operators and formed the same opinion, and I 17 hope today, after you talk to them and listen to 18 them, that you come to that same conclusion, because 19 I feel very strongly that these are three people who
- 20 have the highest integrity. j 21 Now, in our presentation, Jim Scarola 22 will start out the presentation. We're all familiar l
23 with the event, but I'll just go briefly through the
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24 timeline of it. Jim will emphasize our corrective 25 action which we have taken, which has been j
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1 extensive. We'll then turn it then over to Dan 2 Denver, who will cover the apparent violations with 3 respect to violation 50.59, and Bill Bohlke will 4 have wrap-up comments on the improvement aspects.
5 That's our format for this morning.
> 6' If there are no questions, we'll go ahead- $ 7 with that. I'd like to introduce the three 8 operators to you at this. time, if I could, and they .
: 9 can tell you their positions with respect to the 10 dilution event and give you a little background.
, . 11 MR. HONEYSETT: I'm Pete Honeysett, 12 nuclear plant supervisor for St. Lucie 1. I've been ,
13 employed with FPL 15 years and at St. Lucie . 14 since '82. I've been a licensed operator since 15 1985. I've been a nuclear plant supervisor for the 16 past 15 months, prior to that I was assistant 17, nuclear plant supervisor for four and a half years, 18 and prior to that I was a control operator.
19 MR. CONE: My name is Frank Cone. I was 20 a desk operator the night of the dilution event.
- 21 I've been with Florida Power & Light in their 22- nuclear program since 1980, and I've been a licensed 23 . operator for the past four years.
24 MR. HOLZMACHER: My name is Hank , 25- Holzmacher. I've been with Florida Power & Light
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1 since 1984. I've been in the nuclear part of the 2 business since 1987. I've been licensed since 3 November of 1993.
4 MR. PLUNKETT: Thank you.
5 MR. SCAROLA: Good morning. As Tom had 6 mentioned, I'm going to go through the sequence of 7 events, the timeline of the event, but probably what 8 ~ I consider to be more important is our response to 9 the event. I'll cover that in detail, and then I 10 will go forward and carry through on our corrective
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11 action program as a result of this event and what it 12 told us about our management and operation at St.
13 Lucie.
14 To start out with, I want to talk briefly 15 about the sequence that occurred that night, you 16 have to have the right background, and I want to 17 make sure you understand the St. Lucie manning 18 procedures. For each of our control rooms we have 19 two reactor control center operators that are 20- licensed operators, we have an assistant nuclear 21 plant supervisor that is the SRO on each unit, and
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22 we have a nuclear plant supervisor and a watch 23 engineer that are also SROs that are shared between 24 the two units.
25' The night of this event the unit was
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1- '~'perating o at 100. percent power'with steady state-
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operation,~no'surveillances in progress,.and no 3 ' maintenance activities'in progress. At-this-point 4 inLtheJcore l'ife, dilution is' performed.on'a~
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5 frequency of.three to four times a shift or every- -! 6 two to three hours, a fairly routine operation ~for i a
;7 the' crew, in. order to m'aintain 100_ percent power. [
8 Ed has up for us the control room layout
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'9 here, and-I want to step you through.as to where we
'10 had each of the operators stationed.
! 11 Our board operator normally operates 12. within this range of area. Our desk operator is 13' normal'1y stationed here. At the beginning of this
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14 event the board operator was in front of RTGB 105.
. 15 105 is the board that has the CVCS control system.
16 The boron and dilution control valves are located on q 17 this panel.
18 The desk operator had left the control 19 room to heat up his midshift meal and was back in 20- the kitchen. The NPS had relieved the ANPS and was 21 located at this computer station here'with the STA,
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22 the: shift technical - adviser, in-the control room.
- i 23 The board operator commenced a dilution !
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24- activity which, for that activity, requires the 25' manipulation-of-two valves. He has to open up two
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1 valves to have primary water flow through the 2 suction of the charging pump to dilute the primary.
3 Shortly after he commenc.ed that dilution he had 4 received an alarm on RTGB 102. He went from this 5 location over to this area here to acknowledge the 6 alarm and proceeded to head back in this direction 7 when the board RCO or the desk RCO had returned back 8 into the control room in this location. The board 9 RCO requested the desk RCO at that time to relieve 10 him of his watch stand at the controls and proceeded 11 to go back to the kitchen to heat up his meal.
12 The desk RCO moved in to the control 13 panel location between RTGB 103 and 102. He was ,14 located in this location at the time. Now, this is 15 where we have the primary pressure controls. The 16 pressure levels as well as steam generator levels 17 are located right in this corner here, so he had 18 positioned himself here to be at the control panel.
19 Within approximately five minutes, as 20 best as we can estimate, the original board operator 21 then returned from the kitchen. He proceeded to 22 place his meal down on this panel right here. As he 23 did that, he recalled hearing the integrator that is 24 clicking primary' water or counting the gallons of 25 primary water on RTGB 105. He immediately _
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1 recognized that he had left the dilution in 2 progress. He announced that dilution in progress to 3 the desk RCO and to the NPS, immediately moved to 4 RTGB 105, terminated the dilution, and commenced a 5 boration.
6 The NPS had issued a command to the ANPS, 7 who was located back in the kitchen heating his meal 8 at the time. At this point in time the NPS 9 commanded the ANPS to return to the control room and
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10 provide direct oversight of the recovery 11 activities. The ANPS came into the control room, 12 and he provided oversight of the activities that 13 were going on with the boration and the NPS and the 14 STA. When the NPS was assured that we had a stable
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15 condition, he proceeded to review the tech specs and 16 make the appropriate tech spec entry into a two hour 17 LCO for exceeding 549 degrees.
18 What I'd like to do, because we do have 19 the advantage of having the people who were involved 20 in the activity with us, I'd like to take a moment
and ask that each of them discuss a little bit about 22 their perspective during the event.
23 I'd like to start you with Hank, if you 24 would. For this night Hank had the assignment as 25 the board operator, and I'd like Hank to share with
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^]E you what his perspective was and what he believes to' !
f-l: 2- be'the things;that'may have distracted him from his i. 3 focus: on the dilution in progress.
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'4 LMR . GIBSON: Before we begin, Hank, let's 5 try.to' straighten this telephone situation out. !
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6. '(Discussion ~ ensued off the record.) # 7 MR. GIBSON: Mr. Holzmacher was about to
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MR. SCAROLA: Let me start out again here i 10 so we'll get us back.on track. I do want to mention '
<t 11 that in your handout you have a timeline that we've !
12 added in-there that goes through basically the l 13 sequence as we have been able to recollect it.
14 .That's from the plant computer system, some of the 15- information, and some of those times are estimates. !
, 16 We are confident in the sequence. The times you
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-17 need to consider is approximate from the best we're 18 able to determine them. r ie 19 At this time, I'd like to ask Hank to 20 start'out and.give you a perspective from his board !
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21' Lwatch~ position as the board RCO that night. ! 22; .[ MR._HOLZMACHER: Again, my name is Hank i
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23' ~Holzmacher. I was the board control operator the j-24 . night of'the boron dilution event. Routinely we !
; 2 5. have.to' add primary-water.to the-RCS to maintain the !
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1 temperature. Going to the timeline, I initiated'a
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2 boron dilution to the RCS and stepped away from the i
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.3 boron dilution station after receiving an alarm on 4 another board. Following resetting and !
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5 investigating.the alarm, I did not return to the t 6 dilution station.but rather asked for permission for ! l
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7 a brief turnover to go to get my food. t 8 Approximately five to ten minutes later I 9- _ returned to the control room and went back to the 10 desk area in front. of RTGB 105. Upon placing my 11 plate down I heard a click on the integrator, and it 12 lit off what had happened. I realized that I had i j l 13 left a dilution to the RCS and immediately stopped 1
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14- it while announcing to the control room what had l 15 happened. I stopped the dilution and started 16 borating, and I waited there and watched the -
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17 parameters while waiting for further guidance.
18 MR. SCAROLA: Let me take the floor back 19 for a second from Hank here, too. One of the issues 20 that we have been dealing with through this event i
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21 was the turnover, and Hank mentioned the turnover in
order for him to go back to the kitchen and heat up 23 -his lunch. Frank had received that turnover as the 24 desk RCO, and I'd like Frank to-talk to us a little
~25 bit about the turnover and what he expected at that
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1- time.on.his shift.
2 MR. CONE: .I was the desk. operator the , 3 nightgof.'he.
t dilution event. I had returned from
'4" the kitchen-back into the control room when Hank 'S requested that he'd like to go get his meal. This ,
6 .being.a-back shift, there's no maintenance, so there
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7. - was.at this time no maintenance in progress at the 8 controlfroom,,so it was a very controlled atmosphere 9 and quiet. Now, we turn over at eleven o' clock as 10 oncoming' crew, so, we take a full turnover of plant
'll status conditions and walk down the RTGBs. Being 12 the desk operator, I'm cognizant of.where that plant 13 is as far as a generalized statement.
14 When he requested to go to the kitchen, 15 he just said, I'd'like to go to the kitchen to get 16 tay food, I acknowledged that, and I took command and 17 control of the reactor and moved up to the RTGBs. I 18 didn't. expect any more of a turnover because I felt
:19 like I knew where the plant'was. We had a black 20 board, noLalarms in, and at that point I felt I was 21 -cognizant of where the plant was at and didn't 22 expect any.more.of a turnover.
23 MR. SCAROLA: I'll come back to that in a * 24'- little~ bit more detail. This is obviously one of
,2 5 L the areas that1we've learned some things about that
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25-1 can strengthen our practices in'this. area, but I did , 2- want to'make sure you had the opportunity to hear. ! 3- from Frank directly what his expectation was. '
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4 MR. GIBSONi Did you hear the. integrator . 5 clicking? 6 MR. CONE: No, sir, I didn't. From where ? 7 I. was at to the integrator is about 12 or 14 feet, ,
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8- somewhere in.that area. If I'd heard the integrator
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9- clicking I'd have secured the dilution.
- 10 MR. SPAROLA: I'd like to ask Pete to ; 11 talk to you now. Pete had the command position at 4 12 the time in the control room, and I'd like for him 13 to shdre with us his perspective both on the event
. 14 itself and his reaction to the event, and probably !
15 more significant is the communication aspect. He 16 had the accountability for communication'in this
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17 event and the immediate actions following the 18 event. Pete, if you could share that with us. ! 19 MR. HONEYSETT: Of course my immediate
.; 20- concern was.to assure that the dilution was t
r-21 ' terminated when Frank brought this to our attention, { i 22 whi c h ' lus did. They properly started ejecting boric
* - 23 . acid to counteract the effects of the dilution. I 24.
called the ANPS back.into the room to take control 25 of'the situation. When I saw that the plant was
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il stable and returning back to 549, we' reviewed the 2 tech specs and had determined that they should be i 3 entered.because temperature exceeded 549 degrees. [ 4 We~ entered the LCO and made the appropriate log ' 5 entries. I'm sure the appropriate log entries of 6 the event were logged in the chronological log.
7 After the plant was stable, my concern 8- then was exactly what happened, exactly how did Hank t-9 lose track-of'this task. It was clear to me that
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10 Hank had' started the dilution and had been in the 11 room several minutes before he had gone to the ' 12 kitchen, before he turned over to Frank and had gone ; 13 to the kitchen, so my focus was exactly how Hank had 14 lost track of this task. i 15 MR. SCAROLA: Pete's pointing out i
.16 something that I probably should have emphasized. '
17 This task itself, they were expecting to shoot less j 18 than 40 gallons into the primary,. and with one .
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19 charging pump running that should have been a task ; A 20 that took 45 seconds. That helps emphasize exactly ;
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21 where Pete's focus was at that time. ! 22 J4R . HONEYSETT: At'that point I asked the
23- STA to go-ahead and initiate an in-house event
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24 . report. I-asked them to write up a data sheet ' L3 5 seven, which~is an operations problem report. I i h t ..
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1 .then' returned-to my office on Unit 2, andLwhen.I got i 2 back to my' office I reviewed the. criteria for !
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3 notification.. Basically, the. criteria said that I ;
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4 was-responsible for promptly notifying the
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5 operations supervisor under certain circumstances,
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6. and an unplanned or unexplained reactivity change is i 7 one of those criteria. %& knew it was explained ; EU .because we knew exactly what happened from the
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, 9: onset We knew that we didn't have any equipment
'10 ~ pr'oblems or' incident problems. And as far as being i
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lif planned, Hank had planned to water the primary to l
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12 raise the temperature, but that plan went astray, l 13' and of course the temperature increased nine-tenths I 14 higher than'it should have. I
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.i 15 So I made a judgment at this point, !
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16 knowing that the event was over, knowing that an 17 in-house event report was being written up, knowing i 18 that I requested a data sheet seven to be written !
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19 up, and also knowing that in approximately two hours (; 20 the operations supervisor would be calling on his
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21 way to work. He normally calls between 5:30 and ,
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22 5:45 every morning, so I elected to inform him of ' 23 Lthe event when he called on the phone.
24 So approximately two hours'later, when I ! 25- spoke to.him on the phone, I..related the event to ! l
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& him, who was involved, what we had done, how high 2' the temperature had gotten, and when he came to work 3 at six o' clock he came straight to the control room, 4 so at that time I spoke to him face-to-face about 5 the event. I also at that time had a copy of the 6 draft in-house event which I handed him, and I also 7 informed him that the HPES coordina".or had been 8 called and was on site over in Unit 1 control room 9 at the time talking to Hank and Frank and getting 10 some more information on the event.
11 MR. SCAROLA: Thank you, Pete.
la MR. EBNETER: You're the NPS? 13 MR. HONEYSETT: Yes.
14 MR. EBNETER: And your office is over in 15 Unit 2? 16 MR. HONEYSETT: Yes, sir.
17 MR. EBNETER: Who was the ANPS? 18 MR. HONEYSETT: Charlie Simkins.
19 MR. SCAROLA: Do you want to explain your 20 relief at that point, Pete? 21 MR. HONEYSETT: I routinely go back and 22 forth between Unit 1 and Unit 2 throughout the 23 night. I had been over there earlier at 24 approximately 11:30 or 12:00, and I had returned at i 25 approximately 2:00 to 2:15 to collect data for my i
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1 morning report. At that time Charlie asked me if I 2 would stay in the control room while he went- to the
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3 kitchen to get his midday meal, so that's how I came 4 to be in Unit I control room at the time.
5 MR. EBNETER: You guys were pretty 6- hungry.
7 MR. HONEYSETT: It was 2:30 or so, and 8 that's halfway through the shift.
9 MR. EBNETER: If I was that hungry I 10 would leave this conference right now and go get my 11 lunch, right? My duty is not to ga eat my lunch, my 12 duty is to be here. I'm just dismayed that you're 13 so hungry on the shift that you leave in the middle 14 of your task to go get your lunch.
15 MR. SCAROLA: Certainly, Mr. Ebneter, 16 that's a key thing in Pete's focus in his 17 discussions with Hank when he came back in, that an 18 event, an activity that is only to last 45 seconds, 19 is not one we'd expect to turn over on, it's not one s- 20 that Mr. Cone would be expected to be receiving a . 21 turnover on, and it's not our practice at St. Lucie 22 to turn over a dilution in progress, 23 MR. EBNETER: Did you set these guys up 24 for these types of events in the way you do your 25 dilutions? Are you going to discuss that as you go
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t i 1 .through this?
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2 'MR. SCAROLA: Yes, sir. l
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3 MR. EBNETER: So ~ I shouldn't pick on f
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4 them, I should pick on you? 5- , MR. SCAROLA: You have me and my 6 attention, sir. This event goes far up the ladder, 7. and I'll explain to you what we've learned up the ! 8 ladder,'what I've personally learned as we go up the 9 -ladder.
10 MR. GIBSON: I understand there was an ! i 11- alarm that sounded somewhere in this scenario. When 12' did that sound and what did you do in response? ; 13 MR. HONEYSETT: Approximately 30 seconds
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14 after Hank had realized that he had overdiluted he ! 15 began the boration. The control bleed-off to the
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16, RCPs goes directly to the VCT, and what had happened i i 17 was the level in the VCT increased approximately ten -l r 18 percent. As that occurred the pressure increased, !
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19- which caused the back pressure for the control ' 20 bleed-off to increase to its alcrm set point.
21 MR. SCAROLA: I'm not sure, Al, if we're 22' addressing the right one for you. That's the alarm l
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23 followingl Hank coming back into the room. What he *
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24 recalls is that he.did'get the alarm on the VCT. If i 12 5' ' Hank.ha'd not. walked back into the room, it would t
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1 have brought it to frank's attention that something 2 was occurring.
3 MR. GIBSON: For the record, I understand - - 4 you did not receive an alarm on T-cold being above 5 549 degrees.
6 MR. SCAROLA: That's correct, and I'll 7 address that also as we have our discussion.
8 When we get to the second timeline in 9 your handout there, where Pete has left us is with 10 the in-house event report being generated. He had 11 ha'd discussions with the operations supervision, and 12 what I want to pick up from is in this time frame 13 between 6:30 and 7:40.
14 Upon my arrival at the site, I review the 15 logs the first thing in the morning, and the crew 16 had done a very good job in ensuring that the 17 appropriate log entries were made. It was very 18 clear to me that we had had a dilution activity 19 throughout the night that we had not adequately 20 controlled. At 7:40 1 had the in-house event in 21 hand, and we have a routine phone call that we make , 22 with Turkey Point in our corporate management. At 23 that same time I have my staff there, including the 24 operations supervisor and the operations manager.
25 We discussed the in house event, and the information b
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'I ,1 'at that ~ time on the in-house event had a power level ! . .
2 that.had'gone to 100.2 percent power. l
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3 I assigned the ops supervisor the .! 4 accountability to find out what had broken down-and-l 5 what lessons we needed to learn and to com'plete the f 6 in-house event. The in-house event will have the i t 7 initial conditions, the event scenario, and, when it 8. gets down to the root cause analysis and 9 countermeasures section of that, I will assign that 10 'out after I receive it in the morning to the ) 11 individual that I believe to be best accountable to f 12 carry through on those actions. At this particular
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i 15 Now, I want to point out that this is ' 16 withi~n three hours of the event. From my own i 17 perspective, I had adequate information that I 18 should have reacted to a dilution event that had not , 19 been adequately controlled with a higher degree of P
'20 diligence, and I want to make sure that's very j 21 clear, that that's my lesson in this particular t
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~2? MR. EBNETER: Jeff' West is the ops
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t 24 supervisor? ~25 MR. SCAROLA: He's the ops manager.
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] L2 supervisor. ! 4 ; 4 1 3- MR. EBNETER: And who was the ops ! 4 technical-supervisor?
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' 5- MR. SCAROLA: Charlie Marple. He's the , 6 individual we've placed in Chuck Wood's position 7 recently. We had both Mr. Marple as well as Mr.
! ' 8 Wood maintain their licenses and they're off shift, 1 '
'9 but Charlie will carry out his shifts as an NPS
. ? 10 periodically. He will stand watch as an'NPS. '
- , 11 From this point Mr. Marple was assigned ,
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13 to find.out the details that led to this dilution
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14 activity. He spent.the day on the 22nd gathering , 15 the informaLdon that had been put together in the 4 16 in-house event report, the HPES report, the
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17 information out of the logs. He talked to the crew i j 18 that morning and talked to the relief crew. By that
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'20- removed from his license duties. t 21 The following morning, a meeting was 22 conducted with the crew to validate the information
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23 that had been transmitted in writing. There was a i , 24 ' meeting with.Mr. Holzmacher, and at that time Mr.
.25 Holzmacher on the morning of the 23rd was relieved i
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1 of all license duties.
2 Over the next several days Mr. Sager, our 3 site vice president at the time, and Jeff West, who 4 was acting on my behalf at that time as the plant 5 manager, had collected numerous corrective actions, 6 and there had been industry surveys performed to see 7 what the standard practice was for those plants that 8- we considered to be top performers in regard to SRO 9 oversight of routine dilution activities, manual 10 versus automatic operation of 'these activities at 11 other CE units, and they had collected a series of 12 corrective actions that began to be put in place as 13 early as the 23rd.
14 On the 30th, after we had had numerous 15 reviews the previous week, I had taken the in-house 16 event, which at this point had been revised to have
all the corrective actions that we had come to date 18 with, and I reviewed that in detail. In reviewing 19 that, I was not convinced that we had yet learned 20 all there was to learn from this event, that we had 'I a lot of corrective actions, but whether they were 22 the right corrective actions and whether they were 23 through a logical, methodical problem-solving 24 method, it was not evident to me.
25 On the morning of the 31st I relieved
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35 i l 1 five people from their duties. I took some of our 2 most senior people out of the organization and asked 1 i 3 them to form a root cause team and start from 4 scratch in looking at this event and make sure that 5 we had captured all the right lessons.
' 6 What I would like to do now is talk to 7 you from this point about the findings of that 8 team. And also, following that, as Mr. Plunkett had 9 stated earlier, he had commissioned Mr. Selman to 10 come in and take yet a third look at the event and 11 at what this team had performed and provide 12 additional input to us in certain areas. And I'll 13 tell you from my perspective this had some real good 14 value, because he added some value up in the 15 management area to things that I had not adequately 16 addressed or the team had not adequately addressed 17 in their review. So I want to share with you our 18 conclusions here.
19 MR. EBNETER: Let me take you back one 20 second. I'm not sure I underatood what you said.
21 You said on the 31st you relieved five people. That 22 was to say you relieved them to work on this task 23 force?
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24 MR. SCAROLA: Yes. ,
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25 MR. EBNETER: Who were they?
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1 MR. SCAROLA: I'll give you a little bit 2 of their backgrounds. We have an individual in our 3 licensing department, his name is Dick Dietz. He is 4 a former mechanical design engineer from combustion 5 Enginee.ing. He has a tremendous background and 6 experience level. I asked Mike Snyder,-who formerly ; 7 headed up our STA group and works now in our system 8 and component group, to lea', the effort because he 9 has recently been trained in root cause analysis.
10 He had a course taught to several individuals on 11 site recently, and I asked Mike because he has most 12 recently trained in that to head up the methodical
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13 analysis that I wanted performed. The head training i 14 instructor, Larry Rich, who heads up our requal
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15 training program, was asked to join the team.
16 Charlie Marple, who was our technical ops 17 supervisor, was asked to join the team. And we 18 asked Jim Vorhees, who is an SRO certified QA 19 inspector, he was also asked to join the team.
=2 0 So with this group of individuals, I 21 asked them to take a fresh look at the event. We 22 broke out the event in two problem areas, and I 23 think it's important to go through both of those 24 areas.
25 The first one I think is very clear,
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1L because we had a reactivity evolution that was ! i 2; initiated without adequate' controls. And certainly, f 3' Mr. Ebneter, when you say that I'm the guy you need l
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.4- to talk to, this is very clear. This routine boron 5 dilution, to maintain 100 percent power, was not I l
6 treated with the same importance as other reactivity 7 . management evolutions.
8f MR. EBNETER: Let me ask you something. ;
'9 You had all of these incidents, right?
10 MR. SCAROLA: Yes.
> 11 MR. EBNETER: And you .have done something -( 12 with your staff to make them aware of those
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13 incidents; is that right? ! 14 MR. SCAROLA: Yes.
15 MR. EBNETER: Did it not have any 16 effect? That was one of the major things they 17 talked about, reactivity incidents.
18 MR. SCAROLA: It did not have adequate
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19 penetration down through the organization, and I , 20 would ask the RCOs to correct me if I'm wrong, but I 21 would say prior'to this event they had not seen the ! , ' 22 speech that was presented or had discussions on f 23 that. You guys correct me if I'm wrong, i 24 MR. CONE: I got to look at it an
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25- requalification, but I'd not been formally L F
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1 introduced to it'. 2 MR. SCAROLA: We had covered it to a 3 certain extent in requal.
4 MR. HOLZMACHER: No, I have not seen it.
5 MR. EBNETER: Have you ever been involved 6 in a reactivity incident before? 7 MR. HOLZMACHER: No.
8 MR. CONE: No, sir, I have not.
9 MR. HONEYSETT: No.
10 MR. EBNETER: Well, I can't fault you too 11 much on that. I had-a similar experience. But I am 12 constantly amazed at this. We can't ever seem to 13 get it down to the level where the activity occurs.
>14 As part of your investigation did you 15 look at the requal training? To say you put it in 16 requal training and all they do is wave it around 17 doesn't do much with regard to training people.
I 18 MR. SCAROLA: * I agree wholeheartedly. 1 19 What we did the week of the event, before the end of 20 that week we had met with every crew with the Zach - 21 Pate speech on their shift as they were relieved at 22 the relief meeting, and Jeff West, Bill Bohlke, Dave i 23 Sager and myself, various ones of us attended each I I
one of the shifts around the clock until we had '
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1-1 through,the' detail and the key ~ points.of Zach?Pate's 2 speech.
3- MR. EBNETER: IThat report is an important-4 part. Let'sfhear the rest.
5 MR. SCAROLA: The second. problem that I- ;
.6 think is. equally as significant as the event itself ,
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7 is the recognition byEmyself and my' staff that we 8 were sicw in our response. The root cause of this i
:9 problem was really a lack of a well-defined 10; threshold for recognizing the safety significance of j 11 -this. As we looked at the dimensions of each of ;
12, these problems, and both problems have the same 13 dimensions, we have corrective actions in the
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14 personnel area, procedures, documents and policies.
15 MR. EBNETER: Let me stop you for a 16 minute. These are the two problems that you 17 identified from doing your event analysis; is that 18 right? 19 MR. SCAROLA: Yes.
20. MR. EBNETER: And that was your team, .7 21 these five individuals, and independently Mr.
' 22 Plunkett had broughtLin Murray Selman. Was Murray " 23 ' Selman done at.this point?
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24, MR. PLUNKETT: No.
25' MR. EBNETER: I was really interested in
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1: . what ~ the similarities and: differences were between 2- p Murray Selman's analysis versus what your own 'l
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3 'nternal i team found. i 4 MR. PLUNKETT: Let me'just talk about ; 5 what.I saw there. I saw that' team delving into the 6 details, and Murray looked at it much more broadly ; i i
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7. than that. Jim's got Murray's. stuff. As he goes ! 8: through-the presentation, .it's factored.into the ! t 9 whole. thing. ' 10 , Murray was focusing more on Jim and the - 11- operating chain, these things you're getting on, , 12' quite frankly, what had they done to get the 13 operators ready, this whole attitude of following ! 14 procedures, and that's where he came at it from. It i
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15 wasn't the black'and white, so to speak, that the
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16 team tended to focus on.
! 17 MR. EBNETER: Have you seen Murray's h 18' report. !
! '19 MR. MILLER: No, I haven't.
l 20 MR. SCAROLA: He's factored into the - 21 ' problem report we have given you. Let me tell the - i
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I 24 policies-that had not been adequately either ! 25- ' reinforced or established, on Hank's individual
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1 accountability as.an RCO. What they did not captur6 [ t 2 . was;the lessons. learned for myself'and-the l
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'4 Murray sat down with me and said,. Hey, I i
5' ' Jim, what lessons did you learn through this thing,
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6 I went through those with him, and he said the
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9. the organization, they were not as adept at looking .
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10 at management accountability through this, and the
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11 lessons that I felt had been' learned is where Murray . 12 steered me to say that's'the important thing to ! 13 capture in this event. He helped us add that layer 14 of quality to the problem report.
, 15 MR. EBNETER: Mark just pointed out to me 16 that this document you just sent to us -- and I 17 apologize, I have not seen this. I just wanted to . 18 make sure that we knew what Murray was finding and 19 so on. l 20 MR. SCAROLA: That report has 25
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1 respond to those. , 2 MR. EBNETER: Those 25 are in your ' 3 performance improvement? , 4 MR. BOHLKE: Yes, sir, and I'm going to 5 be. talking about that.
6 MR. SCAROLA: Each of the problems broke ' 7 down into these five areas. I'll tell you the 8 significance of that. When Mr. Plunkett spoke 9 earlier about this giving us some real insight into 10 our organization, you can see that the five areas > 11 cover all aspects of our-organization, and the team 12 did a good job in identifying the improvement 13 opportunities in each of those areas.
14 I want to start out backwards here, on 15 the last area, and the reason for it is obvious.
16 This is the one that I consider to be the most 17 significant in this event.
18 First of all, the decision to operate the 19 units at the tech spec level of 549. We had given 20 direction to the operators to maintain a T-cold at 21 549 degrees. The UFSAR description says normal . 22 operation is at 549 degrees. This is, outside of 23 power, the only parameter that we operate at the 24 tech spec limit with no margin. And if you think 25 through the precision in which you perform dilutions
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1 on a routine basis, the management decision to 2 operate at 549 and not believe that we would be 3 going periodically above 549 was not a reasonable 4 expectation.
5 In fact, the second item here is the 6 adjustment of a T-cold alarm. We had an alarm on 7 this unit that was set at 549 by its original 8- design. That particular alarm came off of two 9 temperature elements. When the operators control, 10 they're looking at an average of, I think it's on 11 the order of eight temperature elements. What they 12 had identified through our normal operation is they 13. were receiving nuisance alarms at 549 degrees. That 14 was the first indicator that we as management were
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15 bumping up against the tech spec limit routinely.
16 MR. PEEBLES: And calling it a nuisance 17 alarm.
18 MR. SCAROLA: Yes. This was recognized, 19 and I believe the date is 1993. That alarm was 20 moved to 553 degrees. There were three degrees 21 additional margin provided on that particular alarm, 22 obviously well above the tech spec limit and of no ' l 23 value to the operators.
24 Today we're operating both units at 548 ) 25. to 548.5 degrees. We've done the 50.59 evaluation
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1 to support that in order to-make the UFSAR change.
2 We have also today backed the alarm down to a 3 setting of 549.3, where that allows the equivalent 4 alarm point, when you look at the averages and the 5 delta between the averages of the RTDs where the 6 alarm point comes out of 548.8 is when the alarm 7 would come in from the operators by the instruments 8 they're controlling due to the accuracies of both 9 instruments involved.
10 MR. JOHNSON: Can you read these that 11 closely? 12 MR. SCAROLA: You can. Let me explain to 13 you what we put in on both units now. We do have 14 digital indicators where I can read down to the 15 tenth now. Now, an RTD, typically the 500 degree 16 RTDs, their accuracy is no better than two and a 17 half degrees, and that is typical of what we have on 18 all our protection channels. I believe there's a ' 19 margin of plus or minus two and a half degrees.
20 MR. JOHNSON: What is the reason that you 21 operate so high? Why is that to an advantage to 22 being so close to that limit? 23 MR. SCAROLA: The advantage is really 24 steam carryover in the secondary and the efficiency 25 of the secondary operating plant. The lower you
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1 operate at, the more steam carryover, the more 2 potential you have for blade damage and you will 3 drop megawatts as you drop temperature.
4 MR. JOHNSON: But you can operate at full 5 power at 549 or 547, either one, it's not 6 prohibiting you from -- 7 MR. SCAROLA: Initially when we 8 implemented this we backed the unit down because we 9 did not have the 50.59 in place, so we backed down 10 to 98 percent power, which.was equivalent to 548.5 11 on the old curves. Once we recalibrated all the 12 instruments and engineering did the evaluation, we 13 came back to 100 percent reactor power at the new 14 temperature limit of 548.
15 MR. GIBSON: It sounds to me like you 16 have an instrument problem. You have a tech spec 1.7 which you're controlling to meet an average T-cold 18 number, and you have an instrument that's giving you 19 an indication of something that's something other 20 than the average T-cold.
21 MR. SCAROLA: The alarm comes off a 22 different point.
23 MR. GIBSON: And because of this you're 24 forced to set the alarm point at something other 25 than the tech spec.
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5 MR. GIBSON: And I would want to look ,
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6 closelysto.see if you have sufficient correlation } 7 between that instrument set point and the tech spec : 8 such that-you can say with confidence that you're : i 9 remaining within the tech spec. j 10 , MR. SCAROLA: We do, and that's the 50.59 I 11 evaluation we had our engineering staff perform, i 12 which~ones fed the alarm set point, which ones were !
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13~ the operators controlling to. That was part of the i
'14- logic behind this. Now, the final alarm set point, 15 I'll tel'1 you that we have just accomplished that.
' 16 We got the final alarms in yesterday. We actually
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17 moved those down yesterday and got them reset. ; l' 8 The other area in management lessons : 19 learned that's worthy of talking about is the 20 expectations to the operating crews. I mentioned we ' . ; 21 did meet with each of the crews with Zach Pate's 22 memo. .In addition to that, Bill Bohlke and myself i 23' sent a memo to every licensed operator at his home L2 4' - re'inforcing our expectations for their role in
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.2 MR. EBNETER: What did you do with it?
t 3 MR. CONE: It's still at my house.
4 MR. EBNETER: Is it on your refrigerator 5 or something? i 6 MR. CONE: It's right on my counter. l 7 MR. EBNETER: I'm just curious. Did you~ + 8 not discuss it in face-to-face meetings? 9' MR. SCAROLA: Yes. That was done first.
10 That was the crew meetings that we had with all the 11 operators. Following that we said, Let's further i 12 reinforce this in writing and make sure that every i 13 operator receives the document.
14 MR. EBNETER: You know for a fact that
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16 MR. SCAROLA: Yes.
17 MR. EBNETER: Not like the requal change 18 that was just waved around? 19 MR. SCAROLA: I know for a fact that 20 every crew member had discussions on the importance 21 of control group conduct and the expectations of 22 that as described.
23 MR. EBNETER: Let me lecture you just one 24 minute. I was at another meeting recently right 25 after this. thing happened. I went to the meeting of
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1. their managers and they discussed you guys. They 2- ~ discussed.this dilution event in that. meeting while 3 I was sitting in there.. They picked it off of the 4' NRC wires, and they made a point to go and talk to 5 every one of their operators about the dilution 6 event that happened at your plant. That's the. type 7: .of sensitivity that it carries. If you did all 8 these things, fine, but too frequently things are 9' done like this. Yes, we put it in the procedure and 10 we told the managers to discuss it. The intensity 11 of the discussion isn't always where it should be.
12 Do you-know that all this was done? 13 MR. SCAROLA: I know that all of that has
- 14 been done. Dave was involved in the meetings, I was 15 involved, Jeff West and Bill Bohlke. This was an 16 important communication for us. There is no 17 question in my mind that that expectation for 18 reactor safety for attention to this level of detail 19 is well known by each of the operators. I'll also 20 tell you that I also recognize that it's not a one 21 shot deal. I'm not going to fool myself to think 22 that'because we did it once that that's something !
23 that they'll have for their career. It has to be
- 24 . reinforced on a routine basis, and I still have that i
25 ~ accountability in tront of - me to carry that .
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1 through.
i 2 I want to talk a little bit about the ! 3 communication aspects of this from the management ;
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4 chain. We talked a little bit about Pete's 5 communication to the ops supervisor, the in-house 6 event, the log entries. When I looked at it I still 7 wasn't satisfied, and part of this comes back to the
'8 same lecture, Mr. Ebneter, that you're providing 9 with me, that there's nothing like face-to-face i
10 communication or direct communication.
! 11 I now have a policy in place on any 12 in-house event that within one hour of the NPS being 13 relieved of his crew that he has direct i 14 communication with me on any shift. If we have an
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15 event on Pete's shift, I expect during that shift or 16 immediately.within one hour to have a phone call 17 from the NPS describing from his perspective the 18 details of that event. Now, following that, at the 19 7:15 meeting that we have daily the NPS comes down 20 to that meeting and he presents to us the plant
21 status, and at that meeting we will discuss the 22 in-house event with my staff. This is the NPS's
23 opportunity to provide firsthand information beyond '
24 what is written in the report to his recollection of 1 25 the event. i
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1 Now, in addition-to'that, I recognize -j 2- that there is more experience to be obtained in this ; 3' Lorganization than what we have at St. Lucie. At
' '7:40 each' day we have a phone. call we'make with j 5 Turkey ~ Point and with Mr. Plunkett.and his staff.
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6 These events are shared now and we're at a new level
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7- of' detail and communication in that phone call so !
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r 8. /that I'have'at my access the collective experience ,
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9 of the nuclear division management with the actions
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10 that we're taking or,.just as important or more l' 11 important, the actions that we're not taking. !
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13 The second area that I want to talk about ! l 13 briefly is the personnel area, and I'll be briet on
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14L this, but I think that it's very important that we i 15 cover it. To start out with, as Tom had stated l
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16 earlier, I'll tell you that any event like this : 17 cannot be adequately analyzed without the i 18 cooperation of the people involved. And I will tell i 19 you that this operating crew, I have seen nothing
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20 -but a high level of honesty, integrity and 1 i 21 accountability from the start of this event. At the ! 32 "same time, I'll~tell you that there is that level of 23 accountability that cannot go unrecognized in this l l 24 event'. i i 25 Mr. Holzmacher has lost the ability to i
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1 perform his license duties. We asked Mr. Holzmacher 2 to go and have an evaluation done by our medical
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3 review officer, and the medical review officer has 4 found him fit to perform his license duties. We 5 have developed a program for Mr. Holzmacher that
,6 - involves ten weeks standing in a training capacity 7 on shift followed by a series of examinations on a 8 simulator specifically designed to test attention to 9 ' detail, continuity through events. Mr. Holzmacher 10 will have the opportunity to regain his license 11 through that series of activities.
12 MR. EBNETER: Let me tell you something.
13 This is what I tell operators, and you've probably
'4 heard this when I present the certificates. All of 15 this stuff, putting you through the simulators, you 16 probably didn't need all that. When we grant you a 17 license we've ascertained that you have all of the 18 aptitudes to run that plant, all of these things.
19 ioa can do the boost. I don't have any doubt of 20 that at all. What we don't test and what your crew 21 testing doesn't test is your attitude.
22 All the tests and all the simulators in 23 the world, if you get hungry and you think it's 24 better to have a cheese biscuit than it is to watch 25 your boards, our testa don't show that. So I hope
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1 what you have done and what you get out of this is 2 not to go back over and run through the simulators 3 again but that your primary attention should be 4 right there on that power plant in the control room, 5 your. attitude. If you get a little hunger pang, 6 you'd better make sure the boards are correct before 7 you go and satisfy your hunger pang.
8 I'm sort of picking.on you guys because 9 you are the front line, but I want to make it 10 clear. I don't think Hank needs all the simulator 11 training. I went through that. You know how to run 12 the plant, but you just have to make sure that that 13 is in your forefront all the time, even if you're 14 dying of hunger pangs. And I don't suspect you were 15 dying of hunger pangs, right? 16 MR. HOLZMACHER: No.
17 MR. EBNETER: In fact, I was questioning 18 why you were going to eat only three hours into the 19 shift, but that's none of my business. The 20 regulation doesn't say anything about that. My 21 problem really is that technical training is 22 probably not at fault here. You know what it is, 23 the accountability and the -- ' 24 MR. SCAROLA: Mr. Ebneter, what we are
25 focusing on is the distractability. There's
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1 numerous distractions that operators will be 1 2 confronted with. It's always important that they 3 first assure themselves that the activities in 4 progress are adequately attended to in response to 5 those alarms.
6 Now, Hank has told us and we believe that 7 we do not know exactly what distracted him. I can't 8 tell you that the fact that he went to respond to an 9 alarm is what caused him to lose his focus on the 10' dilution activity in progress, but I'll also be
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11 confident in telling you that it is not Hank's 12 practice or any other operator's in the middle of a 13 dilution activity to plan on going and eating their 14 lunch. We had lost focus of this event long before 15 he had left that control room.
16 MR. EBNETER: Well, I understand that.
37 And Hank, I appreciate these remarks that you do 18 have the highest levels of honesty, integrity and 19 accountability, and I know we all get distracted. I 20 get distracted, but the results of my distraction 21 are a lot less consequential than you people being 22- distracted. I might be distracted by Mr. Gibson, 23 but I don't have a big machine here. That has very 24 serious consequences. That's good that you went 25 through this process. I'm just going to let it go
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1 .that just going through-the' simulator.doesn't
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- MR. PEEBLES:, I thought it was real .!
;4 'important when you said earlier that the evolution '5- wasn't considered'as significant as what you-want to .: '6 do, and1I guess you're going to cover.that.
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- .7. MR. SCAROLA
- Yes. As-you look through t
j '8- our procedures and' policies, this is really where-we : 9 capture that point.
10 When this' activity was performed, it was
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11 performed.by an RCO, assumed to be his .
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12- accountability and one which he was empowered by our i 13 policies to perform independent of'the remainder of
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14 the operating crew. When we took our industry data,
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15- we found^this is not consistent with the top 16 performers out there. There are many plants that do
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17 it this way. However, we found the top performers 18 have SRO involvement in dilution.and boration ;
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'19 activities. So we have changed our policies and 20. programs to where first the activity is announced
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21 and the SRO acknowledges that this activity will l t 22 ' proceed. ;
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23 This second item we've really covered L - 24 ~ already in detail. This is not an activity that we j t .
.I I . 25' would expect to be turned over. Certainly 45 [
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1 seconds of a dilution is never an activity that 2 should be turned over. Likewise, we're expanding 3 this to look at other evolutions, both licensed and 4 non-licensed, that also should not be turned over in 5 progress, and we're identifying those in the conduct 6 of ops so that we have clear expectations for all 7 our operators.
8 MR. EBNETER: I think that's good. I 9 would like in our next meeting with you guys for you 10 to tell me what that is.
11 MR. SCAROLA: We'll be happy to share 12 that with you.
13 The short term turnover process is also 14 one that we've had some discussion about. I would 15 like to share with you that over our preparations 16 for this meeting we have continued to revise the 17 short term turnover process. This again was an area , 18 that we've taken corrective actions on immediately 19 at the time, but we've made some adjustments to
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20 this. In fact, this crew through their
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21 accountability has helped rewrite what the 22 appropriate turnover process is.
23 Now, the turnover, and I'd like to ask 24 perhaps Frank to cover that with us here, the 25 current expectation for turnovers from the board and
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2' MR. CONE: At this' time operators that j i 3 have control.of the' plant, the actual shift holders,
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4 .being the desk _and board RCOs, they must verbalize ; 5 and ~ functionally acknowledge back'the fact of the: 6 general status of the plant, any abnormal trends and j
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7 any evolutions in progress. If anyone comes
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8 outside,'from outside being an actual watch stander !
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a 9. to. relieve.either of us, it must go through a fuel } I 10 turnover, which is a functional walkdown of every !
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11- RTGB, revolume of locks and abnormal trend data, ! 12 night orders. That's where we stand right now. , 13 MR. MILLER: How does that differ from f
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14 what was in place to begin with? !
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15 MR. SCAROLA: What was in place to begin !
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16 -with, Mark, is that we had a policy out there that : '
17 did'not distinguish between watch standers and ;
- . 18 non-watch standers coming to take a' relief and i
19 turnover. What Frank is pointing out here is the ; i 20 distinction between the desk operator has already
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2 1- performed the entire board walkdown at the beginning j
.22 of-his' shift.- I He is cognizant of the plant's <
23 . status. What he is not cognizant of is the
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24l evolutions in progress. So their efforts have been , '25
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how do we focus'in on what's the key-if I'm moving
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1 from the desk position over to the board, what is 2 the critical information that should be transferred 3 to me, and how are we going to assure that transfer 4 of information.
5 So it's incumbent, first of all upon the 6 board operator, to verbalize each of those three
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7 areas. The desk operator has to perform the repeat 8 back of him on those same three areas. So we've 9 formalized now the specific areas of turnover that 10 they have to conduct between those two individuals.
11 MR. GIBSON: So the procedure that was in 12 place required a comprehensive turnover for all 13 situations. Was station management aware that the , 14 comprehensive turnover was not taking place? 15 MR. SCAROLA: I have to acknowledge that 16 we either were aware or should have been aware that 17 that was not occurring. I certainly have been in 18 the control room -- 19 MR. GIBSON: This is similar to the fact 20 that you had made changes, perhaps improvements, in " 21 the Unit 2 dilution procedure but had not made those : 22 same changes to Unit 1 and must have known that the 23 Unit 1 procedure was not being closely followed.
24 MR. SCAROLA: Personally, I did not know 25 we had that discrepancy. At the time that the
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58 ; r i 1 procedure'was-revised for Unit 2 we had implemented i
; ~2 the-verbatim compliance expectation'while we were in 3 the Unit.2 outage. The initial focus was on the l
i 4 ' Unit 2 procedures and'to make sure we had revised i 5 the procedures adequately for the operators to : 6 return Unit 2 to service. In doing that, the Unit 1 7 1 procedure-was idencified for upgrade and was put in . 8 the upgrade program, but it was not immediately
9 upgraded'when we revised Unit 2. - 10 MR. GIBSON: What I'm really searching 11 for with=my comments is if you had procedures in l I 12 place that maybe are difficult to follow or cannot 13 be followed, even in some cases, and you know that
.1 4 - but don't change that, the fact that you say that 15 you expect verbatim compliance is really a rather 16 hollow expectation if you tolerate leaving 17 procedures in place.
.18 MR. SCAROLA: And we have with our 19 improvement plan been trying to change that cultural 20 expectation. I think that all the operators, and 21' these gentlemen'can certainly attest to this or-22 . correct me if I'm wrong, but I don't think there's 23 any._ question as to what verbatim compliance is -
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h 24- -requested now of them.
. As we have performed this, 25 I'll tell you that in the past this has been looked ~ i i i s
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.59-1. :at as: a skill.of the trade evolution, and you know 2. through your inspection that we did not have that 3 procedure out and were not.following that
;4 procedure. It was a matter of maneuvering two 5.~ valves. They had always performed this evolution in 6 that same practice.
7 That's why the discrepancy and the 8 stand-down said, Hey, we can't verbatim comply with 9- .this, and'it was because we had not gone through~and 10 pulled the procedure and said, Hey, we.have a 11 procedure for this evolution, do we comply with it.
12 That's just to acknowledge you're correct, and we've 13 taken actions to address that. And we have a ways
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14 in front of us to go yet in procedures to continue 15 to work through that. We've added three people to 16 our procedure rewrite in the last month, and we're 17 continuing to focus on the ops procedures as our 18 highest priority right now.
. 19 The last area that I want to cover on the 20 procedures and policies is an area that we picked up
21 from Turkey Point. We still have this procedure in 22 a draft format. However, we are implementing it 23 still in the draft format, and that is an event
' -24 response team. We found that the event response-25 teams down at Turkey Point have ensured a timely and <
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1 thorough analysis of the events there, and we're 2 taking that lesson from Turkey Point and we're 3 bringing it up to St. Lucie for implementation.
' 4 The next area, and I'll be brief on this, 5 is the equipment area. This again presented an 6 opportunity for us to focus in on the dark boards, 7 the importance of the dark boards on all the 8 annunciator panels to the operators. We had an 9 annunciator that did distract the operators at that 10 time. It was a nuisance alarm. They did write the 11 work order and initiate the right activity to 12 correct that when it came in, but nonetheless we 13 took this opportunity to bring our engineering 14 manager in. Dan Denver came up to the control room 15 and our maintenance manager and re had a meeting in 16 the control room to discuss the nuisance alarms and 17 the importance of responding quickly to eliminate 18 any nuisance alarms on the operators. And I think 19 that we will continue to give that the highest level 20 of attention.
21 The second area is automatic versus 22 manual mode of operation. From day one St. Lucie 23 has been operated in a manual mode of operation. We 24 took the opportunity here to readdress that with our 25 other CE units that have similar CVCS control
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g 1 syetems.-_ We found'that it is common practice'that i
2- the-dilution and boration systems are operated in ! i 3- manual. Now, the reason for that is to maintain l F '4~ reactivity control.always in the control of the: ; i :
] , -5 ' operator.- We will continue to. operate the system.in- -
l 1 i , 6- , manual, although we are looking at the' auto features t
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-7 as a potential backup to~that operator. ife want the. ;
. ~8 operator.to maintain his hands-on control of i
9l reactivity additions in this power plant, so we'll ; 10- continue with that. philosophy. We do have a 50.59 -
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, '11: that'was put in place that ensures this was 12- consistent with the analysis in the UFSAR.
- 13 In.the training and quality assurance
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14 area, we talked about this being a snapshot in time, j 15 . making sure we don't lose these lessons. The l'6 importance of including them in the continuing 17 . training is how well we're able to sustain these
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18 lessons in the long run. We have incorporated this 19- into our continuing training program. And then also . 20- a lesson learned out of this is the effectiveness of-P !
- 2 1 -_ our corrective action program. Clearly these events 22- thad occurred elsewhere-in-the industry, clearly they I 23 'had occurred at Turkey Point, and there were !
24- corrective actions put-in that we at St. Lucie f 25. shouldIhave' learned better from and did not.
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1 QA will assist us in this area in looking 2 at the industry events and our corrective actions-3 associated with those events, and we will continue 4 to put some emphasis and strength in this particular 5 area.
'6 The last item I want'to talk about 7- briefly is the safety significance of this event, 8 and I'll go through some of the numbers here for 9 yeu. As far as the reactive power, the peak power 10 that we had reached is 101.13' percent, the cold leg 11 temperature, and this is the max indicated 12 temperature. There was one RTD that we had that 13 actually read above this, but what the operhtor's 14 controlled by, the max was 549.75 degrees. The tech 15 spec limit for this particular parameter for T-cold 16 and consideration of DNB is 549. The LCO is that 17 you have to return below 549 within two hours. In 18 this particular event we exceeded 549 for a total of 19 50 minutes. In addition, the UFSAR analysis for 20 this event, it does cover dilution events in Chapter 21 .15 . The discussion in Chapter 15 assumes a dilution 22 of primary water directly to the suction of three 23 running charging pumps, which puts you at 32 gallons 24- :per minute injection.
25 The UFSAR goes on further to discuss that .
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l 63 l t 1 this event would be called to.the operator's 2 attention by VCT alarms, both pressure and level, , 3 and if-the operators did not take the appropriate l 4 action'to terminate'a dilution event at that rate at i 5 that time, then the thermal margin low pressure and
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' 6 variable high power reactor trips would be taken
7 into account and shut the reactor down, protecting ! 4 8 DNB limits. In contrast to this event,'we did have
- 9 one charging pump running, and that put us at 38 10 gallons per minute injection, and it was direct 11 primary water to the suction of the charges pump as
, ! 12 opposed to the analysis of 132 gpm. Again, in this i
- 13 event the operators responded prior to receiving any '
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14 alarms and immediately terminated the event in
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, 15 progress.
, 16 The last point that I want to make is Y 17 t h.- t we did look at this from a PSA standpoint, and i 18 in terms of core damage this event shows no i 19 significance. This event did not affect any of the 20 mitigating systems that would affect core damage.
. 21 We did assume in this analysis that this event went 22 through a reactor trip, that the operators did not 23 .take action, and that it was terminated with a , 24- thermal margin low pressure reactor trip and that it 25 did not increase the core damage frequency making
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2 Un1'ess'there's some' questions that I can I i 3 address,'I'll' turn'this'over-to Dan Denver.
4 MR. EBNETER: So I should conclude, then,- ' 5 that I shouldn't worry about this? ' 6 MR. SCAROLA: No, sir. ; 7 MR. PLUNKETT: You should conclude that 8 the safety significance was not very.large, but
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9 everybody knows that. That's not ~ the point. The 10; ' point is it's a very serious event, the operators'
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11 actions, our actions from management, the whole ball 13 of wax. I don't want you to'think we're not taking 13 this very seriously.
> t 14- MR. EBNETER: I'm just making sure I 15 wasn't getting the wrong message.
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'16 MR. SCAROLA: If I left you with that .;
17- message, Mr. Ebneter, then I missed the whole point
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18 of my presentation. This incident was very serious 1 19 'in. terms of St. Lucie'and where we're not on our !
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20 get-well. plan and where we are. We learned a lot , 21' about.our organization's effectiveness, about our P. 22. - communication expectations to.the operators and l 3 31 where we are in relation to our operational
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2 41 standards with others out there. We recognize we 25. have'a lot-of work in front of us and don't intend
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1 to close the book on our improvement plan, but this 2 certainly aids us in ensuring that the right things 3 are in that improvement plan. From that standpoint 4 it is very significant to us.
5 MR. CONE: May I say something, sir? 6 MR. EBNETER: Sure.
7 MR. CONE: I'm well aware of the 8 responsibility that's on my shoulders having a
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9 license to operate this facility, and I'm just as 10 keenly aware of what the consequences of my poor 11 judgment and poor operating practices may have for 12 all of us. My sensitivity to this has been really 13 tuned up, and I can tell you right now and assure 14 you that when I go back to our plant, St. Lucie, all 15 my peers will also know that directly from me to 16 them.
17 MR. EBNETER: Well, that's good, because 18 I would expect your sensitivity to be tuned up. If 19 it isn't there's something wrong with you. But 20 you're the only ones here, you three guys. How many y , 21 others are sitting back at the plant who are your
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22 peers? 23 MR. CONE: I will speak directly to ' 24 them.
25 MR. EBNETER: That's good. I hope you
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1 do r. and'I hope.you that can' increase the'ir 2' ' sensitivity. More than the fact that you're talking-3 to the NRC, your. company'sfassets are on the line,.
'4 your careers onethe line..
5 MR '. CONE: Yes, sir, I'm aware of that 6 fand have-been aware of that.
'7' _MR. JAUDON: As Mr. Ebneter has made B. , clear, we hold management accountable for carrying 9: out'the1 responsibility of getting that information 10- to you.
11 MR. SCAROLA: And I accept that the 12 accountability, I acknowledge that accountability, 13 and I assure'you we're following through with it.
.14 MR. EBNETER: You need to reinforce what 15 Frank does.
'16 MR. SCAROLA: Mr. Cone can certainly 17 assist management in carrying that expectation out, 18 but management has that accountability.
19 MR. EBNETER: It does have a big impact 20 on your peers when you guys can talk with them 21 .directly.
22. MR. SCAROLA: -And I assure you that we 23 will.'take advantage of Mr. Cone's communication '24 skills with the' rest of his crews.
25' MR. EBNETER: Thank you. That's good,
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1 Frank. I appreciate that.
2 MR. DENVER: My name is Dan Denver, and 3 I'm the engineering manager.
4 MR. EBNETER: And you're here to tell me 5- not to worry, right? 6 MR. DENVER: No. I'm here to tell you 7 how we screwed up. I'd like to talk to you this 8 morning about apparent violations B and C. Apparent 9- violation B is for inadequate design control, and 10 apparent violation C is related to inadequate 10 CFR 11 50.59 evaluation. Apparent violation B says that 12 design control was inadequate in that procedures for 13 adding demineralized water and boric acid to the RCS
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14 did not implement the method in Chapter 15.
15 Our assessment of this particular 16 proposed violation is that we concur with that 17 apparent violation in that the UFSAR describes 18 automatic mode as being the normal mode of operating 19 the plant for the CVCS, and that does not conform to 20 plant practice, nor has it conformed to plant 21 practice for many years.
22 After reviewing that, our conclusions 23 that we would find on that is that it definitely 24 does not describe in the UFSAR exactly how we 25 operate the plant and that this inconsistency is
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2 'UFSAR, .and we've established a plan to eliminate ; 3 these inconsistencies. For this specific concern, 4 the inconsistency.with the CVCS system, we.have .; 5 completed a safety evaluation, and we have put the
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6 UFSAR change information in our library or catalog 7 of'information that will be updated in the next 8 UFSAR update.
9 To go further than that, we have'taken a ! 10 very hard look at our UFSAR, which is a total of 29
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l 11 volumes, between the two units. We put together a
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12 team of ten individuals that were senior
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13 multi-disciplined individuals ranging from licensing 14' to engineering and operations back. grounds, and they
. -; ~15 in a period of a week and a half to two weeks did a-16 review of what was roughly a total of a third of the
, , 17 UFSARs. They roughly reviewed somewhere over 50 ! 18 percent of the text section of the UFSAR and a ! 19 relatively smaller portion of the tables and the
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20. charts that-are in-there.
r-2 1 MR. EBNETER: 'there were ten people on '
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22 that team? ' 23 MR. DENVER: Yes, sir.
'24 ~ MR. EBNETER: Did they include some [ 25 operators?-
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1 MR. DENVER: There were operations 2 personnel, not current operators on shift, but 3 people that held ROs or sos in the past. That was 4 very key to our review, because obviously we needed 5 to make sure we captured the ways the plant is 6 operated, both as in procedure as in practice.
7 The conclusion of the effort that we 8 undertook was in fact that there are a fairly large 9 number of inconsistencies in the UFSAR. The 10 majority of those are internal inconsistencies or 11 editorial type problems. However, there was a 12 fraction of the problems that were identified that 13 were in fact inconsistencies relative to the 14 procedures or operation of the plant or design 15 questions. Based on the review that was completed, 16 we've assessed what the total scope is that we 17 believe the effort to correct the UFSARs will be, 18 and we have initiated that effort at this time.
19 Our plans are to complete the review of 20 the inconsistencies and to establish the change
- 21 information necessary for the UFSAR for Unit 2 by 22 September of this year, and we'll be providing a 23 some report or submittal to the NRC. Our normal six, 24 month update following an outage will occur before 25 that, but we'll make a special report so we don't
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1 -wait until the following one. On Unit 1 we will be
.2 making'the' corrections in time to make it with the ^3 normal report we give six months after the fuel ,
4 outage, which will'be in approximately December of.
5 this year, the refueling outage to start in late 6 April.
7 MR. JOHNSON: This is a one time review? 8; MR. DENVER: Yes, it is.
9: MR. JOHNSON: Now, things go on all the 10 time, activities, and you have systems and * 11 procedures that you're supposed 'to implement to make 12 sure that whatever you do doesn't change the safety 13 basis as described in documents like the UFSAR. Do 14 you have a plant safety review committee? 15 MR. DENVER: Yes.
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'l6 MR. JOHNSON: Do they know what's in the 17 UFSAR before they're qualified to serve on that 18 committee?
19 MR. DENVER: They have a general 20 . knowledge of the UFSAR, but I don't think that you ~ 21- could count on them having a level of detailed 22 knowledge of all 29 volumes of the UFSAR.
23- MR. JOHNSON: When people.come to them
'24 .and say, We want.to do this procedure, we want to 25 make this' modification, they're the ones that have
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.1 to say it doesn't violate any of the-bases in'the.
2 UFSAR, sofhow.can they.do that.without knowing -
)
3 :what's in there? ' 4' MR. PLUNKETT: I don't know what chapter i 5-' to go to to.look forza-specific-system or something. i ,
, , '6~ 211ke that. With an SRO' background I have some i j
, 7. knowledge, and that's what~ I would expect from these
:
8' people. Nobody in God's world is going to know 9 ~what's in all the volumes. * 10 MR. DENVER: If I started stacking them I
- 11 here for you it's going to go this high. But you're
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12 absolutely correct. There has to be a process and l , 13 that process failed us.
, 14 MR. JOHNSON: That's what I'm asking.
15 MR. DENVER: Our process failed us. And 16 if you'll bear with me a second I'll get to that.
. 17 MR. PEEBLES: It appears that you're . 18 saying you've got to change the UFSAR. Were there
l . 19 any instances where you'va got to change the plant 20 procedures because-the UFSAR was indeed right? 21 MR. DENVER: No, not changing plant . p 22' procedures,.nor have we found in our review so far 23 that would result.in an unreviewed safety question.
. 24 MR. CASTO: What number are we talking
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25 about?
4
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t 1 MR. DENVER: In roughly a third of the , 2 UFSAR we found'650~ total inconsistencies. Of those,
-3 approximately 500 were editorial or' spelling, things 4' of that nature. About.150 or 160 were things where 5 we found.an. inconsistency between practice in the
,
6 plant. Our extrapolation based on the type-of
.7 ' population that we'did look at would tell us that we .8 expect.we're probably going to see about 300 of -
9 those total that we're going to.have to look at very 10 hard and make sure we don't have anythi'g n of 11' significance in there by the time we're done. i
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MR. GIBSON: There's one comment I want 13 to make before we-leave this subject altogether.
. 14 The UFSAR, as I recall,' describes this automatic 15 control feature as a safety feature presumably to 16 prevent just the sort of event that occurred here, 17 and I hope-that your review is very careful before 18 you decide that that's not the right way to go,
19 because it would appear, had you done it the way it 20- was described in the UFSAR, that it might have ' } 21 prevented this event. '
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23 MR. SCAROLA: Let me address that. I I 23 think last year one of-the units was operating in 34 auto and the auto cut out, had failed, and they had 25- ~a' dilution event as a1 result of that. I think the -; i I i
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1 proper thing would end up being a combination. But 'i 2 from my perspective the operator in the lead, I 3 Ldon't want his attention off of that, I want him l l 4 accountable to stop it and maybe use the auto
~ !F features as.albackup to that. We have to work i
6. further on that, and we may be the lead unit doing 7 it that way, but to'me logic-wise that may be the 8 right end result.
9- MR. DENVER: If I could move along, 10 process-wise, in addition to actually correcting the l 11 UFSAR, which as you point out is going to be a > 12 one-time shot, we're going to improve the process by 13 which we' continue to maintain the UFSAR so we will '
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14 not have this kind of discrepancy creeping in in the ! 15 future. l 16 I'll elaborate on that a little bit 1. 7 fur'her.after t I finish discussing apparent violation 18 C because they're really intimately tied. Apparent
1
violation C is for a 50.59 evaluation that.vas I 20' inadequate in that the licensee made a change to the , R21' Unit 1 boron dilution procedure to allow i demineralized water in manual and directly to the P 2 2'~ 23: suction.of the charging pumps that was different 24 'from the method stated in the UFSAR, Chapter 15 and 25 without preparing a 50.59 safety evaluation.
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1 Again, we concur.with the violation. And.
2 again, the fundamental problem is that the UFSAR 3 description is just not consistent with the way we 4 operate the plant, and we've been operating the 5 plant with these practices since 1976.
6 MR. GIBSON: Well, that's part of the-7 problem. The other part of the problem is that you 8 made that procedure change last month and did not go 9- back to check the UFSAR in the process of making the 10 change.
11 MR. DENVER: That's exactly correct, and 12 that's the essence of violation C, the comparison 13 that was made by comparison to what was there in 14 time, not back to the root document. And of course 1.5 the screening that was done for this particular 16 temporary change doesn't suppcrt the conclusions 17 that were made, which were that this would not 18 affect the UFSAR, and, as a result, the UFSAR or 19 procedures screening process very definitely needs 20 to be improved. We're developing procedural changes
+
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~ 21 and we're improving the screening process for 22 procedures to approve the process such that the 23 screener that does the evaluation will be required 24 to identify the sections of the UFSAR, the technical
*
25 specifications that have been reviewed. This will
a
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75 , 1 be a partLof the process. It will be documented -}
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2 along with the screening.
' 3 We are at the present' time conducting.
4' - some training- f or ' those persons that do the I 5 screening of procedures to provide a spec'ial [ 6 emphasis on the meaning of the procedures as
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7- described in the UFSAR. We're also intending to 7 8f provide more clear screening criteria directly - 9" associated with the screening procedures, and this
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10 is-related to the identification of the technical :
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T 11 specification and UFSAR sections that will be f r 12 requested for them to identify.
' 13 To make this process easier, while we're ,
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.14 going through the assessment that we t'alked about
'15 earlier in the UFSAR, which will be to essentially 16 require a thorough review of the entire UFSAR and 17 touch every page, we'll be identifying those
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18 sections of the UFSAR that in fact have procedures ! 19 associated with them and providing a 20 cross-referenced set of information to make the job ) 21 easier-for the person sitting there at two or three 22 o' clock in the morning trying to screen a temporary 23 procedure. We're going to take the information from 24: 'the result of that, and the sections of the UFSAR
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25 that will be referenced, they will become a
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1 reference that will appear actually within.the~ 2 ' procedure,Lin the body of the procedure,.so, when !
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3- he's sitting'there in the middle of'the night, at a 4 minimum he'll know where to go to the UFSAR. He may .. l 5' .have additional things heLwants to look at, but it 6 will.make that process easier.
7' The net result we believe that.we'll end ! 8: up with by the time we complete our corrective 9 actions for these two violations is that we will l 10 have improved the UFSAR and brought it up-to-date 11 with current plant practice and procedures with the 12 way.we use the plant, and we will have put in place !
-13 a process which we believe will prevent us from
.14 . causing this kind of discrepancy to occur in the
!
15 future. ; 16 Now, if there aren't any further 17 questions -- 18 MR. EBNETER: When are. you going to do
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19 all this? , 20 MR. DENVER: Mid September for Unit 2 and 5 21 December forcUnit 1. The procedural changes, we
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22 haven't set specific dates now, but I can assure you-2 3. we'll.have them in place within the next few weeks
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'. 24- to a month.
' 25 MR. EBNETER: That would be, say, April i
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1 10th? 2 MR. BOHLKE: March 31st.
l 3 MR. DENVER: That sounds good to me.
4 We've already concluded some of these corrective 5 actions as we were preparing for these meetings, and 6 we haven't actually dragged the rest of the 7 organization along with these dates.
8 MR. EBNETER: What about your screening 9 criteria? 10 MR. DENVER: It will be enhanced as part 11 of the identifying -- 12 MR. EBNETER: March 31st? 13 MR. DENVER: Yes.
14 MR. PLUNKETT: We're meeting with you on 15 April 1st, so we'll tell you by then.
16 MR. EBNETER: I'm not pushing you.
17 MR. BOHLKE: The training that Dan's 18 talking about is already being done.
19 MR. DENVER: That's being done as part of 20 the requal on our STAS, and we had the second week . 21 yesterday. ; 22 MR. EBNETER: And the last one would 23 probably be in conjunction with your UFSAR review; ; i 24 is that right? I
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25 MR. DENVER: The cross-references won't I l
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-1 be available, that's correct.
! 2 MR. JAUDON: ,One question. What are you
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3 comparing inconsistencies'with?
4- MR. DENVER: What are we comparing -- 5 MR. JAUDON: You.said you're identifying 6 inconsistencies. What standard are you comparing 7 the 'UFSAR to? 8' MR. DENVER: To the design basis for the j 9 plant either identified in the fuller context of ; 10 design documents or the plant obviously has been
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11 . changed by change packages occurring over the year.
12 The physical modifications of the plant have been 13 captured very well because there was a very clear 14 process for changing the UFSAR. The biggest areas , 15 that are ripe for having inconsistencies is where [ 16= procedures have changed, where systems are operating 17 somewhat differently than described. Really, when , 18 you get down to it, the essence was describing a ' 2-19 method as normal that we don't any longer use as
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t' 20 part of normal operation. 1
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21 MR. JAUDON: So operations-is a big 22 vulnerability, variations in operation. i i 23- i MR. SCAROLA: Operational practices. ! 24 MR. JAUDON: i What about technical ' 25 specifications, license amendments, things like .r-
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f 1 that? < l
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2 MR. DENVER: A11'those have been. captured
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3 fairly well-. The process was pretty well put in , 4- place :f or capturing.those kind of things.
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~5 MR. SCAROLA: 'The license amendments'and
, 6' the plant modifications, I think that we're in ~ 7 fairly-good shape in terms.of the UFShR. In terms !
!
" Si of operational practices and some inconsistencies in l 9- the UFSAR itself, where it has something in Chapter e l 10 15 and Chapter o may not have those same l
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11 descriptions in there, or, if you look at the 12' drawings, the drawings may show all the paths for , . , 13 normal and manual but the only description is for i
! -14 auto and it has three different modes of operation l
15 that are all shown on the drawing, all discussed and , 16' bound by the Chapter 15 analysis, but when you get , l
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i 17 to the operating description in Chapter 8 there's 18 only one of them described, it's those types of I i 19 thing that is Dan's picking up on. ,
'20 - MR. DENVER: The writeup in the i
i
! [ :21 enforcement letter we received was correct. -These 22 .are on pages that had.never been touched, and I ..
23 'obviously that's one of the areas we have our l
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24 -greatest focus on now to make sure that there are ; i
'25 things that have not gotten.out of kilter. _
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1 MR. JAUDON: We are finding examples of 2 where the technical specification limits, comparing 3 those'to'the UFSAR, if you'd complied with what was 4 in the UFSAR you may have violated technical , 5 specifications; for example, a core offload. l
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6 MR. DENVER: Those kinds of things 7 typically have gotten much more clearly updated when 8 changes have occurred. I
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9: MR. SCAROLA: I think in this case the ! L 10 UFSAR described normal operation at 549. ! 11 MR. DENVER: 549, that had always been , i 12 there, and the basis of the thermal trip had always ! 13 had the lower limit at 549. That was always
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14 inherently a part, and I'd assume that was a flaw in 15 the documentation from day one. It was written that
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, ' 16 way.
17 If there are no further questions, then ' i 18 Mr. Bohlke will conclude. i ' .
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19 MR. BOHLKE: Actually, Tom has some
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20 closing remarks, and I'm going to try to set him up , 21- in a positive sense.
. 22 As Bruno was reading through the overall 23 . structure, it occurred to me that what I was talking * i
: 24 'about'was actually described in ths regs. It's a -i
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25 -common understanding of the significance of issues >
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t__._ __= _ _ . .__m_ _ . _ _ _ _____________J__s_ _ _ , _ _ . - _ _ _ - -- ___ , v -- --.- , - * - - -
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81 1 i i 11 and the need?for lasting-comprehensive action. j 2' That's1 pretty much the theme of what I intend to j
'3- talk abost be afternoon. Another way offputting a-
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:4- theme on my, talk is thinking of it as an answer to 5 .the question: Can the. boron dilution incident be ~ the'
6 watershed' event that. catalyzes the final cultural 7 change that we need here~at the St. 'Lucie plant.. 8 I'm going to talk about five categories. . 9; They're different, but they-overlap the categories 10 that were in Jim's presentation. It's pretty 1 1' . obvious from the way we structured this that, 12 starting with management and ending with management, '
.13 becau'se.although Hank precipitated the incident by q 14 leaving his station, the material we reviewed this 15 morning certainly suggests that we did a lot to set j
16 him up.for failure, and therefore we can't effect !
- 17 permanent corrective action or. permanent cultural t-
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18- change unless management owns up to its l
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19 responsibilities, and that's what I want to talk
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' 20 about. , , , ~ 21 Starting with management, in preparing , 22 for this meeting lwe were working in my conference 23_ room at the plant and we were talking about various 24 issues, and Frank volunteered. As you probably 25- figured out, Frank can do that. Frank' volunteered
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$ * 1 t h'a t ,- you know,-theres a pretty' big. gap between 21 'what goes on in this building and what goes on in 3 the restlof plant. Well, that's not real good news
. .4 for management,'but at 1 east'it's honest and i
5 actionable, and we've been trying .to bridge this
.6 . gap.- What Frank was telling us was that even after
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7- several weeks of-working on it we haven't made 8- enough progress.. When we talk about management's '
'9- expectations, we need to talk about how we
10- communicate them, 'mplement, i monitor and reinforce 11' them.
12 Jim spent a lot of time on operations and
.13 P
what's in'it. Again, we were talking with the
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'14 operators, and they pointed out that our anticipated is requirements for short term turnover in the board l
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16 RCO and desk RCO turnover on the peak shift probably ,
[
17 wasn't a reasonable expectation. I think at that
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18 point the light bulb went on and said it doesn't - 19 make a lot of sense to communicate an expectation
. 20 that 'sn't i a'chievable. Now, we have revised the i e
'21 conduct of, operations at least once since this 22' -event,.and we're planning to revise it again at the !
!
23 end of the month, but we want to take a little
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-24 ?di'fferent' twist on it- .
25. First of all, .Pete Honeysett ~ suggested
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1. '.thataall we.ever.did.was add to it and didn't'take l
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. I 2- anything out of it,.and so we want to open it up for ;
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3' . feedback-from the operations department ~and then. l
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. . .i 4 work on achieving a common' understanding and ;
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5 acceptance of what's in'there. And then, instead of l
, -6 a conduct of operations, it really becomes.more of a l t
7- . contract for operations, a bilateral contract. l
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8 between management and the operators. I think that j
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Eff will be a significant improvement. *
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10 Jim and I have been pushing really hard 1 1' in communications with the whole plant staff, not 'l
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'12 .just the operations s~taff, and we've been hitting ;
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13 areas of accountability, attention to, detail, j i 14 housekeeping, and we got a little extra help with
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: '15 . housekeeping a little while ago, repetitive ~ !
16 equipment failures and personnel safety, and we need i 17 to continue to do that. But it doesn't do us any !
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18 good to talk about it, we've got to figure out how l
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19 well it's being received, and when we get back down 20 to the end, management performance, I'll talk about )i 21 that. ! 22 To. wrap up . the management expectations
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'.2 3 ' Ithing, what we're really trying to.do is make sure j i-24 we set forth the proper expected behavior, reinforce ;
25 Tit-positively when we see it being accomplished, and i
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'l .take. corrective actions when we.see that it's not 2 The second major area I want to talk j
3. about is programs and procedures. As we've gone 4 through this presentation, Jim and Dan.have pointed
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5 to some programs that took some pretty big hits, and.
! 6 -one is the-UFSAR update book. Another is the l 7- operating experience feedback program. You can ask l
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8 whether'the FRG was effective when it approved a
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9 change which led the T alarm further away from the l c 10 te.ch spec limit. Some wrck needs to be done on f 11 -programs, and we've outlined the UFSAR conformance j i 12 review upgrade. That's going to send the right 13 signal through the site, although it's one heck of a l 14 lot of work. Then we've got to make some tough 15. management decisions on what level of resource, both i i 16. numbers and talent-wise, we need to make that an 17 effective program. * 18 The event response team of course is a
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19 new approach arising from a program at Turkey ; 20 Point. Procedures took a hit this morning. We *
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21 talked about procedures when we were up here on the !
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22 8th of February. At that point we said we've got a ; i 23 lot of work left to go on procedures just on the ! i 24' shear standpoint of volume, and we continue to take !
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-25 hits on the' procedures almost every day when we go I
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85' l l 1- o u t' to do work and find they're not adequate, not ; 2 because we're'not trying-as hard as we can but l
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3 because there are so many procedures and the level i 4 of' detail that pervades all of them. l t 5 'And not to be redundant to what we said- i 6- on the 8th of February, but the important things on i i
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7 the quality of procedure are the ability to be t 8' executed, UFSAR conformance and clarity, and we also l l
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9; look for consistency in the level of detail between 10 and among the procedures and making sure, as you
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11 pointed out, that when you upgrade a Unit 2 l
. -12 procedure you ought to be upgrading the Unit 1 13 procedure at the same time so the people can bring .
14 the right level of focus and attention to the 15 operation. l 16 We report on procedures every month in
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17 our monthly indicator book and in a meeting we have, ) 18 and we'll continue to do that as well with any new 19 indicators developed, such as the quality of the ! 20 procedures being produced by virtue of being able to l 21 gauge the number of errors or returns for rewrites. l t , 22 The third area is training. The boron 23 dilution event was a wake-up call for us on 24 training, a real wake-up call'. When we started 25 'looking at it, we could'see that whatever the level i l j
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1 of management expectations we put out there, 2- whatever we think is going on with the operating 3- experience feedback program, if we're not using-4' training to convey those messages and lessons, we're 5 missing the boat; When we looked at it, we 6 determined we-needed to change the training. We 7. need training to'be turning out world-class 8- operators, not turning out operators who've passed 9 licensing exams. There's a pretty substantial 10 difference in f o.c u s when you look at it that way.
11 Let me give you some examples. Zach 12 Pate's memo is eight or nine pages long. It is very-
* 13 focused and very clear. There are some other good 14 things out there that can help us think about 15 improving human performance. We need to use .
16 training to reinforce the expectations of management 17 or to rearticulate them if they have not been 18 . appropriately conveyed. We need to use training to , 19 promote the desired result or desired conduct when
,20 we talk about changes in command and control, when '
21- we ~ talk about changes in the way we approach and 22 conduct routine operations, which was pointed out so 23 succinctly. - 24 We need to'make sure we're getting the 25 'right conduct in the simulator such that when we go
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1 out to: the plant we are reinforcing that conduct by { 2 the ANPSs and the NPS and'the ops supervisors and f i 3 the managers. We.need training to be sure it's t
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4 helping the operators l' earn and be refreshed in i S their learning through their requal cycles. And : 6 probably most importantly, we need training to be. . 7' wil'lingly and aggressively accepting feedback from 38: operations at our plant-and Turkey Point and out in
'9' the. industry, making sure that that is put into the 10 lesson plan.
' 11 Coincidentally, I happened to be L12 observing a training class, and it was on.the . 13 control element drive mechanism. I would tell you l ', , 14 that the operators were absolutely fascinated with
:
15 the discussion. It was a very active exchange ; 16- between the instructor, who was extremely competent 17 and very knowledgeable, and the operators because 18 they wanted to know what was going on and what the ;
'19 differences were, and that was extremely effective. .
20 Why was 1t effective? Because it was really current -
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21 with the condition going on in the plant, so they ; . 22 had and interest. We need to bring that level to 23- more of what we do, and that will help the operators 24 get through those weeks that sometimes I think they
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25 don't.necessarily look forward to.
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l 88 ; b , i 1: The fourth area is personnel ! 2- performance. We also talked about that on the 8th, .
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3 'and at that time we said getting sophisticated 4 indicators to give us examples of personnel. i 5 performance is a major effort'for us and continues !
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6 to'be, but there are some things we need to do, and l
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7 we'll be talking about them on the 15th and again on 8' the 1st. It seems appropriate for us that f 9 activities conducted 24 hours a day are monitored i 10 periodically 24 hours a day so that we can see the [-
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11 way expectations and procedures are consistently ' 12 applied, or perhaps more important, inconsistent 1y' t t 13 applied and to see how various sets of personnel I
: '14 -
respond to the situations that come up.
15- I think we need to take a look at HPES i 16 and see if we're getting our monev s worth out of [ 17 it, not that the HPES individual or individuals
. i 18 aren't doing their job, but the way we're using the -
19- information to help us manage the plant. We need to
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iP 20 be doing a better job analyzing and trending the !
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21 .information. We've got^24 or 25 in-house events as '
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23 of this morning for this year, and that's-a nice 23 number;to'take a look at. It's not too many and 24- 'it's not a.few.
) l 35 We need to get some sense of how things
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1 are going and do the events taking place reflect 2 things we have presumably fixed or do they point to 3 things we haven't yet undertaken and that we need to l 4 take a look at, and we need feedback from these 5 events to take a look at the performance of our 6 operators and other individuals in safety-related 7 spots. So we need to be doing some work on that 8 because we talk about personnel performance in our 9 monthly meeting, and that seems to be a good forum 10 to both report and discuss on these issues.
11 Last but not least, management ;
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12 performance. Jim has owned up that he's learned a )
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13 lot from this from the standpoint of being able to 14 respond to events that cross the defined threshold 15 for safety significance and the appropriateness of 16 management response. I want to take it from a 17 different standpoint.
18 This event is another example of a less 19 than adequate self-assessment program because we 20 didn't take the opportunity to go out and find out 21 whether the conduct of operations was being 22 followed. That's a pretty major hit, and that's an 23 area that we have to really, really improve on. As 24 it stands right now, Jim's root cause team that he 25 established on the 31st of January uncovered a lot
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1 of fertile ground for us to work on, but we can't 2 stop there, and with Tom's approval we're going to , 3 go into a much broader self-assessment effort that 4 we expect to produce a report on in about the July 5 time frame that's going to track our investigation i 6 of the way we do operations, and it will ultimately 7 be reflected of course in the revised conduct of 8 _ operations, but also to point to other areas where 9 we may be encroaching upon a tech spec limit or a 10 design basis limit of some type, places where we set 11 the operators up to fail, much as we set Hank and 12 Frank up to fail by running T-cold at the tech spec 13 limit.
- 14 There are other areas of the plant that I 15 wouldn't say are necessarily equal to a direct 16 impact to nuclear safety, but they could eventually 17 wind up there in the way we do our preventative 18 maintenance processes and the way we account for the
19 fact that St. Lucie is now 20 years old. These are i 20 the kinds of things that we need to be looking at in 21 our self-assessment as well 's, again, the
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j l 22 commitment to look at management self-critically, i 23 Talking with the crews down at Turkey Point has been 24 good for our crews, and we understand they enjoy 25 talking to our crews as well. Making sure that we
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t 1- have?the' appropriate questioning attitude and.that 2 we can count on that being present.in the whole l3 management corps every. day is reall'y important, such ? 4- as.why'are we running a T-cold at 549 and why are we . S' bumping the limit up. Something broke down. ; l 6 Basically, we talk about the 25 7 corrective actions and the problem report that we i 8 provided you a copy of and the additional items'that
'9 wa are going to identify in the self-assessment 10 that's going to go-over the next four or five :
11 months. Our commitment is we want to bring those 12 into the forum for discussion in our monthly 13 ~ indicator meetings or monthly status meetings that
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14 Tom'and representatives from Turkey Point will 15 attend, so we've got a pretty open discussion of 16 what we're finding and where we are.
17 In addition to that, I've asked the 18 company nuclear review board to take an oversight 19 role in terms of constituting a senior review team, 20 and they'll have to augment their resources with an
:21; external person who's pretty knowledgeable and 22 broadly based in the operations area so we get the 23 .right-focus on this thing so that at the end of the ,
24' day we've. extracted the maximum benefit from this 25 event in.that~we've made it part of the fabric of u-
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. y
1 St. Lucie instead of wiping our brows and saying 2 thank God that has passed. Those are our it'entions 3 with respect to what we're going to do and how we're 4 going to report out the results both internally to 5 ourselves and in a form to report to you.
6 Are there any questions? 7 MR. EBNETER: Staff? 8 MR. CASTO: You talked about Turkey 9 Point, and Jim, I think you talked about you and 10 Turkey Point have a conference call now. Do the 11 Turkey Point operators get a letter in their 12 mailbox? 13 MR. SCAROLA: I can't tell you that Don 14 has implemented that. They may have taken similar , 15 actions previously.
16 MR. PLUNKETT: If Ellis was here I know I 17 vot ld have gotten the ques t; ion abou t why w -- e 18 event at Turkey Point in 1993 and then up there.
' 19 The corrective actions taken in 1993 at Turkey Point 20 were very extensive. They don't need a letter.
21 They've got that under control. The question is why 22 wasn't this relayed up north, and it wasn't, and 6 23 I've taken that as my responsibility. We've already 24 had discussion that we've been pretty much operating , 25 as two separate companies, and that's just not the l- _ . _
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. - 93 1 way we are doing business anymore, so the-ball;was 2 pput in-my court a couple of weeks ago-to make sure 3 we're sharing everything, and we are. We're sharing 4 it every morning. We also have other ways of *
5 sharing it now because both sites will use condition 6 reports and we're both going to be operating the 7 same way. Does that answer your question? 8 MR. CASTO: Yes.
' 9 MR. PLUNKETT: Stu, I'll just take a 10 minute here. I want to address something Mr. Gibson l 11 mentioned on the integrator. I had the same i 12 reaction.almost instantly. Unfortunately, it isn't j 13 that audible and that clear in their control room,
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14 so that is on the corrective actions, one of the 25 15 or so.
16 MR. GIBSON: That was a problem at Turkey 17 Point, wasn't it? I 18 MR. PLUNKETT: No. We thought we were
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19 really smart. What we did was the integrator wasn't i + 20 working, it was a high maintenance item, and so we ! 21 replaced it with a high-tech digital with no - 22 audible, which was the wrong thing to do, so we went i 23 back to.the old one. ! 24 MR. EBNETER: I just thought that Frank 2L .had'better hearing than the other fellow.
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, 1 MR. PLUNKETT: No. But my initial -- '
'2 MR. EBNETER: You heard it, right, Frank?. ,
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3 MR. CONE: I heard it, yes.
l 4 MR. PLUNKETT: Just a quick. comment here 5 at the end. We have and'are taking very' extensive i 6 corrective action, and the reason we put the safety 7; significance up there is because that's part of how [ 8 you folks' consider enforcement action, or at least 9 your policy says that. But once again, I want to , 10 make absolutely sure that you don't think that we're
'll underestimating this event at all. We are not, and i
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12. 'I hope it's clear now after today that we've taken 13 this about as seriously as you can. It's much, much
*14 broader than the safety significance that we had up
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15 there.
16 Concerning the UFSAR, the UFSAR is a
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17 regulatory contract we have with you folks. Our 18 contractors, they meet the contract, and we have an i 19 obligation to meet the contract there also. I think i 20 almost every plant in the country is going through ' 21 some exercise now to try and match up plant design 22 with the UFSAR, and we will' meet the action as Dan f 23' indicated on his schedule.
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24~ Tha,t-concludes our presentation, Mr.
25: Ebneter. i If you have any questions we're .!
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2 MR. EBNETER:
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3 MS. WATSON: I have a few points, if I
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:4 -could. The-50.59 evaluation on manual'modefof 5 . dilution and boration I assume has been. completed ;
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~6 .according to your problem report. Did you conclude- , ~ 7. that~it was okay to use manual dilution boration EF directly to the suction and charging pumps? . ~!i MR. DENVER: Yes, we did.
10 MS. WATSON: Do you have a copy of that?- 11; MR. DENVER: I.do. I can let you have 12 .that-if you like.
13- MS. WATSON: I would. On the skill of'
, '14 .the craft versus procedural use, you said that you = 15 - would review that in the control room, and I was 16 . wondering if you had identified .iny other procedures '17 that were being done, skill of the craft when the 18 procedure required ,them the procedure to be.in hand.
19 MR. SCAROLA: As part of our upgrade? . 20 MS. WATSON: Yes, 'a s part of the d 21L corrective actions.
22- MR. SCAROLA: We have an ongoing 23 . improvement _ activity right now that's going through
;24 all.our. procedures, .and that is part of the element '252 fthat we're trying to sort through, what is a skill
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96 1 of the craft activity versus what is an actual l 2 unique specific direction to perform that activity. I 3 It's requiring the addition of some pracedures, and 4 we're finding the deletion of some procedures also 5 through that but we're not complete with that effort 6 yet.
7 MR. GIBSON: I guess Linda's question is 8 that-you have previously identified which procedures 9 you expected to be skill of the craft and which you 10 would use as reference procedures.
, Do you believe 11 the crews are currently following your previous 12 direction, or was this an isolated case? 13 MR. EBNETER: Would you like him to 14 rephrase that? 15 MR. SCAROLA: No, I understand the 16 question. I don't believe this to be an isolated
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17 case. I believe that there are other opportunities 18 out chere that we have still not identified. I'm 19 not uncomfortable with where we're at in the control , 20 room. Outside the control room and the field 21 operators, I think we still have more opportunities 22 out there, or a higher number of opportunities with 23 the field operators certainly. Now, we have
24 instituted, and I'll mention this to you, we have a 25 management obser'aation program that we have put in
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1 place to specifically assess our operating practices 2 versus our procedural requirements. We've been 3 through the first round of that. We're.still making 4 adjustments to get more specific. , 5 Now, Turkey Point has implemented this 6 for quite some time. We took that from them, and 7 we're making adjustments to where I assign to my 8 managers specific sections out of conduct of ops and 9 conduct of maintenance to go out and observe the 10 practice in the field and provide that delta so we 11 can start addressing those deltas, but the deltas 12 still exist.
l '. , MR. EBNETER: Does that answer your 14 question, Linda? 15 MS. WATSON: I think so. It sounds like 16 you don't have an answer yet.
17 MR. SCAROLA: We're still in the 18 assessment phase. I can't tell you how many there 19 are.
20 MS. WATSON: A couple of minor points.
21 In your presentation you said you reached a cold leg 22 temperature of 549.75, and in your report you used 23 the number 550.8. , 24 MR. SCAROLA: If you look in the report, 25 the 550.8 is the single point maximum. There is I
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+ 1 believe a total of. ten.RTDs between' safety channel ,
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2 ' temperature detectors'and control-channel . . 3 temperature detectors.that give-us cold' leg
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. -- 4 temperatures. One of those multitude of temperature. ! .
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5 elements read the 5 5 0'. 8 . So'when we went back' and' -
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6- looked at the~ computer data we had one element that i
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LB- MS.. WATSON: You say that the licensed
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91 condition of maximum steady state thermal power was r 10 not violated during the event. What steady state
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11 thermal ~ power did you reach? .
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12 MR. SCAROLA: We went to 101'.18 percent. ' 13 The guidance on the 100 percent power -- there is
' , .14 - some guidance out. I think it was an early letter : 1.5 in 1980 that talks about the average power over a '16 period of tine.
. 17 MS. NATSON: So you intend that to mean 18 you didn't exceed the NRC guidance? e 19 MR. SCARCLA: That's correct.
i i 2 '0 MS. WATSON: That's all I have.
21 MR. EBNETER: Anything else? > t
'2 2 MR.:GIBSON: I would like to remind the
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'2 3 - ; operators again that if they wish to stay after the
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. 24 meeting we.'llbe happy to talk with them, t-25^ MR. EBNETER: It'doesn't sound like the
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. ' 1 staff has any other questions, so_at this point-in j 2 'the proceeding we normally take a break if the staff I
.3 needs~one to caucus and see if we need to pursue 4 anything.else with you. Does the staff feel the )
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5 necessity.to take a short caucus? l t-6 MR. PEEBLES: No. I thought it was 7 pretty complete. -
8 - MR. EBNETER: Jim Bell? 9 MR. BELL: No. l
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- 10 MR. EBNETER: Jan? !
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11 MS. NORRIS: Not here.
i 12 MR. EBNETER: Does anybody want to'take a f i
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13 break and meet on this issue? , 14 MR. GIBSON: I don't think there's any v 15 disagreement.
j. 16 MR. EBNETER: With that,. P. hen we thank .
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, 17 you for coming in and appreciate your candor, 18 _ gentlemen. I hope you've got something out of this
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19 also, I appreciate the time you put into the 20 preparation. There were some commitments that you 21 made in here -- and when I say commitments, ,
22 commitments have no meaning unless they're in !
: 23 writing, but we think --
well, you know your dates. 1
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24 They'l'l.be'on the record, but we can discuss those l 25 ~ with you..later. We'll close this meeting, and I ).
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1 Lwant to' remind you'that' this-meeting, this 2 pre-decisional 1 conference, is exactly that,.it's 3 pre-decisional, and we still have to go through
'4 other steps in the final procedure.
5 _ I need to remind'you of two qualifiers.
6 First, the' apparent violations we have discussed, 7 c and.there were three of them in this particular 8- _ meeting, are subject to further review and may be 9' subject to change prior to us developing a final 10 enforcement action. Secondly, the statements or 11 views or expressions of opinion made here by the 12: staff or even the lack thereof don't represent any
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13 final agency position. With that, we'll just close 14 the conference and we'l'1 get back with you within 15 ~four weeks, when we would hope to have the 16 enforcement process finished, and let you know the-17 results.
18 Again, thank you for much for coming in.
'f 19 I appreciate it.
" 20 (Proceedings concluded at 1:10 p.m.)
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t 3 C E R T I F I C A T E- [ i-4
-l 5 STATE OF GEORGIA:
f 6 COUNTY OF FULTON:
'7 I hereby certify that the foregoing ,
8 proceedings were taken down, as stated in 9- the caption, and reduced to typewriting under i 10 my direction, and that the' foregoing pages 1 ' l 11 through 100' represent a true, complete, * 12 and correct transcript of said proceedings. -j i 13 This, the 18th day of March 1995. i l
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1 Lh\wr Keith A. Wilkerson, CCR-B-1381 My commission expires on the ! 17 30th day of May, 1999. I
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l NRC CLOSED PREDECISIONAL ENFORCEMENT CONFERENCE , ST. LUCIE NUCLEAR PLANT .
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- AUGUST 19,1996 ;
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A NRC CLOSED PREDECISIONAL ENFORCEMENT CONFERENCE ST. LUCIE NUCLEAR PLANTS AUGUST 19,1996 IAH TITLE
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1 Predecisional Enforcement Conference Agenda
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2 Expected Attendees, Meeting Announcement 3 Opening Remarks and Introductions 4 NRC Enforcement Policy 5 Summary of the issues 6 Statement of Concerns / Apparent Violations 7 Inspection Report No. 50-335/389/96-12 8 Enforcement Pre-Panel Questionnaire (Configuration Manage. ment) 9 Enforcement Pre-Panel Questionnaire (10 CFR 50.59 Safety Evaluations) . 10 TIA Response on FPL Safety Evaluation for EDG Fuel Line isolation i l 11 Closing Remarks l
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PREDECISIONAL ENFORCEMENT CONFERENCE AGENDA
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ST, LUCIE AUGUST 19,1996,' AT 1:00 P.M.
NRC REGION ll OFFICE, ATLANiA, GEORGIA , l l. OPENING REMARKS AND INTRODUCTIONS l L. Reyes, Deputy Regional Administrator 11. NRC ENFORCEMENT POLICY B. Uryc, Director i Enforcement and Investigation Coordination Staff 111. SUMMARY OF THE ISSUES . L. Reyes, Deputy Regional Administrator . IV. STATEMENT OF CONCERNS / APPARENT VIOLATIONS i J. Jaudon, Acting Deputy Director ' Division of Reactor Projects , V. LICENSEE PRESENTATION
T. Plunkett, President, Nuclear Division
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Florida Power and Light VI. BREAK / NRC CAUCUS , Vll. NHC FOLLOWUP QUESTIONS Vill. CLOSING REMARKS L. Reyes, Deputy Regional Administrator
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). L : EXPECTED ATTENDEES i Licensee
L T. Plunkett, President, Nuclear Division !
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W.' Bohlke, Vice President, Engineering . ' A. Stall, Site Vice President, St. Lucie .
'J.' Holt,' infermation Services Supervisor '
i- E. Benken, Licensing Engineer , '
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V . 4-NRC ..
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l: L. Reyes, Deputy Regional Administrator, Region 11 (Rll) ,
J. Jaudon, Acting Deputy Director, Division of Reactor Projects (DRP), ;
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[ - Rll . ll A. Gibson, Director, Division of Reactor Safety (DRS), Ril B. Uryc, Director,-Enforcement and Investigation Coordination Staff- '
(EICS), Ril C. Casto, Chief, Engineering Branch, DRS, Ril .
K. Landis, Chief, Reactor Projects Branch 3, DRP, Ril [ T. Peebles, Chief, Operating Licensing Branch, DRS, Ril
- .C. Evans, Regional Counsel, Ril ,
- - M. Miller, Senior' Resident Inspector, St. Lucie, DRP, Ril i E. Lea, Project Engineer, Reactor. Projects. Branch 3, DRP, Ril l L. Mellen, Project Engineer, Reactor Projects Branch 3, DRP, Ril
- L.' Wiens, Senior Project Manager, Reactor Projects ll/2, NRR -
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OPENING REMARKS AND INTRODUCTIONS j j (L. Reyes) { ! ! Good morning. I am Luis Reyes, Deputy Regional Administrator for the l
. Nuclear Regulatory Commission's Region ll Office. This morning we
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will conduct a predecisional enforcement conference between the NRC
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and St. Lucie which is CLOSED to public observation.
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~ The_ agenda for the conference is shown in the viewgraph. Following .
my brief opening remarks, Mr. Bruno Uryc, the Director of the Region II l l Enforcement Staff, will discuss the Agency's Enforcement Policy. I will l then provide introductory remarks concerning my perspective on the events to be addressed today. Johns Jaudon, Acting Deputy Director
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of the Division of Reactor Projects, will then discuss the apparent violations. You will then be given an opportunity to respond to the l
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apparent violations. In this regard, I wish to reiterate to you that the )
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decision to hold this conference does not mean that the NRC has l determined that violations have occurred or that enforcement action
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will be taken. This conference is an important step in arriving at that decision.
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Following your presentation, I plan to take about a 10-minute break so ; that the NRC can briefly review what it has heard and determine if we
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have follow-up questions. Lastly, I will provide concluding remarks.
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i ! At this point, I would like to have the NRC staff introduce themselves
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and then ask you to introduce your participants.
[lNTRODUCTIONS] Thank you.
Mr. Uryc will now discuss the Agency's Enforcement Policy.
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NRC ENFORCEMENT FOLICY (B. Uryc) l NRC Enforcement Policy and Procedure After an apparent violation is identified, it is assessed in accordance with the Commission's Enforcement Policy, which "> r r:::=l^, .:. ::d ed bec5mu cf' ove un June 30,1955. The Eniciceinuni i'el:c, '.;; I-hea%n published as NUREG-1600. l i l The assessment of an apparent violation involves categorizing the i apparent violation into one of four severity levels based on safety and j regulatory significance. For cases where there is a potential for escalated enforcement action, that is, where the severity level of the apparent violation is categorized at Severity Level 1, ll, or Ill, a predecisional enforcement conference is held.
I There are three primary enforcement sanctions available to the NRC and they are Notices of Violation, civil penalties, and orders. Notices , of Violation and civil penalties are issued based on identified violations.
Orders may be issued for violations, or, in the absence of a violation, because of a significant public health or safety issue.
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; This predecisional enforcement conference is essentially the last step
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final enforcement decision. j
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The purpose of this conference is not to negotiate a sanction. Our i
: purpose here today is to obtain information that will assist us in j
, determining the appropriate enforcement action, such as: (1) a ; i
common understanding of the facts, root causes and missed
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- opportunities associated with the violations, (2) a common ; , s l- understanding of corrective action taken or planned, and (3) a common . understanding of the significance of issues and the need for lasting comprehensive action.
I J , The apparent violations discussed at this conference are subject to : i further review and they may be subject to change prior to any resulting enforcement action. It is important to note that the decision to , conduct this conference does not mean that NRC has determined that a , violation has occurred or that enforcement action will be taken.
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I should also note at this time that statement of views or the expression of opinion made by the NRC staff at this conference, or the lack thereof, are not intended to represent final determinations or beliefs.
Following the conference, the Regional Administrator in conjunction : with the NRC Office of Enforcement and other NRC Headquarters offices will reach an enforcement decision. This process should take about four weeks to accomplish.
/ . cisional enforcement conferences are normal y4 the
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, public as is this c nce. However<the Commission implemented a i i trial program in July 1993dallo ain enforcement conferences to be open for ic observation. [ July 10,1992 - Fe ister] l T' N rial program was recently extended for additional evaluation.
I Finally, if the final enforcement action involves a proposed civil penalty i or an order, the NRC willissue a press release 24 hours after the l
, enforcement action is issued.
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'- SUMMARY OF THE ISSUE (L. Reyes) j j
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Issues: 50.59 Safety Evaluations and Configuration Management i
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This is a Predecisional Enforcement Conference to discuss apparent l - ;
. violations in two areas; conformance with 10 CFR 50.59 and :
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configuration management. Four apparent violations were identified in the area of 10 CFR 50.59 evaluations. Five examples of one apparent violation were also noted in the area of configuration management.
. The apparent 10 CFR 50.59 violations are of concern because they
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indicate that weaknesses exist in both recognizing the need for safety f . evaluations and in the process applied in assessing the impact of
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The apparent violation in the area of configuration management is of concern _because it indicates that deficiencies have existed in '
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themselves in failures to ensure that the design of the plant was properly incorporated into plant procedures and drawings. No plant _ event has been tied to the inaccuracies thus far identified; however, we are concerned about the potential extent of these conditions.
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STATEMENT OF CONCERNS / APPARENT VIOLATION i
(J. Jaudon) .
Issue: Configuration Management Several examples of failures to incorporate design changes or constraints properly into plant procedures and drawings were identified.
Defect: The apparent violation included five examples : I 1) One licensee-identified example of a failure to update an i operating procedure to include operational limitations on the commencement of a full core offload. The limitations were imposed by a Plant Change / Modification which included a . spent fuel pool heat load calculation.
2) One example of a failure to update an annunciator response summary when a hydrazine tank low level alarm setpoint . was changed via Plant Change / Modification.
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, 7 3) One example of a fire to update an engineering drawing l to reflect the deletion, via Plant Change / Modification, of valves and piping for intake Cooling Water System Pump .
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4) One example of a failure to update an annunciator response summary to reflect a change, made via Plant Change / Modification, which removed automatic and control : room operation capability from a pair of Intake Cooling
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5) One example of a failure to update an annunciator response
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procedure to reflect a change, made via Plant , . Change / Modification, which removed the alarm function : when placing Atmospheric Steam Dump Valve Selector Switches in manual. l
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The apparent violation identified above has been determined to be
.similar to annunciator response summary deficiencies di entified in i
previous inspection reports. As a result, we are concerned that the ,
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extent of condition of configuration management deficiencies may not yet be known. , ! <
' consequences: . i The failures to update annunciator response procedures and drawings :
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' following design change implementation resulted in providing - inaccurate or. misleading information to control room operators. In _the- ,
L - case of not properly incorporating the spent fuel pool heat load
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- Issue: 50.59 Safety Evaluations
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Several safety evaluations or issues which potentially required safety.
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' evaluations were found. Problems were identified with four of the.
a . items ' reviewed. The items of concern spanned the areas of whether changes were properly considered for applicability under 10 CFR
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50.59, the adequacy of 50.59 screenings, and conclusions reached ; l during 50.59 evaluations.
l t The four apparent violations, and their associated consequences, are as-follows.
e l 1) A failure to perform a safety evaluation for the construction . of the Unit 2 Control Element Drive Mechanism Control l System room was identified. The room had been i , constructed during the preoperational test phase of the unit and this failure was identified in June 1996. , . I
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Upon conducting an evaluation of the room, it was identified ! - l
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related components were required to ensure that the subject components did.not adversely affect safety-related
components during a seismic event. l
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2) A failure to identify that the installation of a temporary fire
- pump represented a change to the plant as described in the '
I c UFSAR was identified. The gasoline-powered pump was
installed as a replacement for an electrically driven pump, and this change resulted in a change to the P&lD for the fire l ' i protection system provided in the UFSAR and the pump's
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capacity was lower than that for the pump it replaced. j . - The consequences of this action were that a safety ' evaluation of the proposed alteration's impact on an i
operable plant system was not performed. i
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3) The'10 CFR 50.59 screening process failed to identify that , refueling machine underload and overload setpoints were l I
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' included in the UFSAR. This led to a failure to perform a L required safety evaluation. l
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' The consequences'of this failure were minimal, in that the -
licensee's Facility Review Group identified the failure in the ! screening process as a function of their activities prior 'to , recommending approval. * .! :
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, 4) An example of a failure to recognize an unreviewed safety
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- question was identified. In raaking a valve lineup change to
' k the emergency diesel general fuel oil transfer system, l reliance on operator action replaced automatic action and introduced new failure modes to the emergency diesel generator. This increased the probability of malfunction of a - component important to safety.
, As a consequence of making the change without
- recognizing the increased probability of failure, prior NRC j approval was not obtained for the change in qu.:stion.
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A ' ' Our findings are documented in NRC Inspection Report 50-335, 389/96-12, which were transmitted to you on July 26,1996. At this conference, we are affording you the opportunity to provide '
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, information relative to: ' e Any errors the inspection reports :
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t e The severity of the violations '
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e Any escalation or mitigation considerations e Any other application of the Enforcement Policy relevant to this issue.
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ISSUE TO BE DISCUSS $D
, : 10 CFR 50 Appendix B, " Quality Assurance Criteria for Nuclear Power c ; Plants and Fuel Reprocessing Plants," Criterion ill requires, in part, that i
measures be established to assure that applicable regulatory - requirements and the design basis for those structures, systems, and > components to which this appendix applies are correctly translated into , specifications, drawings, procedures, and instructions. j
1. The lic'ensee failed to incorporate the prerequisite conditions j contained in PC/M 054-196, supplement O, "St. Lucie Unit 1 , Cycle 14 Reload," into OP 1-1600023," Refueling Sequencing ' j-
- Guidelines." As a result, requirements for the operation of two j
' Spent Fuel Pool Cooling Pumps, maximum initial Spent Fuel Pool i temperature, minimum time since shutdown, minimum Component Cooling Water system flow to the Spent Fuel Pool i heat exchangers, and operability of control room annunciation ] were not verified prior to the initiation of fuel offload.
' , ! 2. PC/M 109-294 [Setpoint change to the Hydrazine Low Level ;
- Alarm (LIS-07-9)] was completed without assuring that affected
i procedure ONOP 2-0030131," Plant Annunciator Summary," was !
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revised. This resulted in annunciator S-10, "HYDRAZINE TK ! ' LEVEL LO," showing an incorrect setpoint of 35.5 inches in the procedure. ,
3- During implementation of PC/M 341-192 [lCW Lube Water Piping ! i Removal and CW Lube Water Piping Renovation 1. th.e as-built ! I Dwg. No. JPN-341-192-008 was not incorporated in Dwg. No.
8770-G-082," Flow Diagram Circulating and Intake Coo!ing Water
- System," Rev 11, sheet 2 issued May 9,1995 for PC/M 341- ,
- 192. This resulted in Dwg. No 8770-G-082 erroneously showing l valves l-FCV-21-3A & 3B and associated piping still installed.
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4. PC/M 268-292 [lCW Lube Water Piping Removal and CW Lube : Water Piping Renovation) was completed without assuring that ,
[ affected procedure ONOP 2-0030131," Plant Annunciator : Summary," was revised. This resulted in annuncir.tv E-16, l ; " CIRC WTR PP LUBE WTR SPLY BACKUP IN SERVICE," ; incorrectly requiring operators verify the position of valves MV- *
21-4A & 4B following a SIAS signal using control room indication.
These valves no longer received a SIAS signal,-were deenergized and had no control room position indication.
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5. PC/M 275-290 [FIS-14-6 Low Flow Alarm and " Manual" - Annunciator Deletions) was completed without assuring that i i affected procedure ONOP 2-0030131," Plant Annunciator ' Summary," was revised. This resulted in safety-related annunciators LA-12, "ATM STM DUMP MV-08-18A/188 - OVERLOAD /SS ISOL," and LB-12, "ATM STM DUMP MV-08-
- 19A/19B OVERLOAD /SS ISOL," incorrectly requiring operators to check Auto / Manual switch or switches for the MANUAL position.
, The relay contacts which energized these annunciators based on switch ponne., were removed to eliminate nuisance alarms.
. NOTE: The apparent violations discussed iri this predecisional ' enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.
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L ISSUE TO BE DISCUSSED 10 CFR 50.59, " Changes, Tests and Experiments," stated, in part, that a licensee may make changes in the facility as described in the safety ' analysis report without prior Commission approval, unless the' proposed , change involves an unreviewed safety question, and that the licensee , ' shall maintain records of changes in the facility. , 1. The licensee erected an enclosure around the Control Element Drive Mechanism Control System during the Unit 2 preoperational , test phase without performing a safety evaluation. This non-safety related structure was erected in a safety related cable j spread room.
2. During the 1996 Unit 1 refueling outage the licensee installed a ! temporary, 750 gpm, fire pump arranged to take suction from fire j protection water tank 1B and discharge into the fire protection , j water system via fire hydrant No.12 without performing the . l required safety evaluation.
3. The licensee used an engineering evaluation to change the set points and procedures described in the FSAR for operating the l ' fuel hoist without performing a 10 CFR 50.59 safety analysis / evaluation.
- 4. The licensee made a change to the facility which involved an unreviewed safety question when the 2B Emergency Diesel Generator fuel oil line from the fuel oil tank to the day tank was manually isolated to secure a through-wall fuel oil leak, in taking
[ the action, the licensee introduced two failure modes into the 2B
- Emergency Diesel Generator, which necessarily increased the probability of occurrence of a malfunction of the Emergency Diesel Generator above that previously evaluated in the safety i evaluation report, resulting in an unreviewed safety question.
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- 1 NOTE: The apparent violations discussed in this predecisional l enforcement conference are subject to further review and i
- are subject to change prior to any resulting enforcement decision.
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CLOSING REMARKS j (L. Reyes)
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. In closing this predecisional enforcement conference, I remind the , Licensee of two things:
j First, the apparent violations discussed at this predecisional
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enforcement conference are subject to further review and may be , subject to change prior to any resulting enforcement action. . Second, th'e statements of views or expressions of opinion made by .. NRC employees at this predecisional enforcement conference, or the
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- lack thereof, are not intended.to represent final agency determinations or beliefs.
d . PROPOSED ENFORCEMENT ACTloN - NoT FoR PUBLIC Disclosure WITHouT THE APPROVAL oF THE DIRECTOR, oE
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NRC SPECIAL INSPECTION. REPORT 9 NOS. 50-335/96-12,50-389/96-12 PRE-DECISIONAL ENFORCEMENT CONFERENCE AUGUST 19,19% i
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ATLANTA,GA .
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l _ ' , FLORIDA POWER & LIGHT COMPANY ST. LUCIE PLANT l l
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AGENDA t t
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W.H. BOHLKE . e INVESTIGATION OF PROPOSED 10 CFR50.59 VIOLATIONS . '
* CONTROL ELEMENT DRIVE MECHANISM CONTROL SYSTEM ENCLOSURE i
* TEMPORARY FIRE PUMP
* LOAD CELL SETPOINT CHANGE j
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' * DIESEL FUEL OIL SUPPLY VALVE i ! e INVESTIGATION OF CONFIGURATION MANAGEMENT DEFICIENCIES t e SUMMARY ,
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T.F. PLUNKETT *
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o CLOSING REMARKS 2 , i
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UNIT 2 CONTROL ELEMENT DRIVE MECHANISM CONTROL SYSTEM ENCLOSURE APPARENT VIOLATION - FAILURE TO PERFORM A 50.59 SAFETY EVALUATION FOR CEDMCS ENCLOSURE PRIOR TO OR SUBSEQUENT TO ITS INSTALLATION INVESTIGATION ' e FABRICATED PRIOR TO OCTOBER,1982 CEDM PRE-OP TESTING e PLANT LICENSE ISSUED APRIL 6,1983 e NON-SAFETY STRUCTURE FOR NON-SAFETY EQUIPMENT '
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o EVALUATED BY ARCHITECT / ENGINEER FOR INTERACTIONS
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e ENCLOSURE HAS NOT BEEN MODIFIED SINCE FABRICATION
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. PROGRAM REQUIREMENTS ,
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e CHANGE PREDATES PLANT LICENSE; 50.59 DID NOT APPLY-e 10 CFR 50.71(e) REQUIRES UFSAR UPDATE TO CAPTURE CHANGES e REG. GUIDE 1.70 DEFINES UFSAR FORMAT AND CONTENT
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e DESIGNS MUST COMPLY WITH PLANT DESIGN REQUIREMENTS ,
. (e.g., SEISMIC INTERACTION)
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REGULATORY. GUIDE 1.70 1 ' STANDARD FORMAT AND CONTENT OF SAFETY ANALYSIS REPORTS (Emphasis Added) 9.4.3 Auxiliary and Radwaste Area Ventilation System ' 9.4.3.1 Design Bases The design bases for the air handling system for the radwaste area ! and the areas of the auxiliary building containing safety-related
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equipment should be presented. Include requirements for meeting the single-failure criterion, seismic design criteria, requirements for the manual or automatic actuation of system components or , l isolation dampers, ambient temperature limits, preferred direction
of airflow from areas oflow potential radioactivity to areas of high . potential radioactivity, differential pressures to be maintained and measured, requirements for the monitoring of normal and l abnormal radiation levels, and requirements for the treatment of ' exhaust air. Details of the means for protection of system vents or louvers from missiles should be provided. ;
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l ROOT CAUSES e ENCLOSURE INSTALLED PRE-LICENSE AS A TEMPORARY STRUCTURE o ENCLOSURE WAS NEVER MADE INTO A PERMANENT MODIFICATION - NOR WERE DRAWINGS UPDATED e PERMANENT MODIFICATION NOT GIVEN PRIORITY , CORRECTIVE ACTIONS e 50.59 EVALUATION PERFORMED - NO UNREVIEWED SAFETY QUESTION e MINOR MODIFICATIONS MADE.
. e DRAWINGS WILL BE UPDATED i
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J CONCLUSIONS e 50.59 EVALUATION WAS NOT REQUIRED AT TIME OF INSTALLATION e NO OPPORTUNITIES FOR 50.59 EVALUATION POST-CONSTRUCTION ! SINCE NO MODS DONE i
e INCLUSION IN UFSAR NOT REQUIRED PER REG. GUIDE 1.70 e CURRENT PROCESSES (e.g., MODIFICATION, TEMPORARY ALTERATION)
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' WOULD REQUIRE 50.59 CONSIDERATION
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e TEMPORARY ENCLOSURE SHOULD HAVE BEEN MADE PERMANENT l SAFETY SIGNIFICANCE
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e ENGINEERING EVALUATION FOR PAST OPERABILITY AGREED WITH ' , INITIAL ARCHITECT / ENGINEER EVALUATION - NO IMPACT TO PLANT
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SAFETY
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TEMPORARY FIRE PUMP
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APPARENT VIOLATION
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' INSTALL'ATION OF A TEMPORARY FIRE PUMP RESULTED IN A CHANGE.
TO THE PLANT AS DESCRIBED IN THE UFSAR WITHOUT A 50.59 i INVESTIGATION ' e UFSAR DRAWING SHOWS CONNECTION FOR PORTABLE PUMP-
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' e UFSAR TEXT DESCRIBES TEMPORARY PUMP CONNECTION TO CITY WATER STORAGE TANK DRAIN LINE ~
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l ST. LUCIE UNIT 1 UFSAR i
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APPENDIX 9.5A, FIRE PROTECTION PROGRAM REPORT
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EXCERFI' FROM SECTION 3.1.1:
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"A flanged connection is provided from the CWST drain line to allow connection to a portable fire pump to assist the fire protection system if required." .
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l l l l INVRSTIGATION (cont'd) t e TEMPORARY PUMP SUCTION WAS INSTALLED AT LOCATION NOTED IN UFSAR FIGURE e FIRE PROTECTION PLAN (AP 1800022) ALLOWS PUMP OUT OF SERVICE UP TO 37 DAYS e PROCEDURE "LCO" INCORPORATES FORMER TECH SPEC LCO
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e FIRE PUMP WAS OUT OF SERVICE FOR 19 DAYS
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* NO COMPENSATORY ACTIONS REQUIRED e TEMPORARY PUMP NOT FULL CAPACITY I
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, PROGRAM REQUIREMENTS e PLANT QUALITY INSTRUCTIONS REQUIRE PROCEDURES FOR FIRE PROTECTION e TEMPORARY SYSTEM ALTERATION PROCEDURE IS TO BE USED FOR INSTALLATION OF TEMPORARY EQUIPMENT NOT ADDRESSED BY EXISTING PROCEDURES
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ROOT CAUSES e THE ACTIVITY WAS A LONG STANDING PRACTICE - THE TEMPORARY SYSTEM ALTERATION PROCEDURE WAS NOT USED l l '
* INSTALLATION OF TEMPORARY PUMP WAS NOT PROCEDURALIZED-
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CORRECTIVE ACTIONS
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e ENGINEERING TO DETERMINE MINIMUM FIRE WATER CAPACITY AND TO PROVIDE EVALUATION FOR USE OF A TEMPORARY PUMP e FIRE PROTECTION TO REVISE ADMINISTRATIVE PROCEDURE BASED ON ENGINEERING INPUT
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! CONCLUSIONS
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e -USE OF THE TEMPORARY PUMP SHOULD HAVE BEEN IMPLEMENTED
- VIA PLANT PROCEDURE OR TEMPORARY SYSTEM ALTERATION, BOTH REQUIRE A 50.59 SCREEN e 50.59 SCREEN WOULD HAVE CONCLUDED 50.59 EVALUATION WAS i NOT REQUIRED l
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SAFETY SIGNI$'ICANCE
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e THE OPERABLE FIRE PUMP WOULD HAVE BEEN CAPABLE OF MITIGATING A FIRE '
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, UNIT 1 LOAD CELL SETPOINTS APPARENT VIOLATION FAILURE TO PERFORM A 50.59 SAFETY EVALUATION FOR CHANGE TO SETPOINTS DESCRIBED IN UFSAR INVESTIGATION
* TWO PROCEDURES REVISED TO UPDATE OVERLOAD & UNDERLOAD SETPOINTS FOR REFUELING AND SPENT FUEL HANDLINO MACHINES e ENGINEERING PREPARED EVALUATION WHICH PROVIDED NEW SETPOINTS IN SUPPORT OF PROCEDURE CHANGES (NO 50.59)
e UFSAR DESCRIBES INTERLOCKS WITH RESPECT TO LOAD VALUES; EXAMPLE:' i
" ... interlock limits the maximum uplift load to ten percent above load."
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INVESTIGATION (cont'd)
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CHRONOLOGY: 4/29/96 EVALUATION REV. O ISSUED
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5/08/96 EVALUATION REV.1 ISSUED (EDITORIAL CHANGES)
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PROCEDURE CHANGE SCREENED AS NOT REQUIRING 50.59 PROCEDURES FRG APPROVED WITHOUT 50.59 , 5/12/96 LETTER OF INSTRUCTION SCREENED AS REQUIRING 50.59; EVALUATION IS REFERENCED ON SCREENING FORM i '
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FRG REJECTS LOI & EVALUATION BECAUSE 50.59 MISSING 5/12/96 (1400) EVALUATION REV. 2 FRG APPROVED (ADDED 50.59) 5/12/96 (1700) FUEL MOVEMENT COMMENCED 15 -
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PROGRAM REQUIREMENTS
' * ENGINEERING QUALITY INSTRUCTIONS REQUIRE 50.59 FOR A " CHANGE TO THE FACILITY..."
e 50.59 SCREENING REQUIRES DETERMINATION IF UFSAR IS AFFECTED BY THE CHANGE ROOT CAUSR9 e FUELS ENGINEERS DID NOT IMPLEMENT PROCEDURAL REQUIREMENTS e INDIVIDUAL SCREENING PROCEDURE CHANGE FOR 50.59 DID NOT
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IDENTIFY ALL APPLICABLE UFSAR TEXT
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CORRECTIVE ACTIONS
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* TECHNICAL ALERT ISSUED e SUPPLEMENTAL TRAINING FOR FUELS ENGINEERS .
e REVIEW OF OTHER FUEL GROUP EVALUATIONS - NO FINDINGS t CONCLUSIONS
* 50.59 SHOULD HAVE BEEN PROVIDED WITH PROCEDURE. CHANGES
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* 2 BARRIERS FAILED - DESIGN & PROCEDURE 50.59 SCREENING e PROBLEM WAS SELF-IDENTIFIED PRIOR TO FUEL MOVEMENT SAFETY SIGNIFICANCE e NO SAFETY SIGNIFICANCE '
* SETPOINTS WERE TECHNICALLY EVALUATED g
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* NO UNREVIEWED SAFETY QUESTION ;
e FUEL MOVEMENT DID NOT START UNTIL AFTER 50.59 ISSUED
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UNIT 2 DIR5sEL GENERATOR FUEL SUPPLY-VALVE
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APPARENT VIOLATION . REPOSITIONING OF AN EMERGENCY DIESEL GENERATOR FUEL SUPPLY
VALVE CONSTITUTED. AN UNREVIEWED SAFETY QUESTION INVESTIGATION e UNDERGROUND LEAK BETWEEN THE TRANSFER PUMP AND DIESEL DAY TANKS REQUIRED ACTION e EVALUATION ISSUED (7/6/95) TO ALLOW ISOLATION OF THE
- NORMALLY OPEN FUEL LINE TO STOP THE LEAK l * EVALUATI' O N REQUIRED COMPENSATORY MEASURES 18 4
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INVESTIGATION (cont'd)
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e ADEQUATE TIME TO IMPLEMENT MANUAL ACTION:
* DAY TANK CAPACITY = 126 MIN
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* TRANSFER PUMP STARTS AT 40 MIN
* MANUAL ACTION REQUIRED WITHIN 20 MIN BY PROCEDURE
. * EVALUATION IDENTIFIED POTENTIAL FAILURE MODES , e
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L INVESTIGATION (cont'd) .
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e EVALUATION WAS PREPARED CONSISTENT WITH FPL PROCEDURES
- AND NSAC-125 EXCERPT FROM NSAC -125 (Emphasis Added): ,
Changes that result in a change from one frequency class to a more frequent class are examples of changes that increase the probability of occurrence. However, this is not to say that changes within a category may not result i in an increase in the probability of occurrence of an accident if there is a clearly discernable increase or trend.
Compensating effects such as changes in administrative controls may be used to offset an increase or trend in the pmbability of accidents of moderate frequency. Normally, the determination of a probability increase is based , upon a qualitative assessment using engineering evaluations consistent with the original SAR analysis i assumptions. This is not to say that if a plant specific probability calculation can be used to evaluate a change in - a quantitative sense, it should not be used. However, it should be emphasized that PRAs are just one of the tools ' for evaluating safety and their use is not needed to perform 10CFR50.59 evaluations. Licensees should utilize .i reasonable engineering practices, engineering judgement, and PRA techniques, as appropriate, in determining - whether the probability of occurrence of an event increases as a result of implementing a proposed change.
- A large body of knowledge has been developed in the area of event frequency and risit significant sequences through plant specific and generic studies. Licensees should draw on this knowledge where applicable in
, determining what constitutes an increase in the probability of occurrence of an accident or malfunction of equipment important to safety previously evaluated in the safety analysis report. Where a." 7 in 2.d.Iliev is so =n=11 or the uncers i=*iec in '. L.1=25 whether a ch===e in nrnhahilitv han r n ried are ==ch *-* it c--w-be gr;;c d'y crsichih'120 the m J.d.Ility hat scinnally ch]-3 (i.e., tbre is no c'_-
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trentI li,hih Ir- s 2rI = the Drohnhilitvl the chance need not be ; nneidered an i m nrnhahility.
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~ INVESTIGATION (cont'd) e USE OF MANUAL ACTION WAS CONSISTENT WITH GENERIC LtHTER ;
91-l8 (OPERABILITY) - l
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l EXCERIrr FROM GL 91-18 (Emphasis Added): 6.7 Use of Manual Action in Place of Automatic Action '
...the licencee's determination of onerability with reaard to the use of mannni action must focus on
' ~
l - the ohvsical differences between automatic' and mannni action and the ability of the msnnni action
to accomplish the soecified function. 'lhe physical differences to be considered include, but are not
' . . limited to, the ability to recognize input signals for action, ready access to or recognition of i setpoints, design nuances that may complicate subsequent manual operation such as auto-reset,- i repositioning on temperature or pressure, timing required for automatic action, etc., minimun manning requirements, and emergency operation procedures written for the automatic mode of operation. 'lhe licensee should have written orncednies in place and trainina accomnlimhed on those '
orocedures before substitution of any manual action for the loss of an automatic action.
j The assignment of a dedicated operator for manual action is not acceptable without written procedures and a full consideration of all pertinent differences. The concideration of manual action in remote arent nico must include the ability and timina in nettina to the aren trainine of nersonnel to accomplish the task and occupational hanrds to'be incurred such as radiation! temneratum,- ' chemical sound or visibility hanrds_. Nevertheless, this is expected to be a temporary condition until the automatic action can be , romptly corrected in accordance with 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action.
.
. - - - _______ _ ___ __ _ ___ _________________-_ _____ __ _-_________ _ _ _ _ _ _ _ _ _ _ - - _- _ _ _ - _ _ _ - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ -
. . . _ _ _ . _ ._ . . _ __.._ .. .. . _ . . _ _ _ _ _ . _ _ . _ . _ _ _ . . . . _. . _ . . .
..;
PROGRAM REQUIREMENTS
e EVALUATIONS ARE TO BE PREPARED IN ACCORDANCE WITH . ENG PROCEDURES AND 50.59 GUIDANCE DOCUMENT ROOT CAUSE - .
-e GUIDANCE DOCUMENT WAS CONSISTENT WITH NSAC-125 INTERPRETATION WHICH DIFFERS FROM THE NRC POSITION -
ON " INCREASE IN PROBABILITY"
. -i t
22 ,
. .
+
_ _ . . _ _ _ _ _ _ _ _ . _ . _ _ _ _ _ _ _ _ _ . . _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ _.______._____.________.__.___..____________._._____________.___m<_..-______m_ _ _ _ _ .e_ _ . _ _ ._ __.=_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___m___m_ _ _ _ _ _ __ _ . _ ___-______ _ _ _ . ________
.- .- . . - - - -- . - . - . .- - - . - - . - - .. - . . . _ .
. .
.
- CORRECTIVE ACTIONS
'l e REVISED ENGINEERING'S 50.59 GUIDANCE DOCUMENT
' EXCERPT: . Note: Any* qualitative or quantified increase in probability regardless of magnitude must be considered an increase in probability for the purposes of 10CFR50.59.
However, compensating effects (including compensatory actions) such as changes in administrative controls are acceptable in offsetting uncertainties and increases in the probability of occurrence or consequences of an accident previously evaluated in the SAR or reductions in a margin of safety, provided the potential increases or reductions in margin are negligible. Additionally, a change that would result in a slight increase in - the probability of an initiating event for an accident would not be an increase in probability under 10CFR50.59 provided the probability of occurrence of some other , ' event (s) in the same sequence is concomitantly decreased and there is no adverse effect on other plant-specific accident sequences.
- This statement is in effect pending final resolution of this issue between the NRC and NEI. Previous guidance in NSAC 125 had stated that small increases in probability that did not demonstrate a trend towards increasing consequences could tre considered as not constituting an increase in consequences pursuant to 10CFR50.59.
*
___-___ _ - __ _ _ _ - _ _ ___-__ _ _ - _ _ _ _ _ _ _ _ - - _ - - _ _ _ _ _ _ - _ - _ _ _ _ _ _ _ _ _ _ _ - _ _ - _
. ._ , ._. _ _ . .____ _ .. . __ _ _ _ . _ _ . . _ . . _ _ . _ _ _ _ . . . , _ _ _
. .
.
. CORRECTIVE ACTIONS (cont'd) I e- ISSUED TECH ALERT TO ALL ENGINEERS (3/6/96): , -! TECHNICAL ALERT - 50.59 EVALUATIONS -
!
.$
When perforsang 10CFR50.59 m " =. any quantined increase in the probability of occurrence of accidents, or any quasmEed secsease in the probabihty ofoccunence of naalfuncnon of equipnient isaportant to safety, noust be considered an unreviewed safety q=rasian M.csedit for l operitor action in place of aueomanc acean, or credit for operator realignonent of a syseeni to perform its ina- anni Asoction, when that reshgsuneet is not ;
'
normally requered, must receive management review. '
!
BACKGROUND l e A safety evahsanon was issued which calculated a senell increase inr" ' " , of occunence of a malfuncmon of equepment insportant to safety using
--
!
probabalistic safety assessment techasques. Credit for operator action was asken to compensaae'for this increase, aldiough this compe===sian did not !
- quantitatively eliminate the increase in probabehty. The evahsehon concluded that the evaluated condmon was pernused by 50.59. "Ilie NRC ,
* --- , ---2, quesconed this conchesson, and is fierther reviewing the evalushon, j -
l The Nuclear Engmeeting Departnient document "Guedance for Performsag 10CFR50.59 Safety Evahsamans" inchsdes notes on page 15 wtuch discuss y smeN changes in die probability of occurrence of accma-se It is not ima-rinni that quantified increases in the probabdsty of oceanunce of =rna-an or ? ] occanence of mainsection of equipment unpostant to safety, he allowed under 50.59. Addeonelly, taking credit for operator acean to ca=qw= mama for i
'
! increases in she probability of occurrence of accidents, or occunence of nialfunction of equipment is a delicaec undertakmg For this s====a= credit for i gerator action in pism of auenmenc accon, or credit for operneor realignment of a system to perform its intended funcean, when that , " . - is not normally required, must receive - - - - -4 review.
+
.
l ACTIONS i i 1. Engineenng personnel involved in the review of plant and procedust changes must consider quaneRed increases in acculent occunence ! probabehty, or equipment unportant to safety anNhaction probabihty, an inueviewed safety queshon for which prior NRC appmval is required. ;
!
2. 'llut Nuclear Engsteenng Department document hrsance for Performmg 10CFR50.59 Safety Evalushons" will be revised in the 2nd quarter [ of 1996 to further address the topic of dois Technical Alert.
marnaENCES
" Guidance for PerforniIng 10CFR50.59 Safety Ev=e== mans " Rev. 0,10f89 i I
24 !
.
.
E
!
'
__ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ --_ _ _ _ _ _ . _ _ _ _
~ ~
~
. . .
CONCLUSIONS
* CURRENT NRC INTERPRETATION AND INDUSTRY GUIDANCE DiwtiR -
ON THIS ISSUE : ~
SAFETY SIGNIFICANCE
* NO SAFETY SIGNIFICANCE . * CORE DAMAGE FREQUENCY CHANGE <3% * CONSIDERABLE TIME AVAILABLE FOR OPERATOR ACTION l
l
.
m.__. _ 4 -__ _ _ _ _ . - _- ' _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _._m__ __- _ _ _ _ _ ____ _ , - - - - - _ __ --v...- .. # v_________m_ _ _ - _ _ _ _ _ __ _ _ ______ _ _ _ _ _ . _ _ _ _m
.. . . . . - -. -- - - . - . . _ - . - .
SUMMARY
- NO PROGRAMMATIC 50.59 BREAKDOWN:
l CEDMCS ENCLOSURE - PRIOR TO LICENSE
,
TEMPORARY FIRE PUMP - FAILURE TO FOLLOW PROCEDURES ' WHICH WOULD HAVE REQUIRED 50.59 SCREENING (WOULD SCREEN OUT) LOAD CELL SETPOINTS - 50.59 SHOULD HAVE BEEN WRITTEN; SELFIDENTIFIED DG FUEL SUPPLY VALVE- EVALUATION DONEIN ACCORDANCE WITH PROCEDURES ANDINDUSTRY GUIDANCE
*
. . _ . . . _ . _ _ _ _ _ _. _ _. _ . _ . _ . . _ _ . _ . .. _. _ . . _ .
,
.
SUMMARY (cont'd)- e EMPHASIS HAS BEEN PLACED ON THE IMPORTANCE OF 50.59 AND
'
THE UFSAR: . i
' * 50.59 REVIEWER CERTIFICATION ESTABLISHED ,
'
* 50.59 TRAINING OF STAS COMPLETED DURING REQUAL
* FORMALIZING TRAINING MODULE TO QUALIFY 50.59 SCREENERS
-
* IMPROVED 50.59 SCREENING REQUIREMENTS FOR PROCEDURES ,
-
QI 5-1, [ PLANT PROCEDURES]
- AP 0010124, TEMPORARY SYSTEM ALTERATIONS l - AP 0010148, TEMPORARY CHANGES TO PROCEDURES * ALL 50.59 EVALUATIONS MUST BE PREPARED BY ENGINEERING * REVISION TO 50.59 GUIDANCE DOCUMENT * TRAINING OF FUELS PERSONNEL * TECHNICAL ALERT ISSUED TO FUELS PERSONNEL l * UFSAR REVIEW PROJECT e NO SAFET SIGNIFICANCE
.
I
. .. , ,. -, , , .
.. - .. . . . - -- . . .. -. .
CONFIGURATION CONTROL -
. APPARENT VIOLATION
~
FIVE EXAMPLES OF CONFIGURATION CONTROL ISSUES INVOLVE A ; FAILURE TO UPDATE DRAWINGS AND PROCEDURES INVFSTIGATIOR
* 3 ANNUNCIATOR RESPONSE SUMMARY ERRORS * 1 ERROR - RELOAD MODIFICATION PRE-IMPLEMENTATION .
REQUIREMENTS e 1 DRAWING UPDATE ERROR
.
'
_ . _ _ _ _-._ .
_ _ .. . . . _ _ _ _ . . . __ __ _ _ . . _ . . . . _ ._ . __ . _ i INVESTIGATION (cont'd)
-
THREE ERRORS IN ANNUNCIATOR RESPONSE PROCEDURE (UNIT 2) 1. PROCEDURE NOT REVISED TO REFLECT NEW SETPOINT VALUE .i
-
HYDRAZINE TANK LOW LEVEL ALARM (CONTAINMENT SPRAY)
-
MOD CHANGED SETPOINT FROM 35.5" TO 36.7" TO GAIN MARGIN TO TECH SPEC LIMIT t
'
-
PROCNDURE ERROR IS IN CONSERVATIVE DIRECTION
- 2. PROCEDURE NOT REVISED TO DELETE OPERATOR ACTION l
l - INTAKE COOLING WATER PUMPS' LUBE WATER SYSTEM MODIFICATION ,
.
-
MOD ELIMINATED NEED FOR CERTAIN OPERATOR ACTIONS
'
l . l 29 .
;
.
.
l_ _ _ _ _ _ _ _ _ _ . - -_ ____ ___ _____ _ _-_ ____ _ _ -_ _ __ _- _ _ . . . - . - - . . _ - _ _ _ _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ _ _ _
_ .. . .. .. .. .. _ . _ _ INVESTIGATION (cont'd) 3. PROCEDURE NOT REVISED TO REFLECT ANNUNCIATOR DELETION
-
MOD DELETED ATMOSPHERIC DUMP VALVE " MANUAL" INDICATION (INDICATES " MANUAL" CONTROL)
-
RELAY CONTACTS REMOVED BY MOD - ANNUNCIATOR WOULD NOT ALARM
-
NOT AN OPERATIONAL PROBLEM . l l '
,
M
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-
.
- - - -- - - - --_-- --------- - - - - -. .. . - .. .. _ .
_ _ . . . . __ _. . . _ . _ _ _ _ _ . . . _ _ _ . _ . . . _.. . ._. _. . .
,
INVESTIGATION (cont'd)
. RELOAD MODIFICATION PRE-IMPLEMENTATION ERROR
,
o MOD FOR FULL CORE OFF-LOAD / FUEL RELOAD e MOD PACKAGE CONTAINED PREREQUISITES TO BE IMPLEMENTED PRIOR TO FULL CORE OFF-LOAD , i e PLANT PROCEDURE WAS NOT REVISED TO INCLUDE PREREQUISITES
,
e OFF-LOAD COMMENCED WITHOUT VERIFYING PREREQUISITES e ERROR SUBSEQUENTLY IDENTIFIED BY QUALITY ASSURANCE e CORE OFF-LOAD STOPPED UNTIL PROCEDURE CHANGED (7 ASSEMBLIES MOVED) l 31
. .- .. . - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _- _ . _ _ - - - _ _ _ - _ _ _ - - _ _ _ _ . _ _ _ _ - - _ - _ - _ - _ . _ _ _ _ - _ _ - - _ - -
- .
_
. .
e INVESTIGATION (cont'd) . DRAWING UPDATE ERROR e MOD REMOVED LUBE WATER VALVES AND PIPING FOR INTAKE COOLING WATER SYSTEM e DRAWING WAS NOT REVISED TO REFLECT DELETIONS
'
, l
'
s 32 .
~
_ - _ _ - - - - _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ - - - _ - - - _ _ _ _ _ _ _ - - - - - _ . . . -- - . ..
.. .. . . . . _ _ ._. . . - . _ . _ - - _ __ . ._ . . __ .
INVESTIGATION (cont'd)
. * EXAMPLES SPAN THE TIME PERIOD FROM 1992 - 1996 e CONFIG CONTROL PROCESS RELIED ON PERSONNEL STRENGTHS -
NOT RIGOROUSLY PROCEDURALIZED e THE LARGE NUMBER OF MODIFICATION PACKAGES CHALLENGED THE PROCESS AND RESULTED IN A LARGE "OPEN ITEMS" LIST
'
e PERIOD OF GREATEST VULNERABILITY BEGAN AUGUST 1995 PROGRAM REOUIREMENTS
. * DESIGN CHANGES MUST BE ACCURATELY TRANSLATED INTO PROCEDURES AND DRAWINGS
*
__ _--_ _ _ _ _ _ _ - - _ _ _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ . _ - _ _ _ _ _ _ _ - - - _ - _ - - - -__- - -- -- - , . , .-
__ . .. . _.. _ . ._ ._ _ .. _ . _ __ . . _ _ _ . . . _ . _.
. . . A ROOT CAUSFS e CONFIG CONTROL PROCESS RELIED TOO HEAVILY ON INDIVIDUALS 3 INSTEAD OF PROCESS
'
e CONFIG CONTROL PROCESS OVERWHELMED BY LARGE NUMBER OF-MODIFICATION PACKAGES -
e SYSTEMS WERE RETURNED TO SERVICE PRIOR TO ALL REQUIRED ' CONFIG MANAGEMENT CHANGES BEING IMPLEMENTED
'
i I
*
- . - - _ - _ _ _ _ _ - _ _ _ _ - - _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ - - _ _ _ _ - _ _ _ _ - _ _ _ - - _ - _ _ _ _ . _ _ _ _ _ _ _ _ - . _ _ _ _ _ _ - _ _ - - - _ _ _ - _ _ - - - _ - _ _ _ - - _ _ _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ _ -
. _ . . _ . . _. . _ _ _ _ _ _ _ _ _ _ . _ . _ . . _._. . _ . -_
-
)
. CORRECTIVE ACTIONS e - QI 3PR/PSL-1 " DESIGN CONTROL" WAS REVISED TO ENSURE THAT SYSTEMS ARE NOT RETURNED TO SERVICE UNTIL R8 QUIRED DOCUMENTATION IS UPDATED e THE PROCESS FOR MODIFICATION CLOSE OUT WAS FORMALIZED AND MANAGEMENT EXPECTATIONS EMPHASIZED
,
.
o THE NUMBER OF MODIFICATIONS PROCESSED IS BEING REDUCED BY IMPLEMENTATION OF TOP 20/30 LIST , e MODIFICATION RELATED OPEN ITEMS AFFECTING PLANT OPERATIONS : l OF SAFETY SYSTEMS HAVE BEEN CLOSED t l l , l l I l . 35
.
_ - - - . _ _ _ _ _ _ _ _ - _ _ _ _ . - _ . - - - - - _ - - - - _ _ _ - - -_______-----_.__.-a_ - - n , --
-- w~ - -- e a u- - -- --_-_ - +-- - ---_u _-- __ ---
_ _ . __. __ . _ _ . _ _ . _ . _ . . . . __ _ . . .
,
l CORRECTIVE ACTIONS (ront'd)
- .* REVIEWS CONDUCTED FOR THE PERIOD OF GREATEST PROCESS VULNERABILITY (AUGUST 1995 TO MAY 1996)
o VERTICAL SLICE OF PSA RISK SIGNIFICANT SYSTEMS (HIGH PRESS.
INJECTION, EMERGENCY POWER & COMPONENT COOLING WATER) WAS CONDUCTED TO VALIDATE SIGNIFICANT FLOW DIAGRAMS AND PROCEDURE REQUIREMENTS
* ANNUNCIATOR SUMMARY UPGRADE ,
e ASSIGNED A DEDICATED SUPERVISOR AND STAFF TO MODIFICATION CLOSEOUT PROCESS e
'
STANDARDIZING UP-FRONT MODIFICATION REVIEW PROCESS TO EXPLICITLY IDENTIFY AFFECTED PROCEDURES ! l * SYSTEM ENGINEERS WILL HAVE OWNERSHIP OF CONFIGURATION o
~ . _ _ _ . _ . . - _ . . . . . .
. - _ . . - . - . . . . - . . . . - - - - - . . _ - _ _ _ _ _ __
.
'
,,
, Q1344WPS.-1 I
Revision 40
:
M M ' f) , May,1906
-
Ostevedese
#888- , Page 1 of 38
m es seanisem m edi= =
'
d besmuna m m ben e s8sd W
:
i PLORIDA POWER & UGHT COMPANY NUCLEAR EMERGY DEPARTIENT i ST. LUCIE PLANT >
!
, DESIGN CONTROL . 1.0 APPROVAL:
j Reviewed by Plant Nuolear Saisty Commates 7/25 1974 l Approved by K N. Hams Plant Gen 9ral Manager 7/31 19]f,
- <
Resion dg, Reviewed by F R G y1s ig,gg,, l Appmed by J. semia Plant General Manager sia togg., i 2.0 EUBEQSE:
j 2.1 Paids contml of plant changes and modlRostions enowhg pient structures, p; systems and components am installed and mainnahed in acconsonae weh appliosbis design speciRestions and documents.
j 2.2 Ensure plant changes and moddications comply wth:
- 1. 10 CFR 50.59 Domoede Lloonsing of Produedon and UWzadon Fm -
' Changes, Tests and Expenments.
! 2. SOM 3.0 Design Contml l ,
.
.
s oes , DATE DOCT PROCEDURE , DOCN CB41 , . SYS
'
COMP COMPLRED
" "
I i, . J
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. . , . . - - , .- -
- _ _ _ . ..- -- ..- . - . - . . . . - --.-.-. .. - --
i
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\ ;
G Sf9WP8L-1 Revision 40
' May,1998
. Page as of 35 .
:
ATTAQG WfT4 SYSTEM ACCEPTANCE /fURNOVSR SW (Page 1 of 2) Peps i er i
_ unster. u 1 O a O consnan aATs: O Peams = campsee
.
Tue: W* oloalpEne: u eBommel O unchensass O mc a unts.Piepas a sys.Passeson O Oeier.
- O uses ossenes reseneis esquees m undo O This sATs le a sweet numever. Wat rememing menesse the sesoming: .' 1 l
' ,
M 9 s -_ - ^ s wsus: _ AE bq M Wo . b h We @ M M Q ter my depeetnent enkh me not regees for annover me aseed below-t
- vs. .A j DATE:
! O O so seawer. / / " i O O Chemlety: / / . O O. Pwo prosemmon: i i
- O O MosAh Phyelas: i /
- O O mens uaksenenos
- i i
' . O O smeegenor Propensaisse:
'
i i ' l PROCEDURE NO. DATE REQURED CR OR PuAl NO.
t, i 1 I ' I / 3 I i
I /
/ /
aya a suiE - .- _.__. W GFs SUPPWIT seiwife: YES MA
,,see n - - eBa B o , oomp es. .e, . es .o n.es e.
. have been venemassa no CaA. (.A a test hee noen mode essened tar this SATsbO O
t ]
AE DepWenent PfDoethree PCquend for tJmover We cop 41spie afMM3r SCE Depwtmoet proosewes not requend for tumower ase seted aeove.
OO i System Engwiser or OST: ' Oste: 1 i '
.
nuo ! I ' i
.
__ ____.____ . _ _ _ _ _ _ _ _ _ _ _ _ . _ - _ _ _ _ __ __ -- - u _ . _ -- -
.. .- . - . . - - .. . .- _ . - . - . . - , - - . . . - . . _ _ . _ _ - _ - _ - _ _ _ . _ _ _ _ . . .
! Page 7 of 59 ST. LUCIE PLANT , ADMINISTRATTVE PROCEDURE NO. 0006746. REVISION 13 REQUEST FOR ENGINF8 RING Asut!aTANCE (REA) 0M(W , 3.4 (contmuod)
' 25.
' Sponsoring Department Hood - the eponeodng deperiment head is the manager or supervisor of the department in which the sponsor works. , i l > as. Top 20 Priorithed Plant MODS Uet - list of modmondons approved by the
'MRB for work during upcoming refueling outages. There wis be a Top 20 '
Uet for each unit. Any Top 20 modification which is not implemented i
within one sfuehng eyo6e we be canceled and deleted fmm the list unless determmed otherwies by MRB. , i ' 27. ! l Top 30 Prioritized Plant MODS Uet - list of modifications approved by the l MR8 for work during norHxitage or Short Notice Outage (SNO). Any Top 30 moddioedon which is not implemented wahh 52 weeks we be canceled and tietoted from the list unless determined otherwise by MRS.
, 4.0 PRECAUTIONS & LIMITS: i 4.1 AB appucable sections and portions of the REA form should be fmed out as j per this procedure in order to insure proper evaluation and subsequent action.
l 5.0 RESPONSIBILITIES: i 5.1 Serwoes Manager
1. Responsble for REA program.
2.
If REA is considered a Minor Modification authorizes the following types of REAs for implementation. without obtaming MRB rowew and approval: A. RTS REAs for Minor Modifications B. Fast Track REAs C.
Document changes and other issues not disposstioned as major or outage modifications.
.
-----ae.. .. _ _ . . . em 2-.ie _p-..aa-- . . --%...i .as._,aa m. .a
-
w em .2 4.. a .a _...a J., -sm -c .s.a am.aa,._ .- ____a e_A_.*a._.- - -+--- -- - . . -w.a--- ---- --- e q e i lt .. m , ! !
- !!}
m lisil . . d .
< _
A l a ]P .
- i m m m l e z i
$ ji
!ja}iy jI bH il
$
e m ,, m u ;
~
i b Iij ; A;!! k ji3
- .
Il gg
. _ - _ ._ ._ _. _ . _ _ _ . _ _. . _ .. .. . _. . ._.
, ,
.
VERTICAL SLICE REVIEW - FINDINGS
-
CHANGE PROCRRS .
* SOME SETPOINTS WERE FOUND TO BE INCONSISTENT BETWEEN TEDB AND THE ANNUNCIATOR SUMMARY e SEVERAL SETPOINT VALUES AND INSTRUMENT RANGES LISTED
' IN THE FSAR APPEAR TO BE INCONSISTENT WITH OTHER PLANT . DRAWINGS
* IN A FEW EXAMPLES, THE TOTAL EQUIPMENT DATA BASE (TEDB)
WAS NOT UPDATED OR EQUIPMENT REMOVED AS NOTED BY THE CHANGE PACKAGE . i ! 41 ' . _ _ _ . _ _ _ _ . _ _ _ _ . _ _ . _ _ __________m___ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . - -
, _ . _ _ . _. _ _ , . . - .
. . .- . . - . . . . -.. .-..-. - .
VERTICAL SLICE REVIEW - FINDINGS (cont'd) OTHER OBSERVATIONS e FLOW DIAGRAMS DO NOT REFLECT CURRENT VALVE LOCKING PRACTICES DEPICTED IN OPERATING PROCEDURES. VALVE LOCKING AND EQUIPMENT TAGGING OF INSTRUMENT ISOLATION VALVES IS NOT CONSISTENT WITH THE FLOW DIAGRAMS
;
e LINE AND VALVE ORDER / TAKEOFF POINTS ON THE FLOW DIAGRAMS
ARE SOMETIMES INCONSISTENT WITH THE FIELD , e NO ITEMS OF SAFETY SIGNIFICANCE WERE NOTED AND CONDITION : REPORTS WERE GENERATED FOR CORRECTIVE ACTION AND FURTHER REVIEW ' ! ! l l
'
l
' . - - _ _ _ - _ _ _ - _ - - _ _ - _ - - _ _ - _ _ - _ _ _ _ _ _ - - - _ _ _ _ _ _ - _ - _ _ - - _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ - _ _ - -
. . _.- . . . . - . - - . .
,
. l
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I ANNUNCIATOR RESPONSE SUMMARY UPGRADE PROJECT
- PROJECT SCOPE t
e = 1000 CONTROL ROOM ANNUNCIATORS PER UNIT i e NEW FORMAT e SETPOINT VERIFICATION '
'
o- REVIEW OF OPERATOR ACTIONS FOR CONSISTENCY e - UPGRADED REFERENCES ! ! i STATUS
'
e COMPLETED = 10% OF CONTROL ROOM ANNUNCIATORS (PENDING FINAL REVIEW) e UPDATE ANNUNCIATOR RESPONSE SUMMARY- AS REQUIRED; NOT QUARTERLY
;
,
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43 , t
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.._..m _....._a .- _. _ m .____. ____-__ _ _ _ ___.m. _ _ . _.__ _ _ _ ___.______ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _______m ____. . m m___ .-___ _m__ _______.____.____._______.__m_____ __
I
'
l ., . l E II s- ,
- fr_
I:l :e ===. g si; !- 11i i :fini!!!a , _ an !-
:= r! :cance l ;
' 3x-l l E k > wr; _ l- f- lI gi ll
- I" l. ~!! . . : % n:n l .
ci l u a
$s *
sl 4 s-z j g _ i8 l 3 I i M 2l _ g I ;
' , ~
lgl #11ll:
-
ta
_ .. .. .. . __ __.. _. .- . .__ ... . , , ,
~ . .
1~ . SYSTEM ENGINEER ACCOUNTABILITIFR
.
THE SYSTEM ENGINEER WILL: . < e HAVE OWNERSHIP OF THE SYSTEM e UNDERSTAND SYSTEM OPERATION
e CONDUCT INITIAL AND SUBSEQUENT SYSTEM WALKDOWNS .
-
:
* ENSURE AGREEMENT WITH PLANT DRAWINGS 1 o ENSURE AGREEMENT WITH PLANT PROCEDURES e ENSURE AGREEMENT WITH THE UFSAR o
e BE COGNIZANT OF ALL MODIFICATIONS
'
. ++ , , , . w ..w
-._ _ .. . . _ __ _ .
CONCLUSIONS .
* ' CONFIGURATION CONTROL PROCESS REQUIRED ENHANCEMENTS IN
-
ORDER TO MEET MANAGEMENT EXPECTATIONS SAFETY SIGNIFICANCE e NO SAFETY SIGNIFICANT ITEMS HAVE BEEN IDENTIFIED IN THE REVIEWS CONDUCTED TO DATE
.
I
l l 46 - j
. _ . -_ - ._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ .. _ _ -___ _ _ ___ _ . . _ _ - _ _ _ ._
-. . . - -
.
. ..
_
.
SUMMARY e PROCESS HAS BEEN STRENGTHENED AND MORE FORMALIZED
e BASED UPON LOOK BACK REVIEWS, NO SAFETY SIGNIFICANT ITEMS HAVE BEEN IDENTIFIED - l . l l g ;[ s
.
__ _ - _ _ _ _ _ _ _ _ _ - - - - - - - _ _ _ _ _ _ _ _ _ - _ _ _ _ _
. - -- .. -- ... -. . _ _ _ _ ___ _ _ _ _ _ ____
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4
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FLORIDA POWER & LIGHT COMPANY
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i ST. LUCIE UNIT 1 . ll w
- t
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NUCLEAR INSTRUMENTATION i
- DESIGN DEFICIENCIES
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DFRCRIFIION OF CONDITION i On July 30,1996, St. Lucie discovered errors in the' installation'of nuclear instrumentation and associated
- electronics on Unit 1 RPS Channels A, C, and D.
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- CAUSE OF CONDITION Errors in design preparation and design verification, and
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weaknesses in post-modification and start-up testing allowed - nuclear instrumentation to be placed into arvice with latent errors.
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l' ! DFRIGN PREPARATION : ,
Target: provide an accurate and comprehensive design to ! the verifier !
- Failed: human error / latent condition
, Contributing Factors: i l 9 conflicting design information on existing plant j
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O conflicts not identified and resolved , l 9 drawing revisions (labeling) not comprehensive
9 assumed similarity between Unit 1 and Unit 2 , 9 late vendor documentation not properly verified
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DESIGN VERTFICATION Target: ensure prepared design is accurate and complete Failed: weaknesses in verification process 9 drawing not verified point to point by a competent i independent engineer i 9 verification and checking of specifications,
drawings, engineering package, and CRN performed by different individuals ' 9 inadequate time allotted for verification Contributing Factors:
. O assumed similarity between Unit 1 and Unit 2 / i Unit 2 success ' S conflicts on drawings not identified and resolved
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O lack of final vendor documentation 9 approach was to verify correct not prove incorrect 9 PEG I&C workload and available resources
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i - r POST MODIFICATION TFRTING
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i Target: demonstrate nuclear instrumentation (NI) system
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functions and other potentially affected functions f due to implementation of the PC/M i
l i l l Failed: upper and lower detector inputs to axial shape , i index (ASI) not identified as a critical affected
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function in post maintenance test (PMT)
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i i Contributing Factors:
i G Unit 1 PMT procedures based on Unit 2 PMT procedures (assumed similarity between Unit 1
and Unit 2) , . O experienced personnel not involved in PMT process 9 no practical method to demonstrate prior to criticality .
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! EDWER ASCENSION PROGRAM
i Target: verify that nuclear instrumentation is providing proper information regarding core performance , . i Failed: ASI inconsistent trends not detected earlier during
; the Unit 1 Cycle 14 initial power ascension i no target ASI provided to the control room crew i
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no trending of RPS ASI . inadequate follow-up when some ASI values ! questioned by operators
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Contributing Factors: ,
j 9 low power ASI trends difficult to detect and ! frequent ASI calibrations tend to mask trends
- 9 past experience with initial power ascension l i
reinforces that ASI is well behaved and requires no i
special attention i
9 concerns regarding RPS Channel B detector i unknown behavior due to replacement reinforce a perception of expected strange behavior
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- CORRECTIVE ACTIONS
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d G walkdown, modify as required, re-tag cables, and revise l ' drawings as necessary for both units i
' S validate outstanding safety related PC/M's containing 1 l wiring changes , O complete root cause / corrective actions for linear
detector replacement i G provide sufficient lead time for preparation of engineering packages and preparation for installation < a
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Quality Instruction Revisions ; O require that all critical aspects / functions to be ! demonstrated during PMT be identified in the ! engineering package l
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' G identify aspects / functions where in-service testing is required 9 reinforce requirement that verification signatures by independent qualified individuals are required on safety related drawings 9 identify that the same level of verification is required on duplicate packages !
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CORRRCTIVE ACTIONS -
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Reactar Rnaineerin.a
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i 9 provide a target ASI for power ascension program
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- 9 require real time data reduction and trending of SAF data during power ascension to check test data quality
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i I . O expand reactor engineering responsibilities to include performance monitoring-of instruments used to monitor core behavior !
0 trending of performance of instruments or components
that have undergone major modification, maintenance or - replacement
! O provide a training brief regarding this incident and l importance of a questioning attitude, using supporting R ' facts effectively and satisfactory resolution for all parties involved
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post indicator valves are provided throughout the fire main loop to permit isolation of portions of the loop without interrupting the ' entire water
[ supply. 1seletion valves are either provided in branch times to buildings or i i inside buildia- to_mialmini_the ne_ed to close valves in_ the maia loop.
,
- - - _ _ _ _ _- _ _ - ___ _ -_ ;
A flanged connection is pavided f rom the CW8T drain line to allow connection
] to a portable fire p o p to assist the fire protection system if required.
_- y - s_s ~ w - - . - - _ _ _ _
; The parameters used to monitor and control the fire water supply system are listed in Table 9.5A-3.
l The system fire pumps are started automatically by low pressure signals as
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indicated in Table 9.5A-3.. Once started. the peps continue to operate, stil i they are shut down manually. . -
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The domestic water pumps are controlled by pressure and level signals from the hydro- poematic tank. These pwpe can also be started and stopped locally.
. 1 The only automatically operated valves in the fire protection system are those ] used for transformer deluge and the diesel generator building.
Ecca time naa- Fiend 4== Aa=1 vain } a l Water from a ruptured fire line could eventually drain toward the emergency j core cooling system (ECC8y pump room sumps located at elevation -10 f t. Each
- sump is 4 f t x 4 f t x 10 ft deep with a capacity of 1.100 gallons. The pop room is divided into two compartments by a flood wall. Each compartment
' houses the miniassa complement of engineered safety feature pumps.
Pursuant to the Staffs requirement at Section 9.4.1 of its SER dated November 8, 1974 a reevaluatiog of ECC8 pump room flooding potential due to a fire main
- rupture was conducted. To comply with GDC 3 f silure of a fire main cannot
" impair the ability of redundant equipe.ent to (i) safely shutdown and isolate the reactor, or (ii) limit the release of radioactivity to the environment in l the event of a LOCA. This criterion is satisfied if the following conditions , l are satisfied: l i l i) The level at elevation -4.5' does not adversely affect the operability of j the borie acid makeup pumps. The pump motors are about 18 inches above the deck.
f
- ii) The level at elevat ton -10.0' does not adversely af fect the operability of the high pressurt safety injection pumps. The pump motors are 16 inches above t.be deck.?
! The flow rate via a slot ' break in the fire main at elevation -0.5' is 1250 ) spm. Drainage into the 'J." ECCS pump room is via a single 4 inch and a single
'
3 inch lina with a total c pacity of about 130 gym, whereas drainage into the
"B" ECCS pop room is via two 4 inch lines and a single 3 inch line with a total capacity of about ~210 gym. Thus any substantial release of water inventory to elevation -0.5' cannot be accomanodated by any local portion of the floor drainage system. Water will accumulate at elevation -0.5' with
. drainage into both ECCS pump rooms.
! 0051F/17 - 9.5A-110 Am. 11-7/92 D i
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i I U. S. NUCLEAR REGULATORY COMMISSION
. ; REGION I I
- ATLANTA, GEORGIA
'
i DATE: ^" " S t " - * l F1 rida P wer nd Light C mPany
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I NRC SPECIAL INSPECTION REPORT ~ NOS. 50-335/96-12,50-389/96-12
-
' PRE-DECISIONAL ENFORCEMENT CONFERENCE
.
AUGUST 19,1996 ATLANTA,GA .
%' s>- ,
- srtte V *
' i FLORIDA POWER & LIGHT COMPANY h ST. LUCIE PLANT
-
- _ _ __. . ..
,
AGENDA W.H.' BOHLKE o INVESTIGATION OF PROPOSED 10 CFR50.59 VIOLATIONS
* CONTROL ELEMENT DRIVE MECHANISM CONTROL SYSTEM ENCLOSURE
* TEMPORARY FIRE PUMP
* LOAD CELL SETPOINT CHANGE
* DIESEL FUEL OIL SUPPLY VALVE ,
,
i e INVESTIGATION OF CONFIGURATION MANAGEMENT DEFICIENCIES e SUMMARY l T.F. PLUNKETT l e CLOSING REMARKS ,
. . _ _ . - _ . _ . _ _ _ . _ _ . _ _ _ _ _ . _ _ . _ . _ _ . _ _ _ _ . _ _ . _ _ _ _ _ . _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ . _ _- _ _ _ _ _ . . .
. .. . .-=. . - . - .. . . . . . . . ..
.. ..
-
UNIT 2 CONTROL ELEMENT DRIVE MECHANISM CONTROL SYSTEM ENCLOSURE- .
- .
APPARENT VIOLATION FAILURE TO PERFORM A 50.59 SAFETY EVALUATION FOR CEDMCS ENCLOSURE PRIOR TO OR SUBSEQUENT TO ITS INSTALLATION INVESTIGATION
* FABRICATED PRIOR TO OCTOBER,1982 CEDM PRE-OP TESTING
. * PLANT LICENSE ISSUED APRIL 6,1983
* NON-SAFETY STRUCTURE FOR NON-SAFETY EQUIPMENT
' e EVALUATED BY ARCHITECT / ENGINEER FOR INTERACTIONS
-:
l e ENCLOSURE HAS NOT BEEN MODIFIED SINCE FABRICATION l l
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_
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- . .. . . . . . . . .. . . . . -- .. . . . . .. .- -
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PROGRAM REQUIREMENTS e- CHANGE PREDATES PLANT LICENSE; 50.59 DID NOT APPLY
* 10 CFR 50.71(e) REQUIRES UFSAR UPDATE TO CAPTURE CHANGES
,
~
.* REG. GUIDE 1.70 DEFINES UFSAR FORMAT AND CONTENT .
* DESIGNS MUST COMPLY WITH PLANT DESIGN REQUIREMENTS. ;
(e.g., SEISMIC INTERACTION)
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____________________-_____.____2 ___._____________________.__.______________________________m___ _ _ ___ - __1 _ _ -_m_ __ - _ _ _ __ __._.___._.__________ _ _ ____ _ _____ _ _ _ _ _ . _ _ _ _ _ _ _
. ._ _ . _ ._. . . . _ ._. . - _ . . _ . . . .. . .. . _. _. ._ __.
, ,
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:
REGULATORY GUIDE 1.70 ; STANDARD FORMAT AND CONTENT-OF SAFETY ANALYSIS REPORTS (Emphasis Added) -
9.4.3 Auxiliary and Radwaste Area Ventilation System , ' 9.4.3.1 Design Bases
'
The design bases for the air handling system for the radwaste area and the areas of the auxiliary building containing safety-related ; equipment should be presented. Include requirements for meeting i the single-failure criterion, seismic design criteria, requirements for the manual or automatic actuation of system components or 4 isolation dampers, ambient temperature limits, preferred direction of airflow from areas oflow potential radioactivity to areas of high i potential radioactivity, differential pressures to be maintained and measured, requirements for the monitoring of normal and abnormal radiation levels, and requirements for the treatment of exhaust air. Details of the means for protection of system vents or ' louvers from missiles should be provided.
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i i 5 ,
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,._-___._______.---._-._-._.._-._-_-__----_.___.-.--_-,.-._----.__------_-------__-e. .
--- .
. . - - . . .
_A ROOT CAUSES
. * ENCLOSURE INSTALLED PRE-LICENSE AS A TEMPORARY-STRUCTURE * - ENCLOSURE WAS NEVER MADE INTO A PERMANENT MODIFICATION NOR WERE DRAWINGS UPDATED e PERM ANENT MODIFICATION NOT GIVEN PRIORITY .
CORRECTIVE ACTIONS -
* 50.59 EVALUATION PERFORMED - NO UNREVIEWED SAFETY QUESTION * MINOR MODIFICATIONS MADE e DRAWINGS WILL BE UPDATED .
.
_- -
-- - _ , _ _ _ _ _ , -
_ _ _ _ _ _ - - m - _ _ . _ _ . . _ _ _ _ _ _ _ _ _______.__.__________m.______
. __ __ . _ _ _ . _ _. _. _ _ _ _ . _ .. . _ _ _ _
. .
CONCLUSIONS ,
.
e 50.59 EVALUATION WAS NOT REQUIRED AT TIME OF INSTALLATION e NO OPPORTUNITIES FOR 50.59 EVALUATION POST-CONSTRUCTION SINCE NO MODS DONE e INCLUSION IN UFSAR NOT REQUIRED PER REG. GUIDE 1.70 e CURRENT PROCESSES (e.g., MODIFICATION, TEMPORARY ALTERATION) WOULD REQUIRE 50.59 CONSIDERATION
.
e TEMPORARY ENCLOSURE SHOULD HAVE BEEN MADE PERMANENT
- ~
SAFETY SIGNIFICANCE ; e ENGINEERING EVALUATION FOR PAST OPERABILITY AGREED WITH INITIAL ARCHITECT / ENGINEER EVALUATION - NO IMPACT TO PLANT SAFETY .
.
!
,
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_ _ _ _ _ . _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ - - .. _ _ _ _~ .
. . . . . . . . . . . . . . . . . _. .
" '
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i TEMPORARY FIRE PUMP:. y
.
APPARENT VIOLATION
-
INSTALLATION OF A TEMPORARY FIRE PUMP RESULTED IN A CHANGE TO THE PI ANT AS DESCRIBED IN THE UFSAR WITHOUT A 50.59 INVFSTIGATION e UFSAR DRAWING SHOWS CONNECTION FOR PORTABLE PUMP , : e UFSAR TEXT DESCRIBES TEMPORARY PUMP CONNECTION TO CITY WATER STORAGE TANK DRAIN LINE. -
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8
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- - _ _ - - - _ - _ _ _ _ _ _ _ - _ _ - _ _ - - _ - _ _ _ _ _ _ - _ _ - _ _ _ - - - _ - _ _ - _ _ - _ _ - - _ _ - _ - - _ _ - _ _ - _ - _ _ - - - ,. _
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- - _ _ _ _ _ _ _ - - - - - _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ - _ _
. . . . - - .
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ST. LUCIE UNIT 1 UFSAR
.
APPENDIX 9.5A, FIRE PROTECTION PROGRAM REPORT EXCERPT FROM SECTION 3.1.~1:
' - "A flanged connection is provided from the CWST drain line to allow connection to a portable fire pump to assist the fire protection system if required."
1 i l
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h _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ ._ _____.m _ . _ m __ -m.__.___ _ _ _ _ _ _ m ___. _ __._
- . . . . . .- . . - - . ... - . . . . . . - - .-. - . - .-.
. - .
,
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INVFSTIGATION (cont'd) e TEMPORARY PUMP SUCTION WAS INSTALLED AT LOCATION NOTED IN UFSAR FIGURE
,
~
o FIRE PROTECTION PLAN (AP 1800022) ALLOWS PUMP OUT OF SERVICE UP TO 37 DAYS , e PROCEDURE "LCO" INCORPORATES FORMER TECH SPEC L-CO (TECH SPEC AMENDMENT 115; 6/11/92)
'
e FIRE PUMP WAS OUT OF SERVICE FOR 19 DAYS e NO COMPENSATORY ACTIONS REQUIRED ..
,
e TEMPORARY PUMP NOT FULL CAPACITY
10
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i
*
l
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e w =-
.. . - . . . - .. . . - -. . .. . _-. .
EROGRAM REQUIREMENTS e PLANT QUALITY INSTRUCTIONS REQUIRE PROCEDURES FOR FIRE PROTECTION e TEMPORARY SYSTEM ALTERATION PROCEDURE IS TO BE USED FOR INSTALLATION OF TEMPORARY EQUIPMENT NOT ADDRESSED BY EXISTING PROCEDURES
-
ROOT CAUSES e THE ACTIVITY WAS A LONG STANDING PRACTICE - THE TEMPORARY SYSTEM ALTERATION PROCEDURE WAS NOT USED e INSTALLATION OF TEMPORARY PUMP WAS NOT PROCEDURALIZED
.
_ _ - . _ _ _ _ _ _ . - _ _ - . _ - _ _ . - - _ - - _ _ _ . - - _ _ - _ _ _ . _ - - _ - - _ _ . _ _ _ - - < - - -
. .. . . . .- -- .. .- _. . - .
.
CORRECTIVE ACTIONS
.
e ENGINEERING TO DETERMINE MINIMUM FIRE WATER CAPACITY AND TO PROVIDE EVALUATION FOR USE OF A TEMPORARY PUMP
* FIRE PROTECTION TO REVISE ADMINISTRATIVE PROCEDURE BASED ON ENGINEERING INPUT
.
.
--_-____-___-_-__.----_-_.__--__-.__-_________-___-___---._--__________-.___.____-_n_ _ _ . - - _ _ _ - - - _ . - _ - _ _ _ _ _ - _ . _ _ _ _ _ _
. . - . . . -
CONCLUSIONS
. * USE OF THE TEMPORARY PUMP SHOULD HAVE BEEN IMPLEMENTED VIA' PLANT PROCEDURE OR TEMPORARY SYSTEM ALTERATION; ~
BOTH REQUIRE A 50.59 SCREEN .
* 50.59 SCREEN WOULD HAVE CONCLUDED 50.59 EVALUATION WAS NOT REQUIRED SAFETY SIGNIFICANCE e THE OPERABLE FIRE PUMP WOULD HAVE BEEN CAPABLE OF MITIGATING A FIRE
-
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l._____.___... . . _ _ . _ _ _ _ _ _ _ .______..__._______..._____._____.______._________________._______._.m _
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. _ __ _ . _ . . . . . . . _ . _ ..
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UNIT 1 LOAD CELL SETPOINTS
~
APPARENT VIOLATION FAILURE TO PERFORM A 50.59 SAFETY EVALUATION FOR CHANGE TO SETPOINTS DESCRIBED IN UFSAR ,
.
i INVESTIGATION
. * TWO PROCEDURES REVISED TO UPDATE OVERLOAD & UNDERLOAD '
SETPOINTS FOR REFUELING AND SPENT FUEL HANDLING MACHINES ,
* ENGINEERING PREPARED EVALUATION WHICH PROVIDED NEW SETPOINTS IN SUPPORT OF PROCEDURE CHANGES (NO 50.59)
e UFSAR DESCRIBES INTERLOCKS WITH RESPECT TO LOAD VALUES; EXAMPLE:
" ... interlock limits the maximum uplift load to ten percent above load."
.
*
- , . . - - .
. . . . .. . ._ _ . _ . .- . _ - - -
. .
a.-- ' INVESTIGATION (cont'd) l
-
CHRONOLOGY: ,
*
4/29/96 EVALUATION REV. O ISSUED 5/08/96 EVALUATION REV.1 ISSUED (EDITORIAL CHANGES)- - PROCEDURE CHANGE SCREENED AS NOT REQUIRING 50.59 . PROCEDURES FRG APPROVED WITHOUT 50.59 5/12/96 LETTER OF INSTRUCTION SCREENED AS REQUIRING 50.59; EVALUATION IS REFERENCED ON SCREENING FORM i l FRG REJECTS LOI & EVALUATION BECAUSE 50.59 MISSING 5/12/96 (1400) EVALUATION REV. 2 FRG APPROVED (ADDED 50.59) l 5/12/96 (1700) FUEL MOVEMENT COMMENCED
.
e _ _ . _ _ . _ . . _ _ _ _ . . _ _ _ . _ _ ._____._______.__...____________.______________________._e __ _ _ ~ _ _ _ _ _ _ ____ _ __ _ ...m __.- ____ __ _ _ _ .__m -__.- ,
_. . ... . _ _ . __. . . . _ _ _ . ._ _ _ i
l '
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I L PROGRAM REOUIREMENTS , o ENGINEERING QUALITY INSTRUCTIONS REQUIRE 50.59 FOR A .
" CHANGE TO THE FACILITY..."
'
e 50.59 SCREENING REQUIRES DETERMINATION IF UFSAR IS AFFECTED ' BY THE CHANGE ROOT CAUSES
;
e FUELS ENGINEE'RS DID NOT IMPLEMENT PROCEDURAL REQUIREMENTS e INDIVIDUAL SCREENING PROCEDURE CHANGE FOR 50.59 DID NOT.
IDENTIFY ALL APPLICABLE UFSAR TEXT '
.
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.__.__.su_: -_ - _ _ _ _u.-_-- . _ ___m-____.___ _-...-.-___m. -.--.__. .__..-- __.__. .__-..--___.e_. -
. - _ _ . * -we - u__ _ _____-.__.___ . - - _ _ _A.--_a- _ _ _ _ _ _ -- _ _ . _ -__+_ _ _ _ --
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. -. - .. . . - - . _ . - .
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= ..__ , -.
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CORRECTIVE ACTIONS i
:
e TECHNICAL ALERTISSUED
-
e SUPPLEMENTAL TRAINING FOR' FUELS ENGINEERS e REVIEW OF OTHER FUEL GROUP EVALUATIONS - NO FINDINGS
.
4 6 h CONCIISIONS e 50.59 SHOULD HAVE BEEN PROVIDED WITH PROCEDURE CHANGES ' e 2 BARRIERS FAILED - DESIGN & PROCEDURE 50.59 SCREENING e PROBLEM WAS SELF-IDENTIFIED PRIOR TO FUEL. MOVEMENT
.
- SAFETY SIGNIFICANCE
,
e NO SAFETY SIGNIFICANCE e SETPOINTS WERE TECHNICALLY EVALUATED e NO UNREVIEWED SAFETY QUESTION . e FUEL MOVEMENT DID NOT START UNTIL AFTER 50.59 ISSUED
*
I
,
o . . _ . _ _ _ _ _ _ _ . . . _ _ . _ _ . . _ . . _ _ _ _ . _ _ _ .___.__..--____.________m_ . _ __.__m_._.-._ . . _ _ _ _ _____ __ ______ __- _ _ . .,.,m . .m_,-, __ -. ,- - ,w __.., --.
_ _ .. . . . . -- . . .. __.
. _ UNIT 2 DIESEL GENERATOR FUEL SUPPLY VALVE
,
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: APPARENT VIOLATION ,
REPOSITIONING OF AN EMERGENCY DIESEL GENERATOR FUEL SUPPLY VALVE CONSTITUTED AN UNREVIEWED SAFETY QUESTION INVESTIGATION
:
e UNDERGROUND LEAK BETWEEN THE TRANSFER PUMP ANb . DAY TANKS REQUIRED ACTION e EVALUATION ISSUED (7/6/95) TO ALLOW ISOLATION OF THE * NORMALLY OPEN FUEL LINE TO STOP THE LEAK - , l e EVALUATION REQUIRED COMPENSATORY MEASURES
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_ T
. INVESTIGATION (cont'd)
.
* ADEQUATE TIME TO IMPLEMENT MANUAL ACTION:
* DAY TANK CAPACITY = 126 MIN
*. TRANSFER PUMP STARTS AT 40 MIN
* MANUAL ACTION REQUIRED WITHIN 20 MIN BY PROCEDURE e EVALUATION IDENTIFIED POTENTIAL FAILURE MODES
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t
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- - - - _. .-. . - - . . . . - - -.- . .- . -- _ . .
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_ INVFSTIGATION (cont'd)
* EVALUATION WAS PREPARED CONSISTENT WITH FPL PROCEDURES AND NSAC-125 .
EXCERPT FROM NSAC -125 (Emphasis Added):
,
-
Changes that result in a change from one frequency class to a more frequent class are examples of changes that increase the probability of occurrence.. However, this is not to say that changes within a category may not result in an increase in the probability of occurrence of an accident if there is a clearly discernable increase or trend.
Compensating effects such as changes in administrative controls may be used to offset an increase or trend in the
'
probability of accidents of moderate frequency. Normally, the determination of a probability increase is based
. upon a qualitative assessment using engineering evaluations consistent with the original SAR analysis assumptions. 'Ihis is not to say that if a plant specific probability calculation can be used ta evaluate a change in a quantitative sense, it should not be used. However, it should be emphasized that PRAs arejust one of the tools for evaluating safety and their use is not needed to perform 10CFR50.59 evaluations. Licensees should utilize reasonable engineering practices, engineering judgement, and PRA techniques, as appropriate, in determining whether the probability of occurrence of an event increases as a result of implementing a proposed change.
A large body of knowledge has been developed in the area of event frequency and risk signifk: ant sequences ' through plant specific and generic stud?cs. Licensees should draw on this knowledge where applicable in determining what constitutes an increase in the probability of occurrence of an accident or malfunction of equipment important to safety previously evaluated in the safety analysis report. Where a chanoe in erobability is so small or the uricertainties in determinine whether a chance in orobability has occurred are much that it cannat be reasonably concluded that the mobshility has actually chanced (i.e.. there is no clear trend towards incremaina
-
the probability). the change need not be considered an increase in pobability.
.
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- -e _. -- - - - - - - - - - - - n - -----.. - --- -. -_ - - . - - - . - . n - -- -------- - - - .--... --_ - -.-- _ --__._.-_ --
. . . - - . .-_ -- .-.- .
. .
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'1
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INVFSTIGATION (cont'd) e USE OF MANUAL ACTION WAS CONSISTENT WITH GENERIC LETTER . 91-18 (OPERABILITY) 1 EXCERPT FROM GL 91-18 (Emphasis Added):
!
6.7 Use of Manual Action in Place of Automatic Action !
...the licensee's determination of operability with regard to the use of manual action must focus on ;
the ohvsical differences between automatic and manual action and the ability of the mn~nuni action -! to accomplish the soccified function. The physical differences to be consider'ed include, but are not ' limited to, the ability to recognize input signals for action, ready access to or recognition of setpoints, design nuances that may complicate subsequent manual operation such as auto-reset, repositioning on temperature or pressme, timing required for automatic action, etc., minimum i manning requirements, and emergency operation procedures written for the automatic mode of
operation. The licensee should have writtenprocedures in place and training accomnlinhed on those , ' orocedures before substitution of any manual action for the loss of an automatic action.
. . .
:i
;
The assignment of a dedicated operatar for manual action is not acceptable wi'hout written l i procedures and a full consideration of all pertinent differences. The consideration of manual action in remote areas also must include the ability and timine in netting to the area trainine of nersonnel
~
' to accomplish the task. and occucationai hazards to be incurred such as radiation! temperature. i chemicaLsound. or visibility hazards... Nevertheless, this is expected to be a temporary condition , until the automatic action can be promptly corrected in accordance with 10 CFR Part 50, I
- Appendix B, Criterion XVI, Corrective Action.
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w
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L PROGRAM REQUIREMENTS .
* EVALUATIONS ARE TO BE PREPARED IN ACCORDANCE WITH ENG PROCEDURES AND 50.59 GUIDANCE DOCUMENT.
ROOT CAUSE
.
-
e GUIDANCE DOCUMENT WAS CONSISTENT WITH NSAC-125 INTERPRETATION WHICH DIFFERS FROM THE NRC POSITION ON " INCREASE IN PROBABILITY" I . k
.
i
! l
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_ _ _ _ _ _
.__ . - . . . . . . . -..
_ _
. -CORRECTIVE ACTIONS e REVISED ENGINEERING'S 50.59 GUIDANCE DOCUMENT .
EXCERPT:
.
Note: Any* qualitative or quantified increase in. probability regardless of magnitude must- be considered an increase in probability for the purposes of 10CFR50.59.
However, compensating effects (including compensatory actions) such as changes in administrative controls are acceptable in offsetting uncertainties and increases in the probability of occurrence or consequences of an accident previously evaluated in the
. SAR or reductions in a margin of safety, provided the potential increases or reductions -
in margin are negligible. Additionally, change that would result in a slight increase in-the probability of an initiating event for an accident would not be an increase in probability under 10CFR50.59 provided the probability of occurrence of some other event (s) in the same sequence is concomitantly decreased and there is no adverse effect on other plant-specific accident sequences.
! * This statement is in effect pending final resolution of this issue between the NRC and NEI. Previous guidance in NSAC 125 had stated that small increases in probability that did not demonstrate a trend towards increasing consequences could be considered as not constituting an increase in consequences pursuant to 10CFR50.59. ,
.
n
.- - - . . . _ . - _ _ _ _ _ _ _ _ _ - _ _ . _ _ . _ . - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ - _ _ _ - - - _ . _ _ - _ - - _ - _ _ - - - - - - - - _ _ _ - _ _ _ _ _ . _ _ _ _ - - - - - _ - .
y , = === --
-- -
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.
w CORRECTIVE ACTIONS (cont'd)
* ISSUED TECH ALERT TO ALL ENGINEERS (3/6/96): -
m TECHNICAL ALERT- 50,59 EVALUATIONS a I When performing 10CFR50.59 evaluations, any quantified increase in the proLability of occurence of accidents, clany quantified increase in the - probability of oaurrence of malfunction of equipanent important to safety, must be considered an unreviewed safety question. Additionally, credit for operasor action in place of automatic action, or credit for operator realignment of a system to perform its intended function, when that realignment is not normally required, must receive - -- ; ,e.; review.
BACKGROUND A safety evaluation was issued which calculated a small increase in probability of occurrence of a malfunction of equipment important to safety using
- probabalistic safety assessment techmques. Ctedit for operator action was taken to m.v..A for this increase, although this-_ . " ion did not -
quantitatively climinate the increase in probability. "Ihe evaluation concluded that the evaluated condition was g. ;^~,: by 50.59. The NRC i subsequently questioned this conclusion, and is further reviewing the evaluation.
"Ihe Nuclear Engmeering Department document " Guidance for Performing 10CFR50 59 Safety Evaluations" includes notes on page 15 which discuss
.
smallchanges in the probability of occurrence of accidents. It is not interded that quantified increases in the probability of occurrence of accidents, or occurrence of malfunction of equipment important to safety, be allowed under 50.59. Additionally, taking credit for operator action to compensase for mereases in the probability of occurrence of accidents, or occurrence of malfunction of equipment is a delicate undertaking. For this reason, credit for cperator action in place of automatsc action, or credit for operator realignment of a system to perform its intended function, when that realignment is not normally required, must receive management review.
ACTIONS , I. Engineering personnel involved in the review of plant and pmcedure changes must conssder quantified increases in accident occurrence probability, or equipment important to safety malfunction probabdity, an unreviewed safety question for which prior NRC approval is required. ! 2.
-
.r, Department document " Guidance for Performing 10CF250.59 Safety Evaluations" will be revised in the 2nd quarter . 'of 1996 to fuither aldress the topic of this Technical Alert.:he Nuclear Er.,,..- .
REFERENCE $
" Guidance for Performing 10CFR50.59 Safety Evalust, ions," Rev. O,10/89 j
l ! l ' !. !. ' _ _ . _ ._..m_.___.._.____.,_.__m. _ . _ . _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ - _ ___ - m _-..s _. , _ - ._.,_. , ,. _
:~ ^ ' ^ -
. ~.. . . _ _ CONCLUSIONS e CURRENT NRC INTERPRETATION AND INDUSTRY GUIDANCE DIFFER ON THIS ISSUE SAFETY SIGNIFICANCE e NO SAFETY SIGNIFICANCE e CORE DAMAGE FREQUENCY CHANGE <3% e CONSIDERABLE TIME AVAILABLE FOR OPERATOR ACTION
,
^ ^ ~ '^ ~
. .
__ _
>
l
l SUMMARY
* NO PROGRAMMATIC 50.59 BREA-KDOWN: -
CEDMCS ENCLOSURE - PRIOR TO LICENSE TEMPORARY FIRE PUMP - FAILU'RE TO FOLLOW PROCEDURES WHICH WOULD HAVE REQUIRED 50.59 '
.
SCREENING (WOULD SCREEN OUT)
'
LOAD CELL SETPOINTS - 50.59 SHOULD HAVE BEEN WRITTEN; SELFIDENTIFIED DG FUEL SUPPLY VALVE - EVALUATION DONE IN ACCORDANCE WITH PROCEDURES ANDINDUSTRY GUIDANCE
. '
. _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ - .
_. ._ ._ _ . . . . _ . . . ._ . _ . _ _ _ __ .. . . _ y.- - - _ _,
- - .
_ ,. _ t
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SUMMARY (cont'd).
,
* EMPHASIS HAS BEEN PLACED ON THE IMPORTANCE OF 50.59 AND -
THE UFSAR: .
* 50.59 REVIEWER CERTIFICATION ESTABLISHED
* 50.59 TRAINING OF STAS COMPLETED DURING REQUAL
* FORMALIZING TRAINING MODULE TO QUALIFY 50.59 SCREENERS i
* IMPROVED 50.59 SCREENING REQUIREMENTS FOR PROCEDURES ,
-
QI 5-1, [ PLANT PROCEDURES]
-
AP 0010124, TEMPORARY SYSTEM ALTERATIONS
-
AP 0010148, TEMPORARY CHANGES TO PROCEDURES
- * ALL 50.59 EVALUATIONS MUST BE PREPARED BY ENGINEERING ,
* REVISION TO 50.59 GUIDANCE DOCUMENT
* TRAINING OF FUELS PERSONNEL
'
* TECHNICAL ALERT ISSUED TO FUELS PERSONNEL
* UFSAR REVIEW PROJECT e NO SAFETY SIGNIFICANCE
t _ _ _ _ . . _ _ _ _ _ _ . _ _ . _ _ _ _ . . _ . . _ _ _ _ _ _ . _ _ _ . _ _ _ . _ _ _ . _ _ _ _ _ _ . _ _ . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _
- - . .
_ - __.
- - - CONFIGURATION CONTROL APPARENT VIOLATION FIVE EXAMPLES OF CONFIGURATION CONTROL ISSUES INVOLVE A FAILURE TO UPDATE DRAWINGS AND PROCEDURES INVESTIGATION , e 3 ANNUNCIATOR RESPONSE SUMMARY ERRORS e 1 ERROR - RELOAD MODIFICATION PRE-IMPLEMENTATION REQUIREMENTS e 1 DRAWING UPDATE ERROR
' .
_. . . - - .. .- -. -.- .. . . -- . .. n _. . _ . _ _ _ .
,
INVESTIGATION (cont'd) , THREE ERRORS IN ANNUNCIATOR RESPONSE PROCEDURE (UNIT 2)
-
,
'
1. PROCEDURE NOT REVISED TO REFLECT NEW SETPOINT VALUE
-
HYDRAZINE TANK LOW LEVEL ALARM (CONTAINMENT SPRAY) -
, --
MOD CHANGED SETPOINT FROM 35.5" TO 36.7" TO GAIN MARGIN , TO TECH SPEC LIMIT .
-
PROCEDURE ERROR IS IN CONSERVATIVE DIRECTION 2. PROCEDURE NOT REVISED TO DELETE OPERATOR ACTION
: -
INTAKE COOLING WATER PUMPS' LUBE WATER SYSTEM MODIFICATION '
'
:
-
MOD ELIMINATED NEED FOR CERTAIN OPERATOR ACTIONS
.
. - _ - _ _ _ - - - _ - _ - _ _ _ . _ _ - - _ _ _ - _ _ _ _ _ _ _ - . . . .
, = . . . _ . - .- _
_ . . Y , INVESTIGATION (cont'd)
' 3. . -
PROCEDURE NOT REVISED TO REFLECT ANNUNCIATOR DELETION MOD DELETED ATMOSPHERIC DUMP VALVE " MANUAL"
-
-
INDICATION (INDICATES " MANUAL" CONTROL)
-
RELAY CONTACTS REMOVED BY MOD - ANNUNCIATOR WOULD i NOT ALARM .
.
-
NOT AN OPERATIONAL PROBLEM F
-
!
!
!
;
-
30 1 _ _ _ - - _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ - - _ _ _ - _ _ . _ _ _ _ - _ _ _ _ .- _ . - . _ . _ _ _ - - _ _ _ _ _ - _ _ _ _ _ _ .
.. _ . _. _ __ . . . _ . . _ . . _ . . _ _ . -- _ . _ _ _ . _ . . _ . ..
_ , i '
- -
INVESTIGATION (cont'd)
.,
,
l RELOAD MODIFICATION PRE-IMPLEMENTATION ERROR e MOD FOR FULL CORE OFF-LOAD / FUEL RELOAD ~ e MOD PACKAGE CONTAINED PREREQUISITES TO BE IMPLEMENTED PRIOR TO FULL CORE OFF-LOAD e ' PLANT PROCEDURE WAS NOT REVISED TO INCLUDE PREREQUISIT e OFF-LOAD COMMENCED WITHOUT VERIFYING PREREQUISITES 1 e ' - ERROR SUBSEQUENTLY IDENTIFIED BY' QUALITY ASSURANCE e CORE OFF-LOAD STOPPED UNTIL PROCEDURE CHANGED (7 ASSEMBLIES MOVED)
.
i1
: .
,
_ _ _ - _ - - _ _ _ _ _ _ _ _ - _ _ - - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - _ _ _ - - - - _ _ - _ _ _ - _ - - __-____ _-
. _
__ = . _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ - _
. . . - ..
. .
.
_ _ - -. _
-
- . . . . - . _
! c
'f INVESTIGATION (cont'd)
.
'
DRAWING UPDATE ERROR
* MOD REMOVED LUBE WATER VALVES AND PIPING FOR INTAKE COOLING WATER SYSTEM .
* DRAWING -WAS NOT REVISED TO REFLECT DELETIONS
.
.
32
-- .__ _ ___ .--______ ___-___-_ - - _ - _ - _ _ - - - - _ _ _ _ _ _ _ _ _ _ - _ - _ _ _ _ _ _ - _ _ _ _ - . . _ _ - _ _ _ _ _ _ _ - _ - _ . . .
. . .. .. . _ . _. _. . . . _ _ _ . . . _ . . __ . _ ... . . . . . . _ .. _
- .
INVESTIGATION (cont'd) ' e EXAMPLES SPAN THE TIME PERIOD FROM 1992 - 1996
,
* CONFIG CONTROL PROCESS RELIED ON PERSONNEL-STRENGTHS -
NOT RIGOROUSLY PROCEDURALIZED e THE LARGE NUMBER OF MODIFICATION PACKAGES CHALLENGED . THE PROCESS AND RESULTED IN A LARGE "OPEN ITEMS" LIST e PERIOD OF GREATEST VULNERABILITY BEGAN AUGUST 1995 -
.
PROGRAM REQUIREMENIS ' , , '
* DESIGN CHANGES MUST BE ACCURATELY TRANSLATED INTO PROCEDURES AND DRAWINGS h
33 .
.
,
!
_ _ _ _ _ . _ . _ _ . _ _ _ _ _ . _ _ _ _ _ _ . _ _ . _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ . _ _ . - - _
, - - . ~ s . - , __ _
. . . .. .
_
- . .. .. .- .. .. . .. . . . .
' ROOT CAUSES . t e CONFIG CONTROL PROCESS RELIED TOO HEAVILY ON INDIVIDUALS INSTEAD OF PROCESS '
.
i e CONFIG CONTROL PROCESS OVERWHELMED BY LARGE NUMBER OF MODIFICATION PACKAGES :
;
e SYSTEMS WERE RETURNED TO SERVICE PRIOR TO ALL REQUIRED
- CONFIG MANAGEMENT CHANGES BEING IMPLEMENTED .
,
34 l l -
.
i l !
. . .
-
_ _ CORRECTIVE ACTIONS
* QI 3PR/PSL-1 " DESIGN CONTROL" WAS REVISED TO ENSURE THAT SYSTEMS ARE NOT RETURNED TO SERVICE UNTIL REQUIRED DOCUMENTATION IS UPDATED e THE PROCESS FOR MODIFICATION CLOSE OUT WAS FORMALIZED AND MANAGEMENT EXPECTATIONS EMPHASIZED e THE NUMBER OF MODIFICATIONS PROCESSED IS BEING REDUCED BY IMPLEMENTATION OF TOP 20/30 LIST
* MODIFICATION RELATED OPEN ITEMS AFFECTING PLANT OPERATIONS OF SAFETY SYSTEMS HAVE BEEN CLOSED .
.
.
_ - _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ - - - - _ _ _ _ _ _ . _ - _ _
mamm.
CORRECTIVE ACTIONS (cont'd)
-
* REVIEWS CONDUCTED FOR THE PERIOD OF GREATEST PROCESS VULNERABILITY (AUGUST 1995 TO MAY 1996)
e VERTICAL SLICE OF PSA RISK SIGNIFICANT SYSTEMS (HIGH PRESS. ' INJECTION, EMERGENCY POWER & COMPONENT COOLING WATER) WAS CONDUCTED TO VALIDATE SIGNIFICANT FLOW DIAGRAMS AND PROCEDURE REQUIREMENTS
* ANNONCIATOR SUMMARY UPGRADE e ASSIGNED A DEDICATED SUPERVISOR AND STAFFTO MODIFICATION CLOSEOUT PROCESS e STANDARDIZING UP-FRONT MODIFICATION REVIEW PROCESS TO EXPLICITLY IDENTIFY AFFECTED PROCEDURES .
'
* SYSTEM ENGINEERS WILL HAVE OWNERSHIP OF CONFIGURATION l
'
l
. - _ _ _ _ _ _ - _ _ _ _ _ _ _ - - - _ _ _ _ _ _ - . _ _ _ _ _ _ - - - _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ - _ _ _ _ _ - _ _ . . _ . -_ _ _ - _ _ _ _ . _ _ _ _ _ _ _ _ _ - _ _ _ _ - _ _ _ _ _ . _ _ - _ - _ _ _ _ - _ - _ _ _ _ _ - - _
. , ,
QI SffVPSL-1 Revleian 40 May,1996 DateW FOR INF0f0AAM[f#)' held _-
,
Page 1 of 38
-
mdecmentisnotcourWed Bd*'*'**1 dbdormadonish b teriggiped W FLORIDA POWER & LIGHT COMPANY NUCLEAR ENERGY DEPARTMENT ST. LUCIE PLANT DESIGN CONTROL 1.0 APPROVAL: Reviewed by Plant Nuclear Safety Committee 4 7/25 1924,. Approved by K. N. Hards Plant General Manager 7/31 1974 Revision 40 Renewed by F R G 5/16 19 96 Approved by J. Scarola Plant General Manager S/16 19.99., 2.0 PURPOSE: 2.1 Provide control of plant changes and modificat>ons ensuring plant structures, p, systems and components are installed and maintained in accc,rdar.cs with I appUcable design spec!T.c 600s and documents.
2.2 Encure plant changes and modifications comply with: 1. 10 CFR 50.59 Domeste Licensing of Production and Utilization Facilities - . Changes, Tests and Experiments.
2. SOM 3.0 Design Control
! .
S_ OPS DATE DOCT PROCEDURE DOCN 063-1
. SYS COMP COMPLETFD ,
i! Tru 40
.
. . . _ . _. __ ._ _ _ ._ . . _ . . _ .. __ . _ _ _ __ ..__._ ___._. __._ ___ _ .
l.
l* .
- e .
Qi 3 PR/PSL-1 i Rowlsion 40 '
.
May,1996 -
- . Page 36 of 36 .
ATTACMAWfT 4
- SYSTEM AqCEPTANCEMRMMt SHEET
- (Page 1 of 2) Page 1 er -
. ;
- Pom me. nessenen asypeemem
'
'
unam): O1 'O a O common sATs. O Penw a campses.
' Tue: . - innsnamenaed br.
Diempen - O seencas e unchensons a sac 0 usine.Pmpme O Sys.Pmesman O Oper O und. Des ned Teseng is sogend m unde i O This sATs is a poseen tun ===r. work mmemme menudes em tasoning:
,
FOts 9_--- " s usum:
.
,
As pmoodures for my deparenant whle ase seqded for tumower am conpises anGar pmoodse changes . for my depenement wunh are not regubed for tumour me assed besour.
! YES NfA DATE:
,
O O asawar. / / " , O u enemiser. i i < O O. phe P mes m an: i i
!
.
O O- Heesh Physion: / / [ O e Punt Memeenenos: i i .
!
l O O Emergency Properednese:
'
/ / l i
PROCEDURE NO. DATE REQUUWD CR OR PMAI NO. s
/ /
/ /
/ /
1 1 ' i 1 ' W1.ines =---- -- __. OR ops surrosvr . . K.: YEs wA spenem sunomonal tesens has been ammes oemey completed and as test dooumeras used
. ,
have been trenommed to CM. (N/A N tout hee been modo defened for this SATS). O O f The updened PODe for which the SATS is being issued adequately apport the demon change. O Q As Depenment procedums requwed for tumover are comptoie ansor. ace Department pmoodures not regared for tumower are Essed above.
OO !
'
System Enyneer or 06T: Date: 1 i
/R40
<
,
l
!
,
,- , -- , - - - - , , -,. -- -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ l ,.
.
.
Page 7 of 59 ST. LUC 1E PLANT ADMINISTRATIVE PROCEDURE NO. 0005745, REVISION 13 REQUEST FOR ENGINEERING ASSISTANCE (REA) 3.0 SCOPE: (continued) 3.4 (continued) 25.
Sponsoring Dep2tment Head - the sponsoring department head is the manager or supervisor of the department in which the sponsor works.
26.
Top 20 Priorftized Plant f 4CDs Cat - list of mediT.c.ations approved by the MRB for work during upcoming refueling outages. Thors will be a Top 20 List for each unit. Any Top 20 rnodrfication which is not implemented within one refueling cycle will be canceled and deleted from the list unless <
'
determined otherwise by MRB.
27.
Top 30 Priontized Plant MODS List - rest of modsfications approved by the MRB for work during non-outage or Short Notice Outage (SNO). Any Top 30 modification which is not implemented within 52 weeks will be cancekd ; and deleted from the list unless determined otherwise by MRB. !
4.0 PRECAUTIONS & LIMITS: 4.1 All appreable sections and portions of the REA form should be filled out as per this procedure in order to insure proper evaluation and subsequent action.
5.0 RESPONSIBILITIES: 5.1 Sennees Manager 1. Responsible for REA program.
2.
If REA is considered a Minor Modification, authorizes the following types of REAs for implementation, without obtaining MRB review and approval: A. RTS REAs for Minor Mod;feations B. Fast Track REAs C.
Document changes and other issues not dispositioned as major or outage modifications.
,. . _ . . . . . . . _.. . . . ._-_ . _ . ~~ . _ _ _ . . _ _ _ F
' <
PCM OPENITEM LOOK BACK .
*
Idendfied Reviewed And PCM Shows Processed PCMs Which
*
n'h**gg - m _ _ Ub
-
- -
'
" r- -
--
PCM Data Base -- , W K)pesleeses Since August 95
,
, i I pmwHad Initiated Open Itern %w % y Review /Cosecut E DMS Whh - c ggyf%g h Mm
- - -
__ DB M
-
~ * 7 7 7 For PCMs g Revised Dets Base
- -
!
Submitted Cosed Updated Begin
= PCMs To
'
-
PCM Open
-
_
'
h Yam,t heseIWes OfARPt N -
40
* - - _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ .. .. .
. ;;;. _ ,_ _ _ _;_ ; _ _ _
--
_ _
.__ .
VERTICAL SLICE REVIEW - FINDINGS
.
CHANGE PROCESS e SOME SETPOINTS WERE FOUND TO BE INCONSISTENT BETWEEN TEDB -AND THE ANNUNCIATOR SUMMARY
,
e SEVERAL SETPOINT VALUES AND INSTRUMENT RANGES LISTED IN THE FSAR APPEAR TO BE INCONSISTENT WITH OTHER PLANT DRAWINGS'
. * IN A FEW EXAMPLES, THE TOTAL EQUIPMENT DATA BASE (TEDB)
. WAS NOT UPDATED OR EQUIPMENT REMOVED AS NOTED ., BY THE CHANGE PACKAGE J
. . _ . .
. . _. . . . - _ .. . _. .. _ _ _ . . .
. .
-- _- _
_
.
VERTICAL SLICE REVIEW - FINDINGS (cont'd) . OTHER OBSERVATIONS e FLOW DIAGRAMS DO NOT REFLECT CURRENT VALVE LOCKING PRACTICES DEPICTED IN OPERATING PROCEDURES. VALVE LOCKING AND EQUIPMENT TAGGING OF INSTRUMENT ISOLATION VALVES IS NOT CONSISTENT WITH THE FLOW DIAGRAMS
' * LINE AND VALVE ORDERTI'AKEOFF POINTS ON THE FLOW DIAGRAMS ARE SOMETIMES INCONSISTENT WITH THE FIELD * NO ITEMS OF SAFETY SIGNIFICANCE WERE NOTED AND CONDITION REPORTS WERE GENERATED FOR CORRECTIVE ACTION AND FURTHER l REVIEW i
e
l 1 .
. . _ _ . . . . - . . . . ..
_ _ __
<
ANNUNCIATOR RESPONSE SUMMARY UPGRADE PROJECT
.
PROJECT SCOPE ,
* = 1000 CONTROL ROOM ANNUNCIATORS PER UNIT
;
.
e NEW FORMAT e SETPOINT VERIFICATION
* -REVIEW OF OPERATOR ACTIONS FOR CONSISTENCY
'
* UPGRADED REFERENCES STATUS
:
* COMPLETED = 10% OF CONTROL ROOM ANNUNCIATORS (PENDING FINAL REVIEW)
e UPDATE ANNUNCIATOR RESPONSE SUMMARY AS REQUIRED; NOT , QUARTERLY
.
.
-
}
l ,
- _ _ - - - _ - _ _ _-- - _ - _ _ - _ ---
.
- - _-_-- _ _ _ - _ . _.
.
. .
St. Lucie Nuclear Plant Information Services Departmer.t Loca 9109 , R@0RMATION SERVICES SECTION SUPERVISOR 3. Hot.T . I I I l CONFIGURATION AUDIONNUA12 FROCEDURES SUPERvtsoR Mllli.AR RFU*tIV MGMT SUPERV190E fxitasNTR M, K1STOCISR 3. AVALDES Stn Rvtmm D.A M
, T.V 4tSWAl.D SITE ORArtIICS NtEL15.AR pl(1INtW L K DONDINA Tit 1tNK1ANS P. A. BA!!!.E J. A CIMINO f_P.VANRERSCHitT ,, , g.
y, g
-
)ElMANN K D.WI!11 FORD PROCEDURES I WORDPROCFJSfMGTRO I I TECHNICIANS IW K144l N 8 (*INI ptII.
I 11UINMlAN% M P.DOMARCO _ B. S. MMR ,,, 3,g, , g VACMT ,,,,,,,g3,,, t' $8 tittivW PROLT.IM'It93 FRtWN T1tfIN IIIIAM k 1. HAl tI puW TECftNICIAN4 P (6 ff A% fit itW L R. DAVIS YIIkUA\"I K A mzW) I I I AII'*
\At'ANl 7e e
44 ,
.
_ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ - _ _ - - _ _ _ _ _ - - - _ _ _ _ _ - - - - - - =- --
. _ -. . ._. ._ _
,
" '
,.
+
i l SYSTEM ENGINEER ACCOUNTABILITIFS ;
'
.
:
THE SYSTEM ENGINEER WILL: e - HAVE OWNERSHIP OF THE SYSTEM < e. UNDERSTAND SYSTEM OPERATION e CONDUCT INITIAL AND SUBSEQUENT SYSTEM WALKDOWNS e ENSURE AGREEMENT WITH PLANT DRAWINGS .
!
e ENSURE AGREEMENT WITH PLANT PROCEDURES . e ENSURE AGREEMENT WITH THE UFSAR l e BE COGNIZANT OF ALL MODIFICATIONS ;
!
45 :
.
b
l _ _ _ _ _ _ _ . . _ . . . _ _ . _ _ _ _ _..____________.__..._..__._..m_.___ _._________._________m __ _ _ _ ._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______.-..--________-_m - __ .m m. ____ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __ __ ____ _ _ _ _ _________.______m_
. .. ..... = -_ . .- .- - . . . - . . . . _ _ _ _ -
- . . . --
- _
,
'
.
l CONCLUSIONS
. .
e CONFIGURATION CONTROL PROCESS REQUIRED ENHANCEMENTS IN ORDER TO MEET MANAGEMENT. EXPECTATIONS SAFETY SIGNIFICANCE .
'
e NO SAFETY SIGNIFICANT ITEMS HAVE BEEN IDENTIFIED IN THE REVIEWS CONDUCTED TO DATE i
'
,
)
,
'
___.
.- - .
. . -
--=- - . - . . . -- _ :.. _ _ _ _
-
SUMMARY
.
* PROCESS HAS BEEN STRENGTHENED AND MORE FORMALIZED e BASED UPON LOOK BACK REVIEWS, NO SAFETY SIGNIFICANT ITEMS HAVE BEEN IDENTIFIED
.
. - . - . - . . - . . . - - . - . - . . _ . - . . _ . - . - . . - - . _ . _ _ - _ _ . . _ , . _ _ . _ _ . . - . . _ _ . _ - _ - - _ _ _ . _ _ _ _ _ _ _ - - _ - _ _ - - - - - - r . . -- .
.. . . _ _ . _ . . ._. . - _ . , _ .
,
.
.
CORRECTIVE ACTIONS (cont.)
- FOR TEMPORARY FPL EMPLOYEES AND CONTRACTORS, A DATE WHEN SITE ACCESS WILL BE TERMINATED IS NOW' REQUIRED .
-
A PROCESSING CHECKLIST SPECIFYING ACTIONS WHICH MUST BE COMPLETED UPON TERMINATION OF EMPLOYMENT WAS DEVELOPED
-
SECURITY PERSONNEL WERE RE-INSTRUCTED ON SECURITY REPORTABILITY REQUIREMENTS
-
THE EVENT WAS REPORTED IN LER 96-S02'
-
SITE ACCESS TERMINATION WAS ADDRESSED IN A TRAINING BULLETIN AND HAS BEEN INCLUDED IN THE " BASICS OF SUPERVISION" COURSE TO REINFORCE l MANAGEMENT EXPECTATIONS .
~
l
-
FPL NUCLEAR DIVISION GUIDANCE WILL BE DEVELOPED BY DECEMBER 31,1996, TO OUTLINE INTERFACE BETWEEN HUMAN RESOURCES, SECURITY, AND SITE DEPARTMENTS WHEN TERMINATING AN INDIVIDUAL'S EMPLOYMENT WITH FPL FOR ANY REASON O o i +
- . _ . . _ _ _ - _ _ - _ _ _ _- _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - _ - _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ - - - _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ - _ - _ - _ __ . _- _ _ -
. - . . . . . . . - . _ - - - - -
. .
i
!
_ PROGRAMMATIC ISSUES _ ROOT CAUSES t i
-
PROGRAMMATIC WEAKNESSES IDENTIFIED IN THAT SUPERVISORS DID NO
.
ALWAYS NOTIFY SECURITY UPON TERMINATION OF AN INDIVIDUAL .- - THE FAILURE TO NOTIFY SECURITY UPON TERMINATION RESULTED IN INDIVIDUALS NOT HAVING SITE ACCESS REMOVED CORRECTIVE' ACTIONS
-
i THE REQUIREMENT FOR SUPERVISORS TO NOTIFY SECURITY OF EMPLOYEE
'
, TERMINATION HAS BEEN REINFORCED THROUGH TRAINING -
-
SUPERVISORS RESPOND TO SECURITY EVERY 31 DAYS, UNDER THEIR I . SI'GNATURE, OF THE CONTINUING NEED FOR SITE ACCESS BY EMPLOYEES UNDER THEIR COGNIZANCE
-
FAILURE TO PROVIDE THE 31 DAY VALIDATION OF ACCESS NEED WILL IN TERMINATION OF THE SUPERVISOR'S ACCESS
-
QA WILL AUDIT COMPLIANCE WITH PROGRAMMATIC REQUIREMENTS
- -
. - . _ - .. . . --
_ _ _ __ _ _ . __ . . ._ _. .~ ~ . . . . _ . . . _ . _ _ . . . . .
!
-
.
.l<
- CONCLUSION (
-
RESPONSIBLE PERSONNEL FAILED TO FOLLOW ESTABLISHED PROCEDURES
-
THE INDIVIDUAL GAINED ACCESS VIA AN ADMINISTRATIVE ERROR BUT WAS ON-SITE FOR AN AUTHORIZED REASON (JOB INTERVIEW) . i SAFETY SIGNIFICANCE
. -
SAFETY SYSTEMS WERE NOT AFFECTED NOR THREATENED BY THIS EVENT NOR WAS THERE A THREAT TO THE PUBLIC HEALTH AND SAFETY
, -
THERE WAS NO MALEVOLENT INTENT BY THE INDIVIDUAL WHO HAD GAINED SITE ACCESS j ,
-
THE INDIVIDUAL HAD PROPERLY COMPLETED ALL NECESSARY SCREENING TO ALLOW ACCESS PREVIOUSLY AND HAD BEEN AUTHORIZED SITE ACCESS j
-
INTERVIEWS WITH HIS SUPERVISORS DETERMINED EMPLOYEE TRUSTWORTHY AND RELIABLE AND THAT HIS EMPLOYMENT HAD BEEN TERMINATED UNDER
. FAVORABLE CONDITIONS -
THE INDIVIDUAL HAD WORKED AT ST. LUCIE SINCE 1981
-
_.__..__m_ - m _____._m ___.__mm. ___m.___ ______--s____ _ . _ - _ .__ _ _ _ _ _ _ . _ _ _ . __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ . _ _ . _ _
-
- ._- . _ . _ _ . _ _
-
_ . _ _ _ - - - -_ _ _ . _ _ , _ _ - - -
~ . _ _. .. ._ _ . _ __ -
-
. ..
.
EMERGENCY PREPAREDNESS -
- ~
NRC INSPECTION REPORT NOS. 50-335/96-18 AND 50-389/96-18 PRE-DECISIONAL ENFORCEMENT CONFERENCE e
.
DECEMBER 10,1996 . ATLANTA,GA
- .
FLORIDA POWER & LIGHT COMPANY ' ST. LUCIE PLANT l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ .
. ._. _. . ___. _ __. . __ _ _ .. _
, ,
.
EMERGENCY PLANNING OVERVIEW STATEMENT OF APPARENT VIOLATIONS VI. FAILURE TO ADEQUATELY MAINTAIN THE CAPABILITY FOR TIMELY AUGMENTATION OF EMERGENCY REEPONSE ORGANIZATION DURING OFF-HOURS
~
V2. FAILURE TO ESTABLISH AND MAINTAIN ADEQUATE PROCEDURES FOR THE IMPLEMENTATIO>N OF CERTAIN REQUIREMENTS CONTAINED IN THE RADIOLOGICAL EMERGENCY PLAN V3. FAILURE TO IMPLEMENT MULTIPLE ASPECTS OF THE TRAINING PROGRAM FOR EMERGENCY RESPONSE ORGANIZATION PERSONNEL STATEMENT OF APPARENT DEVIATION DI. FAILURE TO REL'OCATE THE REQUIREMENTS FORMERLY FOUND IN TECHNICAL-SPECIFICATIONS.TO THE SECURITY PLAN AND EMERGENCY PLAN j
. . .
. .. . _ _ _ . . . . . . . . . -. ._. - ^ ,
AUGMENTATION APPARENT VIOLATION VI - FAILURE TO ADEQUATELY MAINTAIN THE CAPABILI'l _ FOR TIMELY AUGMENTATION OF EMERGENCY RESPONSE ORGANIZATION DURING OFF-HOURS . INVESTIGATION -
-
AUTODIALER
-
AUTODIALER SOFTWARE WAS NOT FUNCTIONING DUE TO IMPROPER
.
UPDATE METHODS
-
TEST FREQUENCIES NOT SUFFICIENT TO IDENTIFY AUTODIALER PROBLEMS
-
MANUAL CALL TREE
-
SOME EMERGENCY RESPONSE ORGANIZATION MEMBERS DID NOT HAVE CONTROLLED EMERGENCY PLAN CALL OUT DIRECTORY
-
INDIVIDUALS WITHOUT THE CONTROLLED DOCUMENT WOULD USE CALL OUT ROSTERS OR CONTROL ROOM OPERATOR WOULD HAVE SUPPLIED INFORMATION, RESULTING IN ABOUT A 15 MINUTE RESPONSE DELAY
.
. .- _
, ,
ROOT CAUSES
-
INADEQUATE MANAGEMENT PRIORITY GIVEN TO EMERGENCY PREPAREDNESS'
(EP) ISSUES EP SUPERVISOR FREQUENTLY ASSIGNED TO NON-EP SPECIAL PROJECTS - -
EP PERSONNEL NOT HELD ACCOUNTABLE FOR PROGRAM IMPLEMENTATION AND 7EVIEW -
-
INADEQUATE SELF-ASSESSMENT OF THE EP PROGRAM AT ST. LUCIE PLANT
.
FREQUENCY OF TESTING NOT ADEQUATE TO CONFIRM RELIABILITY OF THE
-
-
' AUTODIALER l l l _ - -- -- - - - - - - _ . - -_---- _ - _ _-
. - . .. _ ..
_- . .._ __ - ... .- -
.,
CORRECTIVE ACTIONS - ,
- -
AUTODIALER
. -
CORRECTED AND TESTED AUTODIALER
, -
POST-UPDATE FUNCTIONAL TEST NOW PERFORMED
-
t ROUTINE WEEKLY TESTING OF FUNCTIONALITY I
-
DEVELOPED ADMINISTRATIVE GUIDELINE FOR CONTROLS
-
CONDUCTED SEVEN SUCCESSFUL ADMINISTRATIVE TESTS OF AUTODIALER FUNCTIONALITY
.
\
-
MANUAL CALL TREE ;
-
ENSURED PERSONNEL RESPONSIBLE FOR EMERGENCY RESPONSE : i ORGANIZATION CALL OUT RECEIVE CONTROLLED CALL OUT DIRECTORY
-
i CONDUCTED TRAINING CLASSES FOR CALL OUT-RESPONSIBLE PERSONNEL t
,
, ..____m_. . _ _ _ . _ _ _ . _ _ _ _ - _ _ _ _ _m.- ._____ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ - _ . - _ -a a e- m ' w +4_-- = - w-
- - . .. . . . . . . . -. .. . - . .
CORRECTIVE ACTIONS (cont.)
- GENERIC AUGMENTATION
.
INSTITUTED WEEKLY AUTODIALER TESTING
-
.
--
DEVELOPED AN EMERGENCY RESPONSE ORGANIZATION (ERO) INITIAL RESPONDER WEEKLY DUTY ROSTER
. -
APPLIED ADDITIONAL EMPHASIS ON THE QUARTERLY UPDATE OF THE EMERGENCY RESPONSE DIRECTORY
. -
CONDUCTED A TOTAL OF FOUR AUGMENTATION DRILLS USING THE AUTODIALER (THREE DRII.I.S) AND THE MANUAL CALL TREE (ONE DRILL)
'
l i - __ - - _ _ _ _
-. .. . - _ _ - .. - - . .-
.
r PROCEDURALIZE INSTRUCTIONS APPARENT VIOLATION V2 - FAILURE TO ESTABLISH AND MAINTAIN ADEQUATE PROCEDURES FOR THE IMPLEMENTATION OF CERTAIN REQUIREMENTS CONTAINED IN THE RADIOLOGICAL EMERGENCY PLAN . INVESTIGATION
-
OPERATIONS SUPPORT CENTER RELOCATION CRITERIA, EMERGENCY RESPONSE ORGANIZATION DESCRIPTION, AND RECOVERY PLAN ARE NOT DESIGNATED AS EMERGENCY PLAN IMPLEMENTATION PROCEDURES ROOT CAUSES. !
-
INSTRUCTIONS FOR RELOCATING THE OPERATIONS SUPPORT CENTER WERE NOT CONSIDERED NECESSARY BECAUSE THE SUPERVISOR IN-CHARGE WOULD RELOCATE AS RADIOLOGICAL CONDITIONS DICTATED '
-
INFORMATION GENERALLY PROVIDED OUTSIDE THE EMERGENCY PLAN IMPLEMENTING PROCEDURES WAS CONSIDERED ADEQUATE BY FPL (I.E., RECOVERY PLAN AND EMERGENCY RESPONSE ORGANIZATION DESCRIPTION) .!
_ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ . . _ _ . . _ - -. . . - - - ' - - - - = - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ' - ~ - ~ ' ' ' ~ ~ ~ ~ ~
4 a :4 4 4 4 +AE+ 4.A m 6 e '- ' --- 9.- 4 m E a. 4 --% sk & 4. a. $ 4g4a_
."
CORRECTIVE ACTIONS
' -
OPERATIONS SUPPORT CENTER RELOCATION INSTRUCTIONS WERE PLACED IN AN EMERGENCY PLAN IMPLEMENTATION PROCEDURE
; -
EMERGENCY RESPONSE ORGANIZATION DESCRIPTION WAS INCLUDED IN AN -
' EMERGENCY PLAN IMPLEMENTING PROCEDURE ,
' i i
-
REQUIRED ELEMENTS TO IMPLEMENT THE RECOVERY PLAN WILL BE INCLUDED.
IN AN EMERGENCY PLAN IMPLEMENTATION PROCEDURE BY JANUARY 31,1997
- INPO ASSISTANCE VISIT CONDUCTED THE WEEK OF DECEMBER 2,1996, AND A '
SECOND ASSISTANCE VISIT SCHEDULED FOR JANUARY 1997 - - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ - . _ _ - _ _ _ _ _ _ - - _ - _ _ - - - _ _ . _ _ - _ _ . - . . ___ _ _ _ _ __-- __ _- ___-_ - _ _ - ___ _ _ _ _ \
. .. . . - . - . .. ._
.
,
.
TRAINING APPARENT VIOLATIDN V3 - FAILURE TO IMPLEMENT MULTIPLE ASPECTS OF THE TRAINING PROGRAM FOR EMERGENCY RESPONSE ORGANIZATION PERSONNEL , INVESTIGATION
-
ANNUAL RETRAINING HAD BEEN CONDUCTED IN 1994 AND 1995
-
ST. LUCIE PLANT HAD CONCLUDED THAT NOT ALL POSITIONS IN ITS EMERGENCY RESPONSE ORGANIZATION REQUIRED TRAINING BY EMERGENCY PLAN OR ITS IMPLEMENTING PROCEDURES
-
MECHANICAL MAINTENANCE WORKER
,
ELECTRICAL MAINTENANCE WORKER SIX INDIVIDUALS IN POSITIONS NEEDING RESPIRATOR QUALIFICATION HAD
-
PERMITTED THAT TRAINING TO LAPSE
-
TRAINING WAS BY " READ AND SIGN" FOR MANY EMERGENCY RESPONSE ORGANIZATION POSITIONS
- - _ . _ _ _ _ _ _ _ _ - _ _ - _ _ - - _ _ - _ - - _ - _ - _ _ _ _ _ - _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ -.
-- .. -- .- - . . - . . . . - . . - .- .
.
ROOT CAUSES
'
y
--
INADEQUATE SITE MANAGEMENT SUPPORT GIVEN TO EMERGENCY
~ PREPAREDNESS TRAINING
,
-
ANNUAL DRILL WAS CONSIDERED SUFFICIENT
-
THE SAME DRILL PLAYERS WERE USED DURING EACH ANNUAL DRILL
-
LACK OF STRONG EMERGENCY PREPAREDNESS SUPERVISOR SUPPORT FOR ' EMERGENCY PREPAREDNESS TRAINING
!
-
" READ AND SIGN" TRAINING WAS INEFFECTIVE WITHOUT EMERGENCY DRILL :
:
REINFORCEMENT
;
!
*
.
- _ , . - - _ . - - - . - _ - _ . . _ _ _ _ - _ _ _ _ . _ _ _ _ _ - _ - . - - - _ _ _ _ . _ _ . _ _ _ _ _ - . ~ - . _ _ _ . - - . _ _ - _ . _ _ _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - , _ - e. - - e _ - _ _ - _ _ - _ _ _ - _ -_ _ _ - - - - - _ _ _ _ _ - _ _ - _ -. _
.- . . .- - .
CORRECTIVE ACTIONS
-
REMOVED UNQUALIFIED WORKERS FROM EMERGENCY ROSTER
-
COMPLETED 1996 REQUALIFICATION TRAINING
-
BETTER DEFINED THE REQUIRED EMERGENCY PREPAREDNESS TRAINING FO EACH ERO POSITION
-
DEVELOPED A TRAINING / QUALIFICATION MATRIX FOR EMERGENCY RESPON ORGANIZATION MEMBERS - INSTITUTED QUARTERLY EMERGENCY PREPAREDNESS RESPONSE DRILLS - CONDUCTED SEVEN FACILITY DRILLS INCLUDING TWO INTEGRATED FACILI DRILLS ON DECEMBER 5,1996
,
.
. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - _ - _ - - - . .. . __ _ _ _ -
. __ _ .__ _ . ~
CORRECTIVE ACTIONS (cont.)
,
-
WILL COMPLETE AN UPGRADE OF INITIAL TRAINING 1AODULES BY JANUARY 1997 . ,
-
WILL COMPLETE NEW INITIAL EMERGENCY PREPAREDNESS TRAINING BY APRIL 1997
- -WILL ENSURE THAT ERO INITIAL RESPONDERS PARTICIPATE IN DRILLS OR '
EXERCISES IN 1997
-
REPLACED PROTECTION SERVICES (EP) SUPERVISOR AND TRAINING ~ MANAGER WITH PERSONNEL WITH STRONG COMMITMENTS TO TRAINING
-
CURRENT SITE MANAGEMENT TEAM STRONGLY SUPPORTS PROVIDING REQUIRED EMERGENCY PREPAREDNESS TRAINING
..- .. .. .. . .- . -.. -. . . - . - - . . _ .. . - - ~ . . . - - . . - . .
.
.
TECHNICAL SPECIFICATION REOUIREMENTS APPARENT DEVIATION D1 - FAILURE TO RELOCATE THE REQUIREMENTS FORMERLY FOUND IN TECHNICAL SPECIFICATIONS TO THE SECURITY PLAN AND EMERGENCY PLAN INVESTIGATION
-
GENERIC LETTER 93-07, " MODIFICATION OF THE TECHNICAL SPECIFICATION ADMINISTRATIVE CONTROL REQUIREMENTS FOR EMERGENCY AND SECURITY ; PLANS," PROVIDED GUIDANCE FOR THE REMOVAL OF CERTAIN EMERGENCY PREPAREDNESS PROCEDURAL REQUIREMENTS FROM THE TECHNICAL SPECIFICATIONS
-
FPL APPLIED FOR AMENDMENTS TO THE ST. LUCIE UNITS 1 AND 2 OPERATING-LICENSES, IN ACCORDANCE WITH THE GUIDANCE OF GENERIC LETTER 93-07, BV APPLICATIONS DATED AUGUST 16,1995
-
THE NRC ISSUED THE REQUESTED AMENDMENTS TO THE ST. LUCIE UNITS 1 - AND 2 OPERATING LICENSES (AMENDMEN1 NOS.147 AND 86, RESPECTIVELY) ON AUGUST 20,1996
-a _ _ . _ _ a ._.. - _ _ . . ._ . _._ - _--_-._ _ _ - , --~e
. _ . . . .._ _ _ - . _ . ... . .. . _ _ _ . .. _ - - _ _ - - _ .. .
INVESTIGATION (cont.)
- THE REQUIREMENT TO ESTABLISH, IMPLEMENT, AND MAINTAIN THE EMERGENCY AND SECURITY PLANS AND THEIR IMPLEMENTING PROCEDURES ARE ADDRESSED IN EMERGENCY PLAN SECTIONS 1.3 AND 1.4 AND PHYSICAL SECURITY PLAN SECTION 14.4
-;
i
-
THE FACILITY REVIEW GROUP RESPONSIBILITY TO REVIEW THE EMERGENCY
~
.AND SECURITY PLANS AND THEIR IMPLEMENTING PROCEDURES, AND SUBMIT RECOMMENDED CHANGES TO THE COMPANY NUCLEAR REVIEW BOARD, ARE
.t ADDRESSED IN EMERGENCY PLAN SECTION 7.3 AND PHYSICAL SECURITY PLAN SECTION 14.4
-
THE REQUIREMENTS FROM TECHNICAL SPECIFICATIONS 6.5.1.6 AND 6.8.1 WERE i EITHER RELOCATED OR ALREADY RESIDENT IN THE EMERGENCY AND PHYSICAL SECURITY PLANS
. -
THE REQUIREMENTS ARE NOT IN THE EMERGENCY PLAN VERBATIM FROM THE TECHNICAL SPECIFICATIONS; HOWEVER, THE REQUIREMENTS ARE PRESENT ! -
,
b
.
13 i
--__ _---_-_ ---- --__- _ __-- -
-
-__________ ___--______ - ___ _ ._-_-- _ - _ _______ _
-_ j
. _ _ _ _ . _ _ _ - - . - - -. . . - - - . . . - . - _---... . _ . . *
Apt!N!3TRATI'.*! CGui t !
.
.-
g.g inviTAaLE EVENTS ACTION - _ .
'
_
.
4.s.1 The following actions shall be taken for AEPORTABLE EVENTS: a.
- The iemmission the /eguirenants shall50.be nettffed,3 to 10 CFR Pand of Section I art 50. and
- h.
j - of this review shall be submitted to the QRS Meclear Ofvision.
i
.
8.7 SAFITV LIMIT VIOL &HE
,
4.7.1 j violated: The fellowfag actions shall be takes - is the event a Safety Lief t is
i 4.
The NAC Operettens Center shall be antified by telephone as so sessible and in all cases within 1 bour.
Ofvision and the ORS shall be nettffed withia 24 . ! b. ' A safety Lfstt Violaties Report shall be prepared. .
.
he reviamed by the FRE. .The report shall ' This report shall describe (1) applicable circumstances precedfag the violaties. (2) effen.ts of the vietetten ! .
- actfee taken to prevent recurrence.seen factitty compece
. c.
! I The Safety Limit Violation Report shall be submitted to the Con thethe of QMS..and vfelattee.the president - Nuclear Divistem within 14 days ' d.
Critical by operettee of the unit shall not be ressed until authorized the Ceanissfee.
- 8.8 PROCEDURES AND PROGRAMS 4.8.1 Written precedures shall in established. implemented and unintained covering the activities referenced below: a. . The appitcable precedures recommended la Appendia "A* ef Re eside 1.33. Revision 2. February 1978, and these required for teplementing the requir ments of IRRES 8737.
'b. Refueltog operations.
c.
Surveillance and test activities of safety-related equipment.
d. j s at;j its ig?r:c.;;;fs. def 4l680 e#- e. "m;;g ?!s ic ::n..; ;:a. Hof ilWD ,
- - .. .-,,
- ,,. u. ,,. .,.
. . -
._ _ ._ _ _ _ _ _ _ . _ _ . _ . . _ _ _ _ _ _ _ _ . _ _ _ _ _ . . _ _ _ . _ . _ _ _ . . _ _ [' 1.
GENERAL M. MATION (continued)
.
1.2 DeAntions (condnued) i .
System Operations Power Coordnetor - An FPL System Operations
!
positen which is stsNed 24 houra/ day for uninterrupted coonsnedon of
electical poeer diewitwoon. Communicanon is maintained wah as FPL piants, savice centers, and em General once.
}
Technloal Suppost Center (TSC)- A designated on ehe incaty tot serves as a work area for use by technical and management personnel The TSC i pawides technical support to conow noom personnel in om event of arr j emergency.
i Technical Support Center Supervisor - The pason assiped to supervios ! me personnel and erect the todmical support actMuss h to TSC.
J,
Thyroid Does (CDE) - Tim thyroid exposue from inhaisd r% - l Commated Does Equivalent. Thyroid Does (CDE) is used h Protecthe i ' Acdon determinellon.
i ! Total Does (TEDE) - The total esposure imm both extemal and intemel (seighted) sources - Total E5ecthe Does m=i t M.
1.3 ,
.
and W i The Emergency Plan descrbes Florida Power & Ught Comperr(s plans for [ respondho to .#w-:':: that may develop at em st. Lucie Plant. The plan
has been prepared to meet the requirements of 10 CFR 50.47,10 CFR i 50.72, and 10 CFR 50 Appendix E. The purpose of this pian is to deAne and
.
i ! assign authorty and responshiBty h order to protect he health and selety of the public and plant pwoonami. This plan applies to as plant anergencies which have reeuted in, or whkh increase the risk of em accidental release of j radioecove motorials to the environmort.
! Plans have been developed based upon knowledge of the potential j
consequences, timing, and rolesse characteristics of a spectrum cf events.
Emergency Planning Zones have been defined. Figure 1-1 Bustrates the l Plume Exposure Pathway Emergency Planning Zone for the St. Lucie Plant.
j The nep (Figure 1-1) does not specificaly include the area of ocean east of the plant. Shce there are no islands in that dreceon, any evnenatirwi of
boathg traffic would be addressed on a best eSort basis. A key component , of this pian is coordination with federal, state, and county authodties who i corerttume to em ovmas response enort. This plan audines company
- reapp wthin the framework of the owwaI emagency response organtration, and provides a conceptual basis for the development of the
- detailed procedures necessary to impleman the pien.
i
{' M4 - 1*e
- R. LJagia, Rev. 31
'
-, ,. -
- - - - . . - - - _ - .- - - - - - - . _ _ _ _ _ _ _ - _ . - - ,. ;
1.
- ,, GENERALIfrORMATION (conhusd)
- , 1.4 Concept of opmenone i
'
The Emergency Plan'deAnse emergency condWone and doEneste I responsammes and dunes or sw PPL Emugency Response Orgentze (see pigure a-1). The Emagency Plan le conowned we tw fotow
!
andvWee, whkh me discussed h tw Plan in deteE:
- 1.
Osgenisation and moources adequate to detect the presence ci an
'
emagency conelon, acesse tw conelon, and respond in an i . appspriah snanner(Chapter 2), i 2.
} Assipiment (Chapter 3). of sn osannet event e as proper anergency % ' ne 3.
NoeReedon of e5ete ashorWee, as required, and condnuing F communicadone (Chapte 4).
j t
:
Galhedng and hierprehg data to determine appropriate acdone (Chapter.s).
] ' 5.
Assiedng govemmental agencies in the development of Wormado , the put$c both in terme of preparatory educadon and emergen response informanon (Chapter 6).
i 6.
l Maintaining the FPL Emergency Preparednese Program in a state readness (Chapter 7).
' L ntsi
< . Ase.oined wm te E M ency Pian me iminen.nnn, p,ocedures which > i pn:, vide a source at patinent informadon and dets required by e ogenization Apperuk C. dudng en emergency. These procedures are Ested in < nun l l
.
e
. -
( l \ "
-----____--_] ""
. . . . . .. _ _ . . - _ _ -_ _ _ - '
EElllE.J.EE 1Y.
6.5.1.4 The FRG shall meet at least once per calendar month and as convened
'
by W FRG Chairman or his designated alternate. , ElDRM . 4.5.1.5 The quorum of the FRG necessary for the performance of the FRG responsibility and authority provisions of these Technical Specifications shall censtst of the Chaiman or his designated alternate and four members including alternates.
RESPGISIBILITIES l 6.5.1.6 The Facility Review Group shall be responsible for- ' a
, a. Review of (1) 41 procedures required by specification 4.8 and i changes therste,~(2) all programs required by specification 6.8 and j changes thereto, and (3) any other proposed procedures er changes ;
therete as determined by the plant General Manager to affect au-clear safety. ) b. Review of all proposed tests and experiments that a.ffect nuclear safety.
' c. Review of all proposed changes to Appendix A Technical specifica-tions.
. d. Review of all proposed changes er modifications to unit systems or equipment that affect nuclear safety.
-
e. Investigation of all violations of the Technical Specifications, including the preparation and forwarding of reports covering evaluation and recommendations to prevent recurrence to the President-Nuclear Division and to the chairman of the Company Nuclear Review Board.
f. Review of all REPORTA8tE EVDITS.
g. Review of unit operations to detect potential nuclear safety hazards.
h. Performance of special reviews, investigations or analyses and reports thereon as requested by the Plant General Manager or the Campany Nuclear Review Board. , t 1. "n'.= f tM karit; "h; ;.-4 ";;t- :..tir.; prxed;ree ".=!= ad ;;Mit- ' S:d.
ui f rn: xd:d ;hx;n :: th C: ;ry "xhr
/ prowo *
i i g,o\*M
j.
m Pr;tr :f th: tr;;=y "h: rf igir- .th; prn: dan xd
:_Mittt:1 :f rn:- ;d:d :hx;n t: th: C: ;ry "=hr "=t= ~
h^rd. 1 l Her osso - .
.
6-3 Amendment No. ::,2" C l i ST. LUCIE - LAIIT 2 l
-
_ _ __ _ _____ __ ___ _ _ _ _ _ . _ _ _ . _ _ _ .. _ _ _ _ _ _ _ _
,
l
.
7.
I. MAINTAINireG -v E*"LarasWCY CAfisiW (condnued) 7.3 1 Review Pc.,; dare
.
{ ! The Emmgency Plan and Emmhancy Plan implemendng Prh wm
Aber undw conthing review by the site emagency plannhg gmup.
..,,,Js , 's review of the Emagency Plan wE to conducted - annuaBy. The Emmgency Plan implemenbng Procedures are reviewed
; '
during dras, esmoises, and actumi emagencies and revised as
- y to coneet idendsed desciendes. The Emergency Plan .
- '
lJ- 1,s.L., Procedures wE undergo a thomugh formal review at least l once evwy two yees and be revised as necessary. NodRoeden Beta and * l rosters we tw updated at inset quartedy. r changes esecung .
- emergency response are idenused, theos changes wE in made as
- needed. The revloed Emmgancy Plan ws be dioldbuted wth the latest
! revleion number indicated on each page. Revision hdicadon alongi -
- right margin we be used to indicate where changes have toen made.
If during theos annual reviews no changes are needed, this wE to documented. i
i Changes to the Emmgency Plan wE be submitted,'h writhg, to to l Savions Menegw. The FacBty Review Group wE review as propoe changes to tw Emergency Plan and Enwrgency Plan impismondn , Prh. AI changes to the Emergency Plan shal be appmved by <)
- l
.
- #w Proeident, Nuolear Division, prior to WhwW,. Recommended
. L changes to the Emergency Plan and Emmgency Plan implemend Proc c. ores we to submated to em Chairpanon of sw company
}{
l Nudear Review Board for review.
'
,,
)
!
Document holders wB receive revisions to the Emergency Plan are issued The Services Manager is responsbie for coordinating'the ! - periode reviews of the Emergency Plan. The Services Manager wiB j
'
ensure that elements of #w amagency organization (FPL, state, local, fedwal) are informed of ctanges to the Emagency Plan.
2. Review of Changes by OrHdte Personnes f . The Plant Training Manager win ensure that ort site Emergency i Response Organization personnel are hformed of relevant change ! the Emergency Plan and Emergency Plan implementing Fruc dures.
3. Review of Changes by Off-site ersonnel i , Periodic correspondence and/or meetings wil be held to inform off-site FPL emergency support personnel of changes in the Emergency Pla and Emergency Plan implementing Procedures.
.
/
- EP3:4 1 744 $ St. Lume. Mov. 31
._ . . _ . __ -_ __ _
. . . _ _ _ . . . . . .. .
, ,
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.
I SECURITY
.
NRC INSPECTION REPORT NOS. 50-335/96-19 AND 50-389/96-19 .
- PRE-DECISIONAL ENFORCEMENT CONFERENCE
.
DECEMBER 10,1996 ' ATLANTA,GA FLORIDA POWER & LIGHT COMPANY
; @ ST. LUCIE PLANT
o
.
_ _ _ _ _ _ _ _ . . _ _ _ _ _ . _ . _m_ _ _ _ _ . _ __-__.._._.--___.__._i-
-
-_ ___ ___.___- - -
m. -- ti-- wr u.erw- e --ew-- - we -r w +-
m ._ u-,. m av- s. A m. i-u s. m 4
%. 4
%
SECURITY STATEMENT OF APPARENT VIQLATIONS_ - VI.
FAILURE TO LIMIT UNESCORTED ACCESS TO PROTECTED AND VITAL AREAS DURING NON-EMERGENCY CONDITIONS V2.
FAILURE TO SUBMIT A REPORT WITHIN ONE HOUR OF DISCOVERY OF THE ABOVE OCCURRENCE
.
I
.
.
____.______.____m..-.-_.m_-___________________. --____m._ m_m_ _ e- -_ . - - - - - - - - - - - ' - - - - - v e- -
, w u-, e ~ -m- .- ,-<w
._. . .. . . . . . _ _ _ _ . _ _ ._ .. _. . . .._ _ _. _ _ . . _
.
_
,
INVESTIGATION CHRONOLOGY : < l JULY 28,1996
-
.
-
t TEMPORARY FPL EMPLOYEE TERMINATED UNDER FAVORABLE CONDITIONS SEPTEMBER 19,1996
: -
i FPL IDENTIFIED THREE TERMINATED FPL TEMPORARY EMPLOYEES WHOS ~
-
i ACCESS HAD NOT BEEN DEACTIVATED IN ACCORDANCE WITH PROCEDURES -
- L
/ ACCESS WAs IMMEDIATELY DEACTIVATED FOR THE THREE TERMINATED FPLl TEMPORARY EMPLOYEES . >
~ -
ALL THREE TEMPORARY FPL EMPLOYEES HAD BEEN TERMINATED UNDER FAVORABLE CONDITIONS OCTOBER 7,1996
-
.
' TURKEY POINT SECURITY REQUESTED ST. LUCIE TO PROCESS BADGING THE EMPLOYEE TERMINATED ON JULY 28,1996
, , . . . , _ , . - - . . . . . . . [ .- _. . . . , . - ~ . _ . . . . . . , - . .. . . ~ . . .-.._...-.~,_m., ,-. , .- . - _ ,_ .. .._. . . . .- - , , . _ , ...- ,,m..m,,.., . --_ _ _ ._m..
. - . .. . . _ - - . -_. . .. . . . . . - - - . . ... .... - . . . . . .
~; . -
~
'
,
.s. -
I CHRONOLOGY (cont.)
- OCTOBER 9,1996 .
'
-
THE INDIVIDUAL WAS IDENTIFIED AS HAVING ACCESSED ST. LUCIE PLANT . AFTER HIS TERMINATION (AUGUST 7,9, AND 15,19%) _
-
- THE ACCESS CONTROL SPECIALIST CONFERRED WITH THE PLANT SECURITY OPERATIONS SUPERVISOR AND INCORRECTLY CONCLUDED THAT THIS WAS NOT A REPORTABLE EVENT BECAUSE
~
,
.
-
ACCESS WAS IMMEDIATELY TERMINATED
-
THERE WAS NO MALEVOLENTINTENT 1
,
4 ,
'
i
.
;
'
l
. .
t
,
we -, , r,- ---,,a- - enc,----a,s.,_v-- -a --me--~v -- w ~ m.. -+. - - - - c-r.-- . , , v e- ..., < ----erw--arww-s . m-- w---,*--e -em-,w - -<w
- - -----, u --------~--------n------i-a..wa--. --.-------a.
. . . . _ . .. _ _ . _ _ _ ._ _ __ .
,
'
.
>
CHRONOLOGY (cont.)
i - OCTOBER 11,1996
, -
THE ST. LUCIE PLANT SECURITY SUPERVISOR BECAME AWARE OF THE ACCESS . i
-
INTERVIEWED FPL PERSONNEL WHO KNEW INDIVIDUAL
-
INDEPENDENT ASSESSMENT OF NO MALEVOLENT INTENT
. -
INDIVIDUAL HAD WORKED AT ST. LUCIE SINCE 1981 INDIVIDUAL WAS REQUESTED FOR JOB INTERVIEW DURING ACCESS
-
.
:
-
THE TWO ADDITIONAL TEMPORARY FPL EMPLOYEES TERMINATED ON JULY 27 AND AUGUST 24,1996, HAD NOT ACCESSED THE SITE AFTER THEIR TURMINATION , t
,
l i
4
. -. _ .. --. - -- - - . - .-- . - . .. . . __ _-- -
__ . _ . _ _ . . _ - ._ _ _. _._ . ...
,
h .
';
, CIIRONOLOGY (cont.) . OCTOBER 11,1996 (cont.) i
-
SAFEGUARDS EVENT LOG ENTRY WAS MADE l
-
IT HAD BEEN CONCLUDED THAT THE EVENT WAS LOGGABLE, BUT NOT REPORTABLE, BECAUSE UPON DISCOVERY, CMPLOYEE SITE ACCESS WAS REVOKED
- -
THERE WAS NO MALEVOLENT INTENT BY THE INDIVIDUAL WHO HAD GAINED SITE ACCESS ' r
- '
THE INDIVIDUAL HAD PROPERLY COMPLETED ALL NECESSARY SCREENING TO ALLOW ACCESS PREVIOUSLY AND HAD BEEN AUTHORIZED SITE ACCES
-
INTERVIEWS WITH HIS SUPERVISORS DETERMINED EMPLOYEE TRUSTWORTHY AND RELIABLE AND THAT HIS EMPLOYMENT HAD BEEN * TERMINATED UNDER FAVORABLE CONDITIONS
-
A CONDITION REPORT WAS GENERATED TO FURTHER EVALUATE THE EVENT
.; , . . - . . . -. - , . . .. . - . - . . . . . . - . ~ . . . . .
. . . -- . . .. .__ _. = _ . . - . . . .
;.
CHRONOLOGY (cont.)
. OCTOBER 16,1996
. -
FOLLOWING FURTHER FPL MANAGEMENT AND QUALITY ASSURANCE REVIEW, AND CONDITION REPORT DISPOSITION, THE NRC OPERATIONS CENTER WAS
. NOTIFIED OF THE EVENT
,
.
G
.
. _ - _ _ _ _ _ . ..___. ___ _ - _ _ _ _ . - _ -___ _ . _ _ . - ___-- ____- ----__ _ _ _ _ _ - _ _ _ _ _ - . ._ __ .- _ _ __ _ _ ._ - __ _ _ _ -.
. . - - ._
,
:
PROGRAM /REGUJ ATORY REOUIREMENTS:
-
i TITLE 10 CFR 73.55 (d) (7) (i) (C) REQUIRES INDIVIDUALS INVOLUNTARY : -i t T.:.RMINATED FOR CAUSE HAVE ACCESS REVOKED WITH NOTIFICATION OF
- TERMINATION i -
s-THE ST. LUCIE PLANT PHYSICAL SECURITY PLAN REQUIRES IMMEDIATE INACTIVATION OF CARD KEY AND HAND GEOMETRY ACCESS CAPABILITIES : FOR VOLUNTARY TERMINATION OR TERMINATION FOR CAUSE .
- -
ST. LUCIE PLANT ADMINISTRATIVE PROCEDURE NO. 0010509, PERSONNEL AND
MATERIAL CONTROL, REQUIRES IMMEDIATE SECURITY NOTIFICATION .UPON EMPLOYEE TERMINATION
. -
UNAUTHORIZED PERSONIS DEFINED IN REGULATORY GUIDE 5.62, REVISION 1, REPORTING OFSAFEGUARDSEVENTS, AS "ANY UNESCORTED PERSON IN AN AREA TO WHICH THE PERSON IS NOT AUTHORIZED UNESCORTED ACCESS" .
,
e i
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ . _ _ _ _ . . . _ _ _ _ _ . _ _ _ _ _ . _ _ _
. . .
. .
ROOT CAUSES
. -
DEPARTMENT SUPERVISORS FAILED TO FOLLOW THE ADMINISTRATIVE PROCEDURE PERSONNEL AND MATERML CONTROL REQUIRING IMMEDIATE NOTIFICATION TO SECURITY UPON EMPLOYEE TERMINATIONS
-
THIRTY DAY SCREENING WAS INADEQUATE
-
THE INDIVIDUALS FAILED TO MEET THEIR RESPONSIBILITIES AS EXPLAINED IN GENERAL EMPLOYEE TRAINING AND EXPLAINED IN THE BADGING RESPONSIBILITY ACKNOWLEDGMENT SHEETS SIGNED DURING SITE BADGING IN-PROCESSING
-
SECURITY PERSONNEL RESPONSIBLE FOR REPORTABILITY DETERMINATION FAILED TO DETERMINE THIS TO BE AN UNAUTHORIZED ACCESS BECAUSE OF HIS PAST WORK t
; 8
. _ _ _ _ - . .-_ _ . - - _ . _ . _ _ _ _ _ _ _ _ . . _ _ _ _ . _ . _.__..________-._.-___________m__._ _ _ _ . _ _ - v-w w - =.-
. _ __ ._- _ . . . . . _ . . _ _ _ _ - - . . - . _. _ .
'
CORRECTIVE ACTIONS
-
SECURITY UNASSIGNED THE CARD KEYS FOR THE TERMINATED INDIVIDUALS
-
DEPARTMENT HEADS VALIDATED, UNDER THEIR SIGNATURE, THE NEED FOR CONTINUED PLANT ACCESS FOR ALL LICENSEE- AND CONTRACTOk EMPLOYEES.
UNDER THEIR COGNIZANCE. THE VALIDATION WAS COMPLETED BY NOVEMBER
1,1996
.
i
-
SECURITY COMPLETED A REVIEW, ON OCTOBER 30,1996, OF ALL FPL NUCLEAR-DIVISION EMPLOYEES RELEASED BETWEEN JANUARY l AND OCTOBER 30,1996.
OF THE 2416 EMPLOYEES AND CONTRACTORS RELEASED OR TERMINATED ! DURING THAT PERIOD,27 ADDITIONAL OCCURRENCES WERE IDENTIFIED. NONE ' OF THESE INDIVIDUALS ACCESSED THE SITE AFTER TERMINATION OR. RELEASE
-
PLANT PROCEDURE PERSONNEL AND MATERIAL CONTROL WAS REVISED TO
-
INCLUDE A REQUIREMENT TO IDENTIFY EMPLOYEES AS EITHER FULL TIME OR-_ TEMPORARY, FPL OR CONTRACTOR -
.
9
. . _ _ _ _ _ _. ------- - ---- - - * - - - - - - ^ - - - - - - - " ' ' ' ' - - - - " - " " - " - - - - " " " ' " " -- ' '
a ~ -- . . u- r .sa + ma - n -e_.. x n a_. .- , e
. CONCLUSIONS
_
- -
FPL BELIEVES THAT IT HAS MET ITS COMMITMENT TO ENSURE THAT THE-REQUIREMENTS RELOCATED FROM THE TECHNICAL SPECIFICATIONS ARE RESIDENT IN THE EMERGENCY AND PHYSICAL SECURITY PLANS - _ d
4
.- _ - _ -_ -_-- .., . - -_. - _ ... _ . .. _. _- - .. .- . . - . - __ - . -
_. _ _ _ .
.
.-.. -
.- .;-
!
COMMON THEME OF APPARENT VIOLATIONS
-
MANAGEMEN' OVERSIGHT OF EMERGENCY PLANNING WAS LACKING AS ~- DESCRIBED BY IDENTIFIED WEAKNESS '
'
.
- INVESTIGATION COMMON THEMES - -
INADEQUATE SELF-ASSESSMENT OF THE EP PROGRAM AT ST. LUCIE PLA :
-
COMPLACENCY WAS EVIDENT IN EMERGENCY PREPAREDNESS ACTIVITIi
.
ROOT CAUSE COMMON TIIEMES
-
PERSONNEL WERE COMPLACENT
.
.
-
MANAGEMENT FOCUSED ON " HOT" ISSUES OF THE DAY ^
-
LACK OF STRONG LEADERSHIP IN DEMANDING SUPPORT FROM l t i
-
l l 20
! . . --
. . .. . - - . . - .
' COMMON THEMES OF CORRECTIVE ACTIONS -
-
SUPERVISION NOW IN PLACE WITH PROVEN EXPERIENCE .
- -NEW MANAGEMENT PERSONNEL SUPPORT EMERGENCY PREPAREDNESS AND
' TRAINING
-
REINFORCING PERSONAL ACCOUNTABILITY AND RESPONSIBILITY .
~ -
INSTITUTIONALIZED DEPARTMENT SELF-ASSESSMENT -
-
INCREASED QA OVERSIGHT
-
i
-
IDENTIFIED PROBLEMS TRACKED WITH CONDITION REPORTS t
'
.
1
s
. - _ . _ . - - - - . -....r 4.-.+... v-- . . - _ s . . v- _, . . - , ,.. . ..#.. . .._ ~ ~ _ . . .. , .. m,m... . . . r -_ .*-
. . . . -1 dVERALL CONCLUSIONS '
-
AGGRESSIVE PROGRAM UPGRADE IS IN PROGRESS -
' -
MORE FREQUENT DRILLS AND SELF-ASSESSMENTS WILL ENSURE LONG TERM SUCCESS AND FLEXIBILITY
. . -
WE ARE NOT WHERE WE WANT TO BE I SAFETY SIGNIFICANCE
-
ST. LUCIE WOULD HAVE BEEN ABLE TO RESPOND SUCCESSFULLY TO AN , EMERGENCY USING EXPERIENCED PERSONNEL, PLANT PROCEDURES, PLANS, AND DEPARTMENT CALL ROSTERS
.
'
,
_ _ _ , _ __ _ _ _ __ r = - """* * - ' ~~~ ~
. .
- - . .. .- . .. . . - . .
.
-s E
NUCLEAR INSTRUMENTATION AND CORE MONITORING
~
NRC INSPECTION REPORT NOS. 50-335/96-22,50-389/96-22 i PRE-DECISIONAL ENFORCEMENT CONFERENCE E h
.
-
DECEMBER 10,1996 ATLANTA, GA FLORIDA POWER & LIGHT COMPANY-
.
ST. LUCIE PLANT _ _ _ _ _ _ __ _ _ =. . _ _ _ . . _ . . ..- . - . . . . . . ..- .__ _ . ___
. .
OUTLINE
-
APPARENT VIOLATION 1: FAILURE TO CONTROL DESIGN PROCESSES EXAMPLE 1: FAILURE TO PROVIDE INDEPENDENT REVIEW OF MODIFICATION DRAWINGS EXAMPLE 2: DESIGN INPUTS NOT ADEQUATELY REVIEWED BY AN INDEPENDENT INDIVIDUAL
-
APPARENT VIOLATION 2: FAILURE TO PROPERLY VERIFY AND VALIDATE BEACON SOFTWARE
-
APPARENT VIOLATION 3: FAILURE TO FOLLOW PROCEDURES AND INITIATE A CONDITION REPORT . l
. .- _ . . __ . .. . . . .
,
-
.
9' UNIT I NUCLEAR INSTRUMENTATION UPGRADE APPARENT VIOLATION 1 FAILURE TO CONTROL DESIGN PROCESSES t i EXAMPLE 1: FAILURE TO PROVIDE INDEPENDENT REVIEW OF MODIFICATION DRAWINGS INVESTIGATION - DESIGN ISSUES UNIT 2 MODIFICATION SUCCESSFULLY IMPLEMENTED
- -
ASSUMED SIMILARITY WITH UNIT 2 DESIGN
-
DRAWING CONFLICTS NOT IDENTIFIED IN DEVELOPMENT PHASE
-
INADEQUATE INDEPENDENT VERIFICATION '
-
VERIFY CORRECT vs. PROVE INCORRECT
_ .- --_- __ -_ _- - - _-- ___ __ ___ - _ ____ - _-_____ ____ - _ _ _ - - _ _ _ _ _ _ - - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ . _ _
- - . -_ _ - - - . ._ - _ - _ - . .
_
. i . NIS DETECTOR CONNECTIONS ;
,
- ;
l :
'
UPPER
SECTION
!
REACTOR VESSEL DETECTOR _ NIS ' ELECTRONICS LOWER __ SECTION SIGNAL 2 BOT SIG SUBCHANNEL B
:
SIGNAL 1 - SUBCHANNEL A TOP SIG
.
.
;
'
_ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ . _ _ . . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . . _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ _ _ _
. _ __ _ _ . - . - . ..- - .- .
_
.
;. . .
.
. -
,
INVESTIGATION - TESTING ISSUES
~
4
' -
NO POST-MODIFICATION TEST TO VERIFY WIRING CONNECTIONS.
'
-
; MISSED OPPORTUNITIES.TO IDENTIFY PROBLEM DURING START-UP TESTING (AX1AL SHAPE INDEX (ASI) TRENDING) -
~
-
ASI VALUES QUESTIONED BY OPERATORS ;
* -
IDENTIFIED DURING REVIEW AND ANALYSIS OF STARTUP-DATA-r
.
PROGRAM REOUIREMENTS !
-
MODIFICATION PACKAGES MUST BE INDEPENDENTLY VERIFIED I
-
POST-MODIFICATION TESTING SHALL'BE ADEQUATE TO VA'LIDATE . INSTALLATION i
:
-.
:
!
. _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ _ _ . - _ _ _ _ - _ - _ - - - _ - - _ - _ _ - _ _ _ _ _ _ _ _ _ - - _ _ - _ _ _ _ _ - _ _ _ - _ - _ - . _ _ _ _ _ _ . _ _ _ . . - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ - - - _ - _ - . , . . . - . - . .
. . . . - . . . _ _ _ _ . _ _ _..
l
.
ROOT CAUSES - i
-
INACCURATE AND INCOMPLETE DESIGN PROVIDED TO THE VERIFIER:
-
INADEQUATE VERIFICATION OF THE DESIGN '
-
DlD NOT RECOGNIZE UPPER AND LOWER DETECTOR INPUTS AS AN AFFECTED FUNCTION IN POST-MODIFICATION TEST
:
,
' CORRECTIVE ACTIONS -
-
WITHIN 1 HOUR OF PROBLEM CONFIRMATION LEADS WERE REVERSE TO ACHIEVE PROPER AllGNMENT
-
ENGINEERING STAND-DOWN MEETING HELD TO DISCUSS EVENT,
LESSONS LEARNED AND MANAGEMENT EXPECTATIONS :
-
^
FIELD WALKED DOWN AND DRAWINGS REVISED AS REQUIRED
-
.
n _ _ - _ . _ . _ _ _ _ - - - - - _ - - - - - - - - - - ~ ~ - - - - - - - - - - - - - - - ~- - ~ ~ ~ ~ ~ ~ ~ ~ ~
. _ -. _. . _ .
,
-
.
..
CORRECTIVE ACTIONS (cont'd)
-
VALIDATED OUTSTANDING SAFE'TY RELATED MODIFICATIONS CONTAINING WIRING CHANGES
-
IMPLEMENTED QUALITY INSTRUCTION REVISIONS:
=
REQUIRE ENGINEERING PACKAGES TO IDENTIFY ALL CRITICAL ASPECTS / FUNCTIONS TO BE DEMONSTRATED DURING TESTING
*
REINFORCED IMPORTANCE OF INDEPENDENT VERIFICATION AS
~
PART OF DESIGN CHANGE PROCESS
.
:
* ,
REQUIRE TI-lE SAME LEVEL OF VERIFICATION ON DUPLICATE PACKAGES
!
l i
,
, , . . , . . - - , ~ , - - . . . , ,, . - . . , , . , . . . ., . - , - . . , , , . , , , , , , , , , .,
. .
i
.
CORRECTIVE ACTIONS (Cc,nt'd) ,
; -
PROVIDED A TRAINING BRIEF TO REACTOR ENGINEERING REGARDING-TlllS INCIDENT AND IMPORTANCE OF A QUESTIONING ATTITUDE .
-
START-UP TESTING TO BE IMPROVED TO INCLUDE IDENTIFICATION OF A-TARGET ASI VALUE AND REAL TIME DATA REDUCTION AND TRENDING OF CORE PERFORMANCE DURING POWER ASCENSION (DUE 1/15/97).
, a CONCLUSIONS t
-
PROBLEM WAS SELF-IDENTIFIED AS PART OF THE START-UP TESTING PROGRAM
-
FAILURE TO IMPLEMENT PLANT MODIFICATION IN ACCORDANCE WITI-I QUALITY INSTRUCTIONS
-
LACK OF QUESTIONING ATTITUDE BY ENGINEERING STAFF
" .
,
m_ _ _ _ . . _ . _ . . _ _ _ _ _ _ . _ . _ _ _ _ _ . _ _ _ . . _ _ _ _ . _ . _ _ _ _ . . . _ _ _ _ _ _ _ _ _ _ . . _ . _ . _ _ _ . _ _ _ _ _ _ _ _ _ _ . _ . _ _ _ _ _ _ _ _ _ _ _ . . _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ . .... .-.-,
_. . _ . _
~
.,
'
SAFETY SIGNIFICANCE
-
,
- WITH REVERSED LEADS, ALL SAFETY LIMITS WERE' SATISFIED FORL PLANT START-UP TESTING CONDITIONS
.
-
IN THE MOST LIMITING CASE THE MARGIN TO SAFETY LIMITS WAS REDUCED FROM 3% TO 0.4%
~ -
THE CONDITION WAS IDENTIFIED DURING REVIEW AND ANALYSIS OF START-UP DATA AND WOULD HAVE BEEN IDENTIFIED DURING THE , . NEXT START-UP RELATED TEST (MODERATOR TEMPERATURE COEFFICIENT TEST) WHICH BEGAN WITHIN TWO DAYS OF ACHIEVING 100% POWER
,
a
l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ ._ _ _ _ . _ _ . - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -
_ _ , _. . . _. _. . . -- _ _ . .
.
,
.
BEACON CORE MONITORING SYSTEM
,
APPARENT VIOLATION I
.! -
FAILURE TO CONTROL DESIGN PROCESSES ; EXAMPLE 2: DESIGN INPUTS NOT ADEQUATELY REVIEWED BY AN-
- INDEPENDENT INDIVIDUAL (CORE OFFSET NOT IDENTIFIED) .
,
,
APPARENT VIOLATION 2 FAILURE TO PROPERLY VERIFY AND VALIDATE BEACON SOFTWARE IN *
~ -
THAT BEACON WAS NOT BENCHMARKED AGAINST INPAX- ; i
,
: . . _ _ _ - _ .
_ -. . , _ . - _ . _ _ _
- ' - -
-
.
, , _
e BEACON OVERVIEW ,
-
ADVANCED ON-LINE CORE MONITORING SYSTEM -
-
USES WESTINGI-LOUSE ADVANCED NODAL CODE a
-
REPLACES CORE MONITORING ~ SOFTWARE - INPAX (UNIT 1) AND
.CECOR (UNIT 2) -
EXTENSIVE USE IN OTHER PRESSURIZED WATER REACTORS
e d
.
t p
' . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . . _ --
_ ._ _ - _ __ _
. _ ..- . . _ ..- . _ _ - . _
. -- - .-. - . - ._ . - - - - .- - - - -. - - ..._.- _ _
,
_ ! BEACON CORE MONITORING SYSTEM
! l
.
'
ANC
-
l PHYSICS
- -
MODEL ..
i GEOMETRY Y m..,...,~. .. , o ,73
* " " "
BEACON : cone l ' omcionseemu
.
cEArosmONS
- cone surTame.
! .
% >
I
-
, /
V CORE MONITORING CORE EXAMINATION CORE SUMMARY RADIAL ANALYSIS AXIAL POWER l 3-D CALCULATION AXIAL ANALYSIS AXIAL SHAPES _ i ECCs QUADRANTTILT CEA INSERTION , SHUTDOWN MARGIN CORE DATA TRENDS LOAD SWING l RADIAL POWER l
-
CYCLE LIFETIME . .
,
___________ -_-_______-____-_-___-__-__ _ - _ - -_ _ _ - _ _ _ - --_- -_ ____-_ __
. . . _ . __ _ _ _
,
.
.
j
.
INVESTIGATION OF SOFTWARE VALIDATION ^
-.
BEACON PURCHASED AS SAFETY RELATED
-
. NRC APPROVED TOPICAL REPORT (WCAP-12472-P-A)
-
WESTINGHOUSE PERFORMED EXTENSIVE VERIFICATION AND VALIDATION OF BEACON
. -
FPL PERFORMED VALIDATION OF BEACON SYSTEM BY EXECUTING - SITE ACCEPTANCE TESTING
-
FPL PROCEDURE PROVIDES SEVERAL OPTIONS FOR VALIDATION: .
~
a) HAND CALCULATIONS - i b) PREVIOUSLY VALIDATED EQUIVALENT SOFTWARE ' c) EXPERIMENT AND TEST RESULTS d) STANDARD PROBLEMS WITH KNOWN SOLUTIONS
c) CONFIRMED PUBLISHED DATA AND CORRELATIONS
-
PROCEDURAL REQUIREMENTS FOR VERIFICATION AND VALIDATION WERE SATISFIED -
13 . - _ _ _ - _ _ _ _ - - _ . _ _ - _ _ _ _ - - . . ._- ... - - ... .-. _ . . .- . . . - _ . _ _ - . _ _ - . _ _ .
- .
INVESTIGATION OF SOFTWARE VALIDATION ADDITIONAL VERIFICATION OF BEACON:
'
-
* FPL PERFORMED ADDITIONAL TESTING BY COMPARING RESULTS TO CECOR (UNIT 2) * BEACON RESULTS COMPARED TO PREDICTION USING DATA FROM TWO PREVIOUS CYCLES (BOTH UNITS) * BEACON COMPARED TO PREDICTIONS DURING POWER ASCENSION (BOTH UNITS)
.--
- _ _ _ _ .
, .
INVESTIGATION OF DATA INPUT ,
-
DATA INPUT TO BEACON WAS PHYSICALLY CORRECT .
-
THE SAFETY ANALYSIS USES AN ADJUSTED MID-PLANE TO COMPENSATE FOR LONGER FUEL END CAPS
-
INPUT TO BEACON DID NOT ADDRESS THIS ANALYTICAL COMPENSATION
-
THIS RESULTED IN THE EXCORE DETECTORS NOT ACCURATELY REFLECTING CORE POWER DISTRIBUTION
-
NO DOCUMENT EXISTED TO IDENTIFY THE ADJUSTED MID-PLANE AS AN IMPORTANT FEATURE
-
PROBLEM SELF-IDENTIFIED DURING ROUTINE CORE MONITORING
.
. _. . . _
,
.
I PROGRAM REOUIREMENTS - CALCULATION PACKAGES MUST BE INDEPENDENTLY VERIFIED SOFTWARE SHALL BE VERIFIED AND VALIDATED
'
- ROOT CAUSES - THE USE OF A MODELING OFFSET WAS NOT FORMALLY DOCUMENTED WITHIN FPL TO ALLOW USE IN OTHER ANALYSES - OFFSET WAS NOT INCORPORATED INTO THE BEACON ANALYSIS t 16 ,. e ,- - - <-a,., s ~.
. _ . . . .._ _
,
.
CORRECTIVE ACTIONS
-
SHORT TERM CORRECTIVE ACTIONS
~ * EFFECTS OF TI-lE MID-PLANE OFFSET WERE QUANTIFIED AND DISPOSITIONED USING AVAILABLE MARGIN * BEACON GEOMETRY DATA WAS REVISED TO BE CONSISTENT WITH THE SAFETY ANALYSIS
'
* COMPARISON OF BEACON OUTPUTS vs. PREDICTED VALUES DEMONSTRATED THERE ARE NO OTHER PROBLEMS WITH SYSTEM = EXCORE DETECTORS WERE RECALIBRATED
-
LONG TERM CORRECTIVE ACTIONS -
* MODELING OFFSET WILL BE ELIMINATED FOR NEXT CYCLE * FUEL DESIGN STANDARDS REVISED TO INCORPORATE A LIST OF -
KEY DESIGN FEATURES
_ _ _ _ _ . . . . . - . . .. . - . . __ __ . _ - .
. -. . . . . . _ _ _- .
, ,
1 -
.
CONCLUSIONS '
' -
FAILURE TO IDENTIFY AND VERIFY APPROPRIATE PLANT SPECIFIC GEOMETRY DATA USED AS INPUT TO BEACON CORE MONITORING SYSTEM
'
~
-
BEACON SOFTWARE VERIFICATION AND VALIDATION WAS~ PERFORMED IN ACCORDANCE WITH FPL PROCEDURES AND IS ACCEPTABLE P
-
THE COMBINED EFFECT OF THE ABOVE LED TO AN UNDESIRABLE RESULT
-
PROBLEM WAS SELF-IDENTIFIED DURING ROUTINE CORE MONITORING l . .
-
!
!
_ _ . - - - _ _ _ - - _ _ _ _ _ - - - _ _ - - _ - _ _ _ _ _ _ _ _ _ - _ _ - _ - _ - _ _ _ _ _ _ - - - _ _ _ _ - _ _ - _ - _ - _ _ - _ _ - - _ = . . . . . - . . - _-.- .. .
- _. . . .
,
.
SAFETY SIGNIFICANCE
- WITH THE INCONSISTENT MODELING OFFSET, ALL SAFETY LIMITS WERE SATISFIED AND' WOULD HAVE BEEN SATISFIED THROUGHOUT THE ENTIRE CYCLE -
IN THE MOST LIMITING CASE THE MARGIN TO SAFETY LIMITS WAS REDUCED FROM 3% TO 0.2% .
- - - . - _ _ _ . - .-_. .- -._ - _ - - . - _ _ _ . _ _ . _ _ _ - _ _ _ - - _ _ _ _ _ - - - - _ _ _ _ _ _ _ = _ . _ -
- - - . . _ - . _ . . . . . .- .. .. . -
~
. f
.
EXCORE DETECTOR LABELING DISCREPANCY APPARENT VIOLATION 3
.
'
FAILURE TO FOLLOW PROCEDURES AND INITIATE A CONDITION REPORT t INVESTIGATION t
-
MARKING ON REPLACEMENT EXCORE DETECTOR WAS DIFF$ RENT FROM DRAWING (A/B vs. TOP SIG/ BOT SIG) i CABLES WERE CONNECTED BASED ON KNOWLEDGE OF THE SYSTEM
-
, AND THE SITUATION WAS DISCUSSED BY THE MODIFICATION TEAM ! MODIFICATION TEAM CONCLUDED CONNECTIONS MADE PROPERLY
-
;
-
13 CONDITION REPORTS INITIATED DURING MODIFICATION PROCESS l I
. . _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . . _ , _ . - . . _ . - . . _ . ..____ _ - , _ . . _ _ _ _ . . _ _ . _ _ _ _ _ _ . . _ . _ _
~ . . -
. -. - .
;- . . . . . . - . . . _
. .
. PROGRAM REOUIREMENTS
- .
A CONDITION REPORT IS REQUIRED FOR FAILURE TO MEET DRAWING-OR WRITTEN SPECIFICATIONS
.
. ROOT CAUSE
-
MODIFICATION TEAM ERRONEOUSLY BELIEVED THEIR ACTIONS ' SUPERSEDED THE NEED TO INITIATE A CONDITION REPORT ' CORRECTIVE ACTIONS
-
CONDITION REPORT PROCEDURAL REQUIREMENTS WERE DISCUSSED
- AT STAND-DOWN MEETINGS
. - - . . . . .- .. , , ., -
_. .._ . . . . . ..
.
CONCLUSIONS
-
CONDITION REPORT.SHOULD HAVE BEEN WRITTEN
: -
NOT A PROGRAMMATIC BREAKDOWN AS EVIDENCED BY THE 13
'
CONDITION REPORTS WRITTEN DURING EXCORE REPLACEMENTS AND 2932 WRITTEN YEAR-TO-DATE t SAFETY SIGNIFICANCE
-
MISSED OPPORTUNITY TO IDENTIFY THE REVERSED LEADS THROUGH THE CONDITION REPORT PROCESS
_ _ _ - __ ___ - _ _ _____ _ _ __-_ - ____ _ _ __ _ _ _ _ - _ __.-_.- _____ _ _ _ . _ __ ___=_ - _ ___ -. . --__-
- . - _ _ - _ _ _ _ _ _ - _ . . - - _ - . ______l
.. . . . . . . .- . . .. . . .
...
, ,
.
;
.
l i ENFORCEMENT CONFERENCE AGENDA
, ST. LUCIE '
DECEMBER 10.19%. AT 8:00 A.M. I
-
NRC REGION II 0FFICE. ATLANTA. GEORGIA I
:
.
.
. I. OPENING REMARKS AND INTRODUCTIONS ~ j S. Ebneter. Regi.onal Administrator
;
.II . .NRC ENFORCEMENT POLICY j B. Uryc. Director ,
"
Enforcement and Investigation Coordination Staff
- i
.III. SUMMARY OF THE ISSUES . 1 -
S. Ebneter, Regional Administrator ; IV .' STATEMENT OF CONCERNS / APPARENT VIOLATIONS .l ' A. Gibson.' Director - Division of Reactor Safety
'
V. LICENSEE PRESENTATION , VI. BREAK / NRC CAUCUS VII. NRC FOLLOWUP OVESTIONS i i ! VIII. CLOSING REMARKS l S. Ebneter. Regional Administrator l I I l . I
;
:
!
'
Enclosure 7
- ,
_ __ _ _ ~ ___ . _ - _ _
-
\
l
!
,
;
APPARENT VIOLATIONS l
'
VIOLATION A 10 CFR 73.55(7) requires that licensee's shall establish an access , authorization system to limit unescorted access to vital areas during non- ; emergency conditions to individuals who require access in order to perform ! their duties. .
;
:
The licensee's Physical Security Plan (PSP), Revision 48, dated 2/23/96 .) states, "Only those individuals with identified need for access and having : appropriate authorization, shall be granted unescorted Vital Area access." , From July 28, 1996 to September 19, 1996 an individual whose employment I terminated on July 28, 1996. had unescorted access to protected and vital areas without appropriate authorization. In addition, on August 7: August 9: . and August 15, 1996, that individual entered the protected area and had access to vital areas.
l Also, five other individuals had unescorted access to the protected ard vital areas after they were terminated from the period of July 27 to September 19, . 1996, without appropriate authorization. However, those individuals did not ; access the protected or vital areas.
t NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any .
'
resulting enforcement decision.
i
;
i l
. . > APPARENT VIOLATIONS VIOLATION B 10 CFR 73. Appendix G. states that an actual entry of an unauthorized person into a protected area or vital area be reported within one hour of discovery.
10 CFR 73. Appendix G, states that any failure, degradation, or discovered ; vulnerability in a safeguards system that could have allowed unauthorized or undetected access to a protected area or a vital area had compensatory measures not been established, be recorded within 24 hours of discovery in the safeguards event log.
On October 9, 1996, the licensee discovered that an individual had been terminated on July 28, 1996, and had entered the protected area on five different occasions. yet failed to make a report within the one hour timeframe. In addition, on September 19. 1996, the licensee discovered three individuals who had previously been terminated on July 27. July 28. and August 24, 1996 that had access to the protected area and failed to report that discovery in the safeguards event log.
NOTE: The apparent violation discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.
,
. ..
..
;
i
.
APPARENT VIOLATICN A 10 CFR 50.54(q) requires that nuclear power plant licensees follow and i maintain in effect emergency plans which meet the planning standards of : 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR.Part 50. ! Section 2.4 of the licensee's Radiological Emergency Plan (REP) Revision 31.
states that activation of the Technical Support Center (TSC) and the j Operational Support Center (OSC) will be initiated by the Emergency Coordinator in the event of an Alert. Site Area Emergency. or General Emergency, and that arrangements have been made to staff the TSC and OSC in a R timely manner. Also specified is that activation of the Emergency Operations -1 Facility (E0F) is -aauired for a Site Area Emergency or General Emergency. and i that arrangements nave been made to activate the E0F in a timely manner. .)
'
The REP requirements delineated above are imp'emented in part by Emergency Plan Implementing Procedure (EPIP) 3100023E. "On Site Emergency Organization
'and Call Directory". Revision 72. The instruction in Section 8.2 of that procedure states that, upon the declaration of an emergency classification, the Duty Call Supervisor will initiate staff augmentation" using the " Emergency Recall System or Appendix A. Duty Call Supervisor Call Directory to noti fy persons . . . "
From approximatel'y July 22 to October 3.1996, arrangements were not available
' to staff or activate the TSC. OSC. or EOF in a timely manner because the licensee did not have the capability to adequately implement either the primary method (using the Emergency Recall System) or the backup method (using the Duty Call Supervisor Call Directory) for notifying its personnel during off-hours to staff and activate the TSC. OSC, and EOF.
NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision
!
!
* .
. _ . _ .
_ - - -. - .
-
- i
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APPARENT VIOLATION.B
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As of August 19. 1996. Technical Specification (TS) 6.8.1.e required that written procedures be established, implemented, and maintained covering Emergency Plan implementation. (The subject TS was deleted with NRC approval effective August 20, 1996, but these examples of inadequate EPIPs existed in the same form prior to August 20, 1996 as when identified during the inspection.)
Procedures covering Bnergency Plan implementation were not adequately , established, implemented, and maintained with respect to the following_ aspects of the Emergency Plan: a. recovery activities, as discussed conceptually in REP Section 5.4- ; b. description and delineation of the licensee's emergency response ' organization (ERO) and the detailed means for notifying ERO members in an emergency, as discussed generally in REP Section 2.2 c. relocation of the OSC if required by radiological or other adverse conditions during an emergency, as referenced in REP Section 2.4.4 NOTEITheapparentviolationsdiscussedinthisenforcementconferenceare subject to further review and are subject to change prior to any resulting enforcement decision. ;
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REP Section 7.2.1 " Objectives". stated the following: "The primary objectives of emergency response training are as follows: 1. Familiarize appropriate individuals with Emergency' Plan and related implementing procedures. 2.
Instruct individuals in their specific duties to ensure effective and expeditious action during an emergency. 3. Periodically present significant changes in the scope or content of the Emergency Plan. 4. Provide refresher training to ensure that personnel are familiar with their duties and responsibilities." REP Section 7.2.2. " Training of On-Site Emergency Response Organization [ER0] Personnel". states. "The training program for members of the on-site emergency response organization will include practical drills as appropriate and participation in exercises, in which each individual demonstrates an ability to perform assigned emergency functions... For employees with specific assignments or authorities as members of emeraenCY teams, initial training and annual retraining 3rograms will be provided.
Training must be current to be maintained on tie site Emergency Team Roster."
REP.Section 7.3.2 states "The Plant Training Manager will ensure that on-site .
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Emergency Response Organization personnel are informed of relevant changes in the Emergency Plan and Emergency Plan Implementing Procedures [EPIPs]." 6. In 1994, the licensee failed to provide initial training or annual I retraining for 17 positions (approximately 92 individuals) identified as part of the on-site response organization. In 1995, the licensee failed to provide initial training or annual retraining for 8 positions 1 (approximately 54 individuals) identified as part of the on-site j response organization, b. The licensee's training program failed to include initial training or annual retraining on all procedures required to be implemented by ERO personnel in several identified positions. Examples: EPIP 3100027E.
"Re-entry" - Emergency Coordinator. Radiation Team Leader. OSC Supervisor. Re-entry Team Supervisor. Re-entry Team Member. OSC Status Board Keeper, and OSC Dose Recorder. EPIP 3100026E. " Criteria for and Conduct of Evacuation" - Emergency Coordinator. Assembly Area l Supervisor, and TSC Security Supervisor. EPIP 3100035E. "Off-site l Radiation Monitoring" - Radiation Team Leader and TSC Supervisor.
The Plant Training Manager failed to ensure that ERO personnel in : several identified positions were informed of relevant changes in 3rocedures. Example: EPIP 3100026E. " Criteria for and Conduct of Evacuations".
c. For the calendar year 1995, the licensee failed to remove from the emergency response organization two individuals who had not completed retraining as required, and whose qualifications had expired in 1994. 1 The licensee also failed to remove six individuals from the emergency ! team roster effective October 6.1996, who had not remained qualified to fill response team requirements as a result of allowing their respirator j qualifications to lapse. j l
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APPARENT DEVIATION Amendment Nos. 147 and 86 to the operating licenses for Units 1 and 2.
respectively, were approved by the NRC on August 20. 1996, and consisted of changes to the TS in response to the licensee's application dated August 16.
1995. Among numerous changes in these amendments were the deletion (for both Units 1 and 2) of the previous TS 6.8.1.d and TS 6.8.1.e. which formerly specified that " Written procedures shall be established. implemented and maintained" to cover " Security Plan implementation" and " Emergency Plan implementation", respectively. In Attachment 2. " Safety Analysis", to the August 15. 1995 application. the licensee stated (in the introduction to the section addressing modifications to TS 6.5.1.6.i . 6.5.1.6.J. 6.8.1.d. and 6.8.1.e) that the " selected Technical Specifications are being relocated to the Emergency Plan or Security Plan as appropriate. Relocating these requirements to the appropriate plan will ensure the control of future changes are under the requirements of 10 CFR 50.54.10 CFR 73.55 and 10 CFR 73.56."
The NRC's referenced approval of the subject application stated that the
" licensee proposes to relocate these review requirements and their implementing procedures to the St. Lucie Security and Emergency Plans..."
The licensee failed to relocate the requirements formerly found in TS 6.8.1.d and 6.8.1.e to the Security Plan or Emergency Plan, as applicable, in accordance with the commitment to the NRC contained in t1e licensee's application dated August 16, 1995.
I l l NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. , i l l i i
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APPARENT VIOLATIONS APPARENT VIOLATION A 10 CFR 50. Appendix B. Criterion III. Design Control, requires, in part, that measures be established to ensure that the design basis is correctly translated into drawings and that design control measures provide for verifying the adequacy of the design by individuals other than those who performed the original design.
FPL Topical Quality Assurance Report. TOR 3.0, Revision 11. " Design Control."
Section 3.2.4. " Design Verification." stated in part. " Design control measures shall be established to independently verify design input... Design verification shall be performed by technically qualified individuals or groups other than those who performed the design."
Engineering Quality Instructions (01) 1.7. Design Input / Verification. dated July 5,1995, states, in part, that " Design verification is the process whereby a competent individual, who has remained independent of the design process, reviews the design inputs. ... and design output to verify design adequacy. This independent review is provided to minimize the likelihood of design errors in. items that are important to nuclear safety."
1) On July 30, 1996, it was discovered that a design change (PC/M 009-195) to install new nuclear instrumentation system drawers did not receive an independent design verification by a competent individual inde)endent of the design process. Design change PC/M 009-195 was completed )y 6 lead designer and a lead engineer. This design change was independently verified by a second designer who had no special knowledge of the design. The design was then approved by tne lead engineer whom was not independent of the design process.
2) On July 30, 1996, it was discovered that an independent design review was not conducted for the installation of a new core flux monitoring computer code BEACON. During initial operation of BEACON it was found that the code did not compensate for a core mid-plane offset created by a previous core modification. The engineer who prepared the design was not aware of the core mid-plane offset and the lack of an independent review of the new BEACON code did not provide the opportunity to identify this omission.
NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.
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,g 3-APPARENT VIOLATION B I
. Technical' Specification'6.8. Procedures and Programs, paragraph 6.8.1-requires, in part that written procedures recommended in Appendix A of e Regulatory Guide 1.33 revision 2. February 1978, shall be established and- , . implemented. 1 Engineering Quality Instruction (01) 3:7.- Com) uter Software Control. Revision-1. Section 5.4. requires that 50A1. software s1all be validated and verified ; (V8V'ed) .in accordance with Section 5.6 of 013.7. Section 5.6 states that t new software shall be V&V'ed prior to use. . The V&V process includes.the use i of test cases to ensure the new software produces correct results. Item 4 of- i Section 5.6.stato . that technical. adequacy shall be determined by comparing the test case to results from alternative methods such as functionally equivalent and previously validated software. ; 'During the Unit 1 Cycle 14' outage. BEACON core monitoring system was placed into service on Unit I without any benchmarking against IMPAX. the on-line core performance monitoring code BEACON was. replacing. .Instead. BEACON was 1 installed on Unit 2 and benchmarked against CECORE. the core monitoring system installed on Unit 2 which did not require any modifications to accommodate the core midplane offset. *
NOTE: The. apparent violations discussed in this enforcement conference are ; subject to further review and are subject to change prior to any ' resulting enforcement decision. :
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APPARENT VIOLATION C Technical Specification 6.8, Procedures and Programs, paragraph 6.8.1.
requires in part that written procedures recommended in Appendix A of Regulatory Guide 1.33 revision 2. February 1978, shall be established and implemented. . Administrative Procedure No. 0006130. Condition Reports. Revision 4. dated March 22,1996. Par. 8.1.1.A states in part that "Any individual who becomes aware of a problem or discrepant condition . . should initiate a CR. If doubt exists, a CR form should be initiated". - On July 30. 1996. Instrument and Control technicians installing Modification PC/M 009-195 did not initiate a Condition Report when they became aware of a discrepant condition when markings for electrical terminal connectors differed from existing cable markings. The failure to resolve the discrepant condition resulted in incorrectly installing two excore nuclear instrumentation system detectors.
NOTE: The apparent violations discussed in this enforcement conference are subject to further review.and are subject to change prior to any resulting enforcement decision, i .
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ENFORCEMENT CONFERENCE AGENDA ST. LUCIE DECEMER 10, 1996. AT 8:00 A.N.
NRC REGION II 0FFICE. ATLANTA. GEORGIA I. OPENING REMARKS AND INTRODUCTIONS S. Ebneter. Regional Administrator II. NRC ENFORCEMENT POLICY B. Uryc. Director Enforcement and Investigation Coordination Staff > III. SumARY OF THE ISSUES 5. Ebneter. Regional Administrator I V-. STATEMENT OF CONCERNS / APPARENT VIOLATIONS A. Gibson. Director i Division of Reactor Safety - V. LICENSEE PRESENTATION VI. BREAK / NRC CAUCUS l VII. NRC FOLLOWUP OUESTIONS VIII. CLOSING REMARKS S. Ebneter. Regional Administrator
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- APPARENT VIOLATIONS
j VIOLATION A
- 10 CFR 50. Appendix 8. Criterion III. Design Control. requires. in part, that measures be established to ensure that the design basis is correctly 1- translated into drawings and that design control measures provide for verifying the adequacy of the design by individuals other than those who performed the original design.
. FPL Topical Quality Assurance Report. TOR 3.0.-Revision 11. " Design Control."
Section 3.2.4. " Design Verification." stated. in part. " Design control measures shall be established to independently verify design input... Design , ' verification shall be performed by technically qualified individuals. or groups ,
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other than those who performed the design." ,
, Engineering Quality Instructions (01) 1.7. Design Input / Verification. dated Ju ,y 5.1995. states. in part. that " Design verification is the process whereby a competent individual. who has remained independent of the design ' process. reviews the design inputs. ... and design output to verify design adequacy. This independent review is provided to minimize the likelihood of design errors in items that are important to nuclear safety."
1) On July 30. 1996. it was discovered that a design change (PC/M 009-195) ' to install new nuclear instrumentation system drawers did not receive an independent design verification by a congetent individdal inde)endent of - the design process. Design change PC/M 009-195 was completed .)y a lead designer and a lead engineer. This design change was independently verified by a second designer who had no s)ecial knowledge of the i design. The design was then approved by t1e lead engineer whom was not , i independent of the design process. ' i 2) On July 30. 1996. it was discovered that an independent design review was not conducted for the installation of a new core flux monitoring i computer code BEACON. During initial operation of BEACON it was found i that the code did not compensate for a core mid-plane offset created by a previous core modification. The engineer who prepared the design was , not aware of the core mid-plane offset and the lack of an independent - review of the new BEACON code did not provide the opportunity to identify this omission.
NDTE: The apparent violations discussed in this enforcement conference are i subject to further review and are subject to change prior to any resulting enforcement decision.
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APPARENT VIOLATIONS VIOLATION B 10 CFR 73. Appendix G. states that an actual entry of an unauthorized person into a protected area or vital area be reported within one hour of discovery.
10 CFR 73. Appendix G. states that any failure. degradation. or discovered vulnerability in a safeguards system that could have allowed unauthorized or undetected access to a protected area or a vital area had compensatory measures not been Established. be recorded within 24 hours of discovery in the safeguards event log.
On October 9.1996. the licensee discovered that an individual had been terminated on July 28, 1996, and had entered the protected area on five different occasions, yet failed to make a renc.4 within the one hour timeframe. In addition, on September 19. 1996. the licensee discovered three individuals who had previously been terminated on July 27. July 28. and August i 24. 1996 that had access to the protected area and failed to report that discovery in the safeguards event log.
NOTE: The apparent violation discussed in this enforcement conference are subject to further review and are subject to change prior to any j resulting enforcement decision. ;
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APPARENT VIOLATIONS VIOLATION A 10 CFR 73.55(7) requires that licensee's shall establish an access authorization system to limit unescorted access to vital areas during non-
. emergency conditions to~ individuals who require access in order to perform their duties.
The licensee's Physical' Security Plan (PSP). Revision 48.. dated 2/23/96 states. "Only those individuals with identified need for access and having appropriate authorization, shall be granted unescorted Vital Area access." .
From July 28, 1996 to September 19. 1996 an individual whose employment terminated on July 28, 1996. had unescorted access to protected and vital areas without appropriate authorization. In addition, on August 7: August 9: and Au9ust 15.1996.- that individual entered the protected area and had access to vital areas.
Also, five other individuals had unescorted access to the protected and vital ;
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areas'after they were terminated from the period of July 27 to September 19.
1996. without appropriate authorization. However, those individuals did not i access the protected or vital areas.
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- The apparent violations discussed in this enforcement conference are -
' subject to further review and are subject to change prior to any resulting enforcement decision.
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- : .- . . . . - . APPARENT VIOLATION B .
As of August 19. 1996. Technical Specification (TS) 6.8.1.e required that
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i written procedures be established. implemented. and maintained covering Emergency Plan implementation. (The subject TS was deleted with NRC approval effective August 20. 1996. but these examples of inadequate EPIPs existed in the same form prior to August 20, 1996 as when identified during the
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inspection.)
~ Procedures covering Emergency Plan implementation were not adequately established. implemented, and maintained with respect to the following aspects ; of the Emergency Plan:
a. recovery activities, as discussed conceptually in REP Section 5.4 b. description and delineation of the licensee's emergency response organization.(ERO) and the detailed means for notifying ERO members in an emergency, as discussed generally in REP Section 2.2 i c. relocation of the OSC if required by radiological or other adverse , conditions during an emergency, as referenced in REP Section 2.4.4 NOTE: The apparent violations discussed in this enforcement confererice are ! subject to further review and are subject to change prior to any : resulting enforcement decision. ,
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APPARENT V10LATION C: . . I
._10 CFR 50.54(q) requires that nuclear power plant licensees follow and maintain in effect emergency plans which meet the planning standards of ~
10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50.
- "The primary objectives REP Section 7.2.1.
of emergency " Objectives".
response training-are stated the following:liarize as follows: 1. Fami appropriate-individuals with Emergency Plan and related implementing procedures. 2. , Instruct individuals.:in their-specific duties to ensure effective and - expeditious action during an emergency. 3. Periodically present significant .;
-changes in the scope or content of the Emergency Plan. 4. Provide refresher
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i training to ensure that personnel are familiar with their duties and ! responsibilities." REP Section 7.2.2. " Training of On-Site Emergency Response
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' Organization [ER0] Personnel". ' states "The training program for members of
' the on-site emergency response organization will include practical drills as ,
appropriate and participation in exercises, in which each individual- ! demonstrates an ability to perform assigned emergency functions... For employees with specific assignments or authorities as %rs of :.urswv : igAm. Initial training and annual retraining programs will be provided. . j Training must be current to be maintained on the site Emergency Team Roster."
' REP.Section 7.3.2 states. "The Plant Training Manager will ensure that on-site ! Emergency Response Organ 12ation personnel are informed of relevant changes in i the Emergency Plan and Emergency Plan Implementing Procedures [EPIPs).
a. In 1994 the licensee failed to provide initial training or annual l retraining for 17 positions (approximately 92 individuals) identified as j part of the on-site response organization In 1995, the licensee failed ) to provide initial training or annual retraining for 8 positions '
(approximately 54 individuals) identified as part of the on site l response organization.
b. The licensee's training program failed to include initial training or j t annual retraining on all procedures required to be implemented by ERO j L ' personnel in several identified positions. Examples: EPIP 3100027E. l
"Re-entry" - Emergency Coordinator. Radiation Team Leader. OSC 1
- Supervisor. Re-entry Team Supervisor. Re-entry Team Member. OSC Status I . ' Board Keeper. and OSC Dose Recorder. EPIP 3100026E. " Criteria for and l Conduct of Evacuation" - Emergency Coordinator. Assembly Area i 4 Supervisor. and TSC Security Supervisor. EPIP 3100035E. "Off-site J
- Radiation Monitoring" - Radiation Team Leader and TSC Supervisor. ;
. The Plant Training Manager failed to ensure that ERO personnel in several identified positions were infonned of relevant changes in I procedures. Example: EPIP 3100026E. " Criteria for and Conduct of -) Evacuations".
] c. For the calendar year 1995, the licensee failed to remove from the I emergency response organization two individuals who had not completed ; retraining as required, and whose qualifications had expired in 1994. l The licensee also failed to remove six individuals from the emergency 1 .!- team roster effective October 6.1996. who had not remained qualified to l fill response team requirements as a result of allowing their respirator i
. qualifications to lapse.- ,
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APPARENT VIOLATION A l , i 10 CFR 50.54(q) requires that nuclear power plant licensees follow and i maintain in effect emergency plans which meet the planning standards of 10 CFR 50.47(b) and the requirements in Appendix E to 10 CFR Part 50.
4 Section 2.4 of the licensee's Radiological Emergency Plan (REP). Revision 31.
, states that activation of the Technical Support Center (TSC) and the ! Operational Support Center (OSC) will be initiated by the y l Coordinator in the event of an Alert. Site Area Emergency, or ral l
: -Emergency, and that arrangements have been made to staff the TSC and OSC in a . J i timely manne**. Also specified is that activation of tne Emergency Operations l Facility (E06 is required for a Site Area Emergency or General Emergenc '
l > that arrangements have been made to activate the EOF in a timely manner.y, and i ' The REP requirements delineated above are implemented in part by Emergency Plan Inolementing Procedure (EPIP) 3100023E. "On-Site Emergency Organization
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and Call Directory". Revision 72. The instruction in Section 8.2 of that procedure states that, upon the declaration of an emergency classification.
"the Duty Call Supervisor will initiate staff augmentation" using the !
" Emergency Recall System or Appendix A. Duty Call Supervisor Call Directory to j notify persons. . . "
From approximately July 22 to October 3. 1996, arrangements were not available to staff or activate the TSC. OSC. or EOF in a timely manner because the , licensee did not have the capability to adequately implement either the ; primary method (using the Emergency Recall System) or the backup method (using i i the Duty Call Supervisor Call Directory) for notifying its personnel during ' off-hours to staff and activate the TSC. OSC. and EOF.
- NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any
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, resulting enforcement decision.
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VIOLATION B . Technical Specification 6.8. Procedures and Programs. paragraph 6.8.1 - requires. in part. that written procedures recommended in Appendix A of Regulatory Guide 1.33 revision 2. February 1978 shall be established and implemented.
- Engineering Quality Instruction (01) 3.7. Commter Software Control. Revision 1. Section 5.4. requires that S(R1 software s1all be validated and verified
' (V&V'ed) in accordance with Section 5.6 of 013.7. Section 5.6 states that new software shall.be V&V'ed prior to use. The V8V process includes the use of test cases to ensure the new software produces correct results. Item 4 of Section 5.6 states that technical adequacy shall be detensined by comparing the test case to results from' alternative methods such as functionally equivalent and previously validated software.
i During the Unit 1 Cycle 14 outage. BEACON core monitoring system was placed into service on Unit I without any benchmarking against IMPAX. the on-line i ' i core performance monitoring code BEACON was replacing. Instead. BEACON was installed on Unit 2 and be 'hmarked against CECORE. the core monitoring system , installed on Unit 2. whien did not require any modifications to acconnodate the core midplane offset.
NOTE $ The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision. - t
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E, VIOLATION C -l Technical Specification 6.8. Procedures and Programs, paragrapn 6.8.1.
- requires in part that written procedures recommended in Appendix A of ,
Regulatory Guide 1.33 revision 2. February 1978. shall be established and implemented. :
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Administrative Procedure No. 0006130. Condition Reports. Revision 4. dated I Marcil 22. 1996. Par. 8.1.1.A states in part that "Any individual who becomes ! " aware of a voblem or discrepant condition ... should initiate a CR. If doubt - exists, a Ct form should be initiated".
! I i On July 30. 1996. Instrument and Control technicians installing Modification ( PC/M 009-195 did not initiate a Condition Report when they became aware of a , discrepant condition when markings for electrical terminal connectors differed from existing cable markings. The failure to resolve the discrepant condition , resulted in incorrectly installing two excore nuclear instrumentation system - detectors.
, l NOTE: The apparent violations discussed in this enforcement conference are ., subject to further review and are subject to change prior to any :
- resulting enforcement decision. '
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APPARENT DEVIATION Amendment Nos. 147 and 86 to the operating licenses for Units 1 and 2. I respectively, were approved by the NRC on August 20.' 1996, and consisted of changes to the TS in response to the licensee's application dated August 16. ; 1995. Among numerous changes in these amendments were the deletion (for both ' Units 1 and 2) of the previous TS 6.8.1.d and TS 6.8.1.e. which formerly
. < specified that "Writt'en procedures shall be established. implemented and maintained" to cover " Security Plan implementation" and " Emergency Plan implementation". respectively. In Attachment 2. " Safety Analysis". to the ,
August 15. 1995 application. the licensee stated (in the introduction to the section addressing modifications to TS 6.5.1.6.1. 6.5.1.6.J. 6.8.1.d. and 6.8.1.e) that the " selected Technical Specifications are being relocated to the Emergency Plan or Security Plan as appropriate. Relocating these requirements to the appropriate plan will ensure the control of future changes are under the requirements of 10 CFR 50.54, 10 CFR 73.55 and 10 CFR 73.56."
The NRC's referenced approval of the subject application stated that the
" licensee proposes to relocate these review requirements and their implementing procedures to the St. Lucie Security and Emergency Plans..."
The licensee failed to relocate the requirements formerly found in TS 6.8.1.d and 6.8.1.e to the Security Plan or Emergency Plan, as applicable in accordance with the comm1tment to the NRC contained in the licensee's application dated August 16. 1995.
, - l NOTE: The apparent violations discussed in this enforcement conference are subject to further review and are subject to change prior to any . resulting enforcement decision.
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a - 01-08-97 05:25p Directory H:\1960 PEN.ENF\96040STL.DIR\*.* FrCO: 5,259,264
. Current <Dir> .. Parent <Dir>
EAW . 101,153 03-11-96 04:15p ENFINAL , 16,928 03-25-96 02:46p FINALSIG.SDE 40,801 04-01-96 03:06p NAMEADDR.OPR 1,010 03-21-96 04:28p RARRETF 96.A77 01-11-96 01 47p REPORT . 142,495 03-11-96 03:23p
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NRC CLOSED PREDECISIONAL ENFORCEMENT CONFERENCE
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i ST LUCIE NUCLEAR PLANT l
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NRC CLOSED PREDECISIONAL ENFORCEMENT CONFERENCE ST LUCIE NUCLEAR PLANT ! l MARCH 8,1996 IAS TITLE ,
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1 Predecisional Enforcement Conference Agenda 2 Expected Attendees, Meeting Announcement
3 Opening Remarks and introductions 4 NRC Enforcement Policy 5 Summary of the issues 6 Statement of Concerns / Apparent Violations 7 Inspection Report No. 50-335,389/96-03 ]l 8 Unit 1 Control Room Arrangement, CVCS Charging System Flow Diagram, Enforcement Pre-Panel Questionnaire 9 Licensee Procedure OP 1-0250020, Boron Concentration Control - Normal Operation; and TC 1-96-017 to OP 1-0250020 of 1/23/96 10 Licensee Procedure Ol5-PR/PSL-1, Preparation, Revision, Review / Approval of Procedures 11 Licensee Procedure AP 0010120, Conduct of Operations; and TC 0-96-014 to AP 0010120 ; of 1/29/96 I i
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12 Memo from E. Jordan on Licensed Power Level-
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of 8/22/80 : 13 St. Lucie Unit 1.FSAR
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.1 PREDEC!SIONAL ENFORCEMENT CONFERENCE AGENDA ST LUCIE l MARCH 8,1996, AT 10:30 A.M. i NRC REGION ll OFFICE, ATLANTA, GEORGIA
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l. OPENING REMARKS AND INTRODUCTIONS , ' S. Ebneter, Regional Administrator i t 11. NRC ENFORCEMENT POLICY i B. Uryc, Director ' Enforcement and investigation Coordination Staff !
' ; lll. SUMMARY OF THE ISSUES '
S. Ebneter, Regional Administrator
l < IV. STATEMENT OF CONCERNS / APPARENT VIOLATIONS !
! A. Gibson, Director !
. Division of Reactor Safety
V. LICENSEE PRESENTATION
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- T. Plunkett, President - Nuclear Division ]
Florida Power & Light Company ;
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VI. DREAK / NRC CAUCUS Vll. NRC FOLLOWUP QUESTIONS Vill. CLOSING REMARKS S. Ebneter, Regional Administrator l l i
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.a l a : EXPECTED ATTENDEES. ,
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Tom Plunkett, President .- Nuclear, Division,L FPL ~ ' ,
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Bill Bohlke, Vice President,' St. Lucie Nuclear Plant j j- 1 Jim Scar'ola, Plant General Manager. St. Lucie:
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i ~ Dan-Denver, Engineering Manager, St. Lucie . r Ed Weinkam,. Licensing Manager, St. L'ucie. j li Peter Honeysett, Nuclear Plant Supervisor, St. Lucie
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Frank Cone, Reactor. Controls. Operator, St. Lucie 'l' - Hank Holzmacher, Reactor Controls. Operator, St. Lucie .
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['- NaC { I ' Stew Ebneter, Regional Administrator, Region 11 (Rll) s Luis Reyes, Deputy Regional Administrator, Rll Al Gibson,- Director, Division of Reactor Safety (DRS), Rll - Ellis Merschoff, Director, Division of Reactor Projects'(DRP), Ril L , Gene Imbro; Director, Project Directorate Il-2, NRR
- James Beall, Enforcement Coordinator, Office of Enforcement (OE)
Johns Jaudon, Deputy Director, DRS, Ril
- .Jon Johnson, Deputy Director, DRP, Ril Bruno Uryc, Director, Enforcement and Investigation Coordination Staff
! (EICS), Ril [ Charles Casto, Chief, Engineering Branch, DRS, Ril
Tom Peebles, Chief, Operations Branch, DRS, Ril
Kerry Landis, Reactor Projects Branch 3, DRP, Ril ' Jan Norris, Project Manager, NRR . Linda Watson, Senior Enforcement Specialist, EICS, Ril i F Carolyn Evans, Regional Counsel, Ril .) , ~ Mark Miller, Senior Resident inspector, St. Lucie, DRP, Ril i
- Robert Schin, Reactor inspector,. Engineering Branch, DRS, Rll Edwin Lea, Project Engineer, Reector Projects' Branch 3, DRP, Ril -
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OPENING REMARKS AND INTRODUCTIONS F (S. Ebneter)
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Good morning. I am Stew Ebneter, Regional Administrator for the
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Nuclear Regulatory Commission's Region ll Office. This morning we will conduct a predecisional enforcement conference between the NRC e and St. Lucie which is CLOSED to public observation. l
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The agenda for the conference is shown in the viewgraph. Following my brief opening remarks, Mr. Bruno Uryc, the Director of the Region ll Enforcement Staff, will discuss the Agency's Enforcement Policy. I will then provide introductory remarks concerning my perspective on the
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events to be addressed today. Mr. Albert Gibson, Director of the f Division of Reactor Safety, will then discuss the apparent violations.
] , You will then be given an opportunity to respond to the apparent ; violations. In this regard, I wish to reiterate to you that the decision to hold this conference does not mean that the NRC has determined that violations have occurred or that enforcement action will be taken. This conference is an important step in arriving at that decision.
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Following your presentation, l plan to take about a 10-minute break so that the NRC can briefly review what it has heard and determine if we ;
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have follow-up questions. Lastly, I will provide concluding remarks.
At this point, I would like to have the NRC staff introduce themselves i and then ask you to introduce your participants.
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[lNTRODUCTIONS)
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Thank you.
Mr. Uryc will now discuss the Agency's Enforcement Policy.
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NRC~ ENFORCEMENT POLICY AND PROCEDURE d (B. Uryc) j
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After an' apparent violation is identified, it is assessed in accordance' j a with the Commission's Enforcement Policy, which was recently revised and became effective on June 30,1995. The Enforcement Policy has - !
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been published as NUREG-1600. ] l i The assessment of an apparent violati'a involves categorizing the
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apparent violation'into one of four severity levels based on safety and regulatory significance. For cases where there is a potential for
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escalated enforcement action, that is, where the severity level of the
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apparent violation is categorized 'at Severity Levei 1, ll, or Ill, a 1 I ' predecisional enforcement conference is held. i 4 ;
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There are three primary enforcement sanctions available to the NRC , ' and they are Notices of Violation, civil penalties, and orders. Notices . of Violation and civil penalties are issued based on identified violations.
Orders may be issued for violations, or, in the absence of a violation,
'because of a significant public health 'or safety issue. .
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This predecisional enforcement conference is essentially _ the last step 1
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final enforcement decision. -j
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' purpose here today-is to obtain information that will assist us in i
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idetermining the appropriate enforcement action, such as: -(1) a j
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'~ common understanding.of the facts, root causes and missed 1
, y opportunities associated with the violations, (2) a common : e j "
' understanding of corrective action taken or planned, and (3) a common i
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understanding of the significance of issues and the need for lasting
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" comprehensive action.
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'The apparent violations discussed at this conference are subject to
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l t ! L further review and they may be subject to change prior to any resulting ; . ' enforcement action. It is important'to note that the decision to ,
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conduct this conference does not mean that NRC has determined that a !
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.. violation has occurred or.that enforcement action will be taken. l
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' l should'also' note at this time that statement of views or the l
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a expression of ' opinion _made by.the Nhc staff at this' conference, or' the.
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/ack thereof,' are not intended to represent final determinations or ;
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Following the. conference, the Regional Administrator in conjunction with the NRC Office of Enforcement and other NRC Headquarters t
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offices will reach an~ enforcement decision. This process should take !
' about four weeks to accomplish.
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E Predecisional' enforcement conferences are ncrmally closed to the , public as is this conference. However, the Commission implemented a , trial program in July 1992 to allow certain enforcement conferences to-be open for public observation. [ July 10,1992 - Federal Register] This >, trial program was recently.exte'nded for additional evaluation.
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. Finally, if the final enforcement action involves a proposed civil penalty or an order, the NRC willissue a press release 24 hours after the [
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l ~ enforcement action is issued.
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SUMMARY OF THE ISSUES (S. Ebneter)
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Issues:
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- 1) Apparent V!olations of St. Lucie Operating Procedures for Reactor Coolant System Boron Dilution, Watch Turnover, Adherence to Procedures, and Prompt Reporting of Events ]
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i l 2) Apparent Violation of '10 CFR 50, Appendix B, Design Control, Requirements in that a Procedure for Adding a Mixture of Demineralized Water and Boric Acid to the Reactor Coolant i
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System did not implement the Method Stated in the FSAR I 3) Apparent Violation of 10 CFR 50.59 in that a Change was Made to the Unit 1 Procedure for Reactor Coolant System Boron Dilution on January 23,1996, that Differed from the Method Stated in the FSAR, Without Performing a Safety Evaluation I l
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Consequences:
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Operators allowed an unmonitored reactivity addition, which caused
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the Unit 1 nuclear reactor to exceed 100% power, and then did not ; promptly report'the event to licensee management. Also, during this ,
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event, reactivity was added to the Unit 1 reactor in a method that was : different from that described in the FSAR, l
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STATEMENT OF CONCERNS / APPARENT VIOLATIONS (A. Gibson)
This is a Predecisional Enforcement Conference to discuss three . apparent violations. -The first one is associated with the apparent violations of operating procedures by licensed operators. These involve operators failing to follow procedures for reactor coolant system boron dilution, watch turnover, adherence to procedures, and prompt reporting of events. These apparent violations were identified by the licensee.
. The second and third apparent violations involve the failure to implement operating methods described in the FSAR into an operating procedure and then changing that procedure to further deviate from operating methods described in the FSAR, without performing a required safety evaluation. These apparent violations were identified by the NRC.
In view of these apparent violations, we are concerned with licensee control of licensed activities.
.. - . .. - . k Our findings are documented in NRC Inspection Report 50-335,389/96-03, which was transmitted to you on February 22,1996. At this conference, we are affording -you the opportunity to provide information relative to:
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Any errors in the inspection report
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The severity of the violations
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Any escalation or mitigation considerations
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, . ISSUES TO BE DISCUSSED l
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1. Technical Specification'6.8.1.a required that written procedures be l established, implemented, and maintained covering the activities: !' recommended in Appendix A of Regulatory Guide 1.33, Rev 2, February.1978. Appendix A. includes operating procedures for the ,
' . chemical and' volume control system and administrative procedures for relief turnover, procedural adherence, and authorities and !
responsibilities for safe ' operation. l i Operating Procedure No. 1-0250020, Boron Concentration Control - )' Normal Control, Rev. 35, step 8.5.14 required that, when adding a blend of primary makeup water and boric acid to the reactor. coolant ; system by 'using the manual mode of operation and a flow path directly ; to the charging pump suction, operators monitor the water flow i totalizer and close valve V2525 after the desired volume was added. i
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Administrative Procedure No. 0010120, Conduct of Operations, Rev i 79, Appendix D, Crew Relief / Shift Turnover, required that, for short term watchstander relief, a turnover be conducted including: general l watchstation status, off-normal conditions, and tests in progress.
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Administrative Procedure No. 0010120, Appendix M, Procedural l Compliance and implementation, required .that controlled procedures be.
implemented and complied with in accordance with the instructions j provided in QI 5-PR/PSL-1. Procedure Qi 5-PR/PSL-1, Preparation, l Revision,. Review / Approval of Procedures, Rev 67, Section 5.13.2, stated that all procedures shall be strictly adhered to and identified that Operating Procedure 1-0250020 was not considered " skill of the trade" and was not to be performed from memory without referring to the 1 procedure.
Administrative Procedure No. 0010120, Appendix E, Notification of Operations Supervisor /FPL Management, required prompt verbal
. notification of the Operations Supervisor for unplanned reactivity changes.
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a.. On January 22,1996, at approximately 2:30 a.m., Unit 1 operators failed.to monitor the water flow totalizer and failed to close valve V2525 after the desired volume of primary makeup water.was added to the reactor coolant-system when using the manual mode of operation and a flow path directly to the charging-pump suction. Operators had desired to add between 25 and 40
. gallons of primary makeup water, but failed to stop the dilution
_ j until approximately 400 gallons were added. During'this time, the - '
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temporary relief operator at the controls was unaware that a i boron concentration dilution was in progress, which resulted in an
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unmonitored reactivity addition. The senior reactor operator and . other operators in the control room were also unaware that a l reactivity addition was in progress. {
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b.. On January 22,1996, at approximately 2:30 a.m., the Unit 1- i operator at the controls conducted a short term watchstander i relief'with an inadequate turnover in that it failed to include ) general watchstation status and conditions including that a boron j concentration dilution.was in progress. As a result, the relief j operator at the controls was unaware that a boron concentration j dilution was in progress and failed to adequately monitor and control the dilution.
c. On January 22,1996, at approximately 2:30 a.m., operators performed Operating Procedure 1-0250020 from memory, without referring to the procedure, and without strictly adhering to the' procedure. At the time, the procedure was written such that the boron concentration dilution that was performed could not have been performed by strictly adhering to the procedure.
d. On January 22,1996, between 2:30 a.m. and 5:45 a.m., operators failed to give prompt verbal notification to the Operations Supervisor for unplanned reactivity changes that had 1 occurred. i ,
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NOTE:- The apparent violations discussed in this predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.
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ISSUES TO BE DISCUSSED 2. 10 CFR 50, Appendix B, Criterion ill, Design Control, requires that measures be established to assure that applicable regulatory.
requirements and the design basis, as specified in the license application, are correctly translated into procedures.
The design basis, as specified in the license application, was not correctly translated into procedures in that, from approximately January 24,1976 (before the Unit 1 operating license was issued), through January 23,1996, the Safety Analysis Report description of the method for adding a mixture of boric acid and primary water to the reactor coolant system had not been correctly translated into procedures. The Unit 1 procedure for adding a mixture of boric acid and demineralized water to the reactor coolant system (in manual and directly to the suction of the charging pumps) was different from the method stated in the SAR (in automatic and to the volume control j tank). The method used in the Unit 1 procedure allowed adding reactivity faster and without an automatic shutoff. l i l . f ( .
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NOTE: The apparent violations discussed in this predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement decision.
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ISSUES-TO BE-DISCUSSED i
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I 10 CFR 50.59 allows the.Ilcensee.to make changes to the procedures l3. ! i as described in the Safety Analysis Report (SAR), without prior, ) L - Commission approval, unless~the change involves, in part, ari j I .unreviewed safety question. A proposed change shall be deemed to 1 involve an unreviewed safety question if, in part, the probability of .; ) ' occurrence of an accident important to safety previously evaluated in' l . :the' SAR may be increased. The licensee shall maintain records of- . ! !
. changes in procedures made pursuant to this section, to the extent that .:
.they. constitute changes in procedures as described in the SAR. These f records must include a written safety evaluation which provides a basis. l forlthe determination that the change does not involve an unreviewed j safety question. j
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On January 23,1996, the licensee made a change to Unit 1 l procedures as described in the SAR and the records for that change did j not' include a written safety evaluation. The SAR, paragraph 15.2.4.1, ! states that boron dilution must be conducted in automatic (such that l when the specific amount has been injected, the demineralized water
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control valve is shut automatically) and describes a flow path into the volume control tank. The SAR states that, in part, because of the procedures involved, the probability of a sustained or erroneous dilution is very low. However, Temporary Change 1-96-017 to procedure 1- : 0250020, Boron Concentration Control - Normal Operation, Rev. 35, l added instructions for dilution in manual and directly to the suction of i the charging pumps. The TC allowed adding reactivity faster than the l SAR method and without an automatic shutoff. The licensee l implemented the TC on January 23,1996, without a written safety ! evaluation. l
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NOTE: The apparent violations discussed in this predecisional l enforcement conference are subject to further review and are j subject to change prior to any resulting enforcement decision.
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CLOSING REMARKS (S. Ebneter) In closing this predecisional enforcement conference, I remind the Licensee : of two things:
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First, the apparent violations discussed at this predecisional enforcement conference are subject to further review and may be subject to change prior
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to any resulting enforcement action.
Second, the statements of views or expressions of opinion made by NRC employees at this predecisional enforcement conference, or the lack thereof, are not intended to represent final agency determinations or beliefs.
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01-08-97 05:25p Directory H:\1960 PEN.ENF\96040STL.DIR\*.* { Frco 5,259,264 .j.
.- Current <Dir> .. Parent <Dir> [ EAW . 101,153 03-11-96 04:15p ENFINAL . 16,928 03-25-96 02:46p t FINALSIG.SDE 40,801 04-01-96 03:06p NAMEADDR.OPR 1,010 03-21-96'04:28p RABREIF . 96,672 03-11-96 03:42p REPORT . 142,495 03-11-96 03e22n
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A e EA 96-040 Florida Power & Light Company ATTN: President - Nuclear Division P. O. Box 14000 Juno Beach. Florida 33408-0420 SUBJECT: NRC INSPECTION REPORT N05, 50-335/96-03 AND 50-389/96-03
Dear Mr. Goldberg:
This refers to the special followup inspection of the January 22. 1996. Unit 1 overdilution event. The inspection was conducted on January 26-30, 1996. at the St. Lucie facility. This matter was again discussed on February 8. 1996, in a meeting in Atlanta. The )urpose of the inspection was to determine whether activities authorized )y the license were conducted safely and in accordance with NRC recuirements. At the conclusion of the inspection, the findings were discussec with you and those members of your staff identified in the enclosed report.
Areas examined during the inspection are identified in the report. Within these areas the inspection consisted of selective examinations of procedures and representative records, interviews with personnel, and observation of activities in progress.
Based on the results of this inspection, three apparent violations were identified and are being considered for escalated enforcement action in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy). NUREG-1600. The first apparent violation involves operator failures to follow procedures for reactor coolant system boron dilution, watch turnover, adherence to procedures, and prompt reporting of events. As a result of these errors, operators exceeded 100% reactor power on January 22, 1996. The second apparent violation involves inadequate design control in that the procedure for adding a mixture of demineralized water and boric acid to the reactor coolant system did not implement the method stated in the Final Safety Analysis Report (FSAR), and had not done so since January 1976. The third apparent violation involves a change that was made to the Unit 1 procedure for reactor coolant system boron dilution on January 23, 1996, that differed from the method stated in the FSAR. without performing a required safety evaluation.
No Notice of Violation is presently being issued for these inspection findings. In addition, please be advised that the number and characterization of the apparent violations described in the enclosed inspection report may change as a result of further NRC review.
A predecisional enforcement conference to discuss these apparent violations has been scheduled for March 8, 1996. Also, you have been requested to bring i
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FPL 2 the three licensed operators who were invo l ved in the overdilution event to 3 the enforcement conference. The decision to hold a predecisional enforcement 1 conference does not mean that the NRC has determined that a violation has , occurred or that enforcement action will be taken. This conference is being held to obtain information to enable the NRC to make an enforcement decision, such as a common understanding of the facts, root causes, missed opportunities j to identify the apparent violations sooner, corrective actions, significance l of the issues, and the need for lasting and effective corrective action. In , addition, this is an opportunity for you to point out any errors in our t inspection report and for you to provide any information concerning your perspectives on 1) the severity of the violations, 2) the application of the ; factors that the NRC considers when it determines the amount of a civil . Senalty that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy, and 3) any other application of the Enforcement Policy to , this case, including the exercise of discretion in accordance with Section VII, l
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You will be advised by separate correspondence of the results of our deliberations on this matter. No response regarding these apparent violations ! is required at this time.
In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
Should you have any questions concerning this letter, please contact us.
Sincerely . Albert F. Gibson, Director Division of Reactor Safety Docket Nos. 50-335, 50-389 !
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License Nos. DPR-67. NPF-16
Enclosures:
1. Inspection Report 2. Enforcement Policy: Section V. "Predecisional Enforcement Conferences"
REGION ll OFFICE, ATLANTA, GEORGIA ,
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l. OPENING REMARKS AND INTRODUCTIONS [ L. Reyes, Deputy Regional Administrator
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11. NRC ENFORCEMENT POLICY
- B. Uryc, Director
- Enforcement and Investigation Coordination Staff Ill. SUMMARY OF THE !SSUES L. Reyes, Deputy Regional Administrator IV. STATEMENT OF CONCERNS / APPARENT VIOLATIONS
J. Jaudon, Acting Deputy Director
- Division of Reactor Projects V. LICENSEE PRESENTATION T. Plunkett, President, Nuclear Division Florida Power and Light VI. BREAK / NRC CAUCUS Vll. NRC FOLLOWUP QUESTIONS i
Vill. CLOSING REMARKS L. Reyes,' Deputy Regional Administrator , i
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a , ~ EXPECTED ATTENDEES
' Licensee , ,
t T. Plunkett,. President, Nuclear Division ; W. Bohlke,.Vice President, Engineering _ A. Stall, Site Vice President, St. Lucie
-J. Holt, Information Services Supervisor-E. Benken, Licensing Engineer ;
- NRC L. Reyes, Deputy Regional Administrator, Region 11 (Rll) . J. Jaudon, Acting Deputy Director, Division of Reactor Projects (DRP), Ril;
A.'Gibson, Director, Division of Reactor Safety (DRS), Ril B.' Uryc, Director, Enforcement and investigation Coordination Staff . (EICS), Rll ' C. Casto, Chief, Engineering Branch, DRS, Ril - K. Landis, Chief, Reactor Projects Branch 3, DRP, Ril T. Peebles, Chief, Operating Licensing Branch, DRS, Ril C. Evans, Regional Counsel, Ril M. Miller, Senior Resident inspector, St. Lucie, DRP, Ril r E. Lea, Project Engineer, Reactor Projects Branch 3, DRP, Ril
- L. Mellen, Proje'ct Engineer, Reactor Projects Branch 3, DRP, Ril L. Wiens, Senior Project Manager, Reactor Projects 11/2, NRR 2.
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> OPENING REMARKS AND INTRODUCTIONS !
(L. Reyes) !
l Good morning. I am Luis Reyes, Deputy. Regional Administrator for the Nuclear Regulatory Commission's Region II Office. This morning we will conduct a predecisional enforcement conference between the NRC and St. Lucie which is CLOSED to public observation.
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The agenda for the conference is shown in the.viewgraph. Following my brief opening remarks, Mr. Bruno Uryc, the Director of the Region ll Enforcement Staff, will discuss the Agency's Enforcement Policy. I will then provide introductory remarks concerning my perspective on the events to be addressed today. Johns Jaudon, Acting Deputy Director of the Division of Reactor Projects, will then discuss the apparent ! violations. You will then be given an opportunity to respond to the apparent violations, in this regard, I wish to reiterate to you that the ; decision to hold this conference does not mean that the NRC has determined that violations have occurred or that enforcement action
will be taken.- This conference is an important step in arriving at that decision. ;
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e.am - o y J..-.-, 2 - A ~ sa& . e I
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Following your presentation, I plan to take about a 10-minute break so that the NRC can briefly review what it has heard and determine if we r have follow-up questions. Lastly, I will provide concluding remarks.
At this point, I would like to have the NRC staff introduce themselves and then ask you to introduce your participants.
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[lNTRODUCTIONS) - Thank you.
Mr. Uryc will now discuss the Agency's Enforcement Policy.
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NRC ENFORCEMENT POLICY j (B. Uryc) ;
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NRC Enforcement Policy and Procedure After an apparent violation is identified, it is assessed in accordance with the Commission's Enforcement Policy, which was recently revised j
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and became effective on June 30,1995. The Enforcement Policy has ; i ; j been published as NUREG-1600. ;
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- . The assessment of an apparent violation involves categorizing the i apparent violation into one of four severity levels based on safety and
!
- regulatory significance. For cases where there is a potential for
;
escalated enforcement action, that is, where the severity level of the i apparent violation is categorized at Severity Level I, ll, or Ill, a predecisional enforcement conference is held.
:
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'There are three primary enforcement sanctions available to the NRC l
and they are Notices'of Violation, civil penalties, and orders. Notices , of Violation and civil penaltie's are issued based on identified violations. [ Orders may be issued for violations, or, in the absence of a violation, because of a significant public health or safety issue. 3 i
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1e This predecisional enforcement conference is essentially the last step- i
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' of the inspection or investigation process before the staff makes its
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i final enforcement decision. j
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~ The purpose of this conference is not to negotiate a sanction. Our i
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purpose' here today is:to obtain information that will assist us in l r determining the 'appropriato enforcement action, such as: (1) a common understanding of the facts, root causes and missed , opportunities associated with the violations, (2) a common
!
understanding of corrective action taken or planned, and (3) a common ;
,
understanding of the significance of issues and the need for lasting comprehensive action. .
:
The apparent violations discussed at this conference are subject to
:
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further review and they may be subject to change prior to any resulting enforcement action. It is important to note that the decision to conduct this conference does not mean that NRC has determined.that a
- violation has occurred.or that enforcement action will be taken.
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I should also note at this time that statement of views or the , expression of opinion made by the NRC staff at this conference, or the
/ack there'of, are not intended to represent final determinations or: [
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' beliefs.' . :
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. Following the conference, the Regional Administrator in conjunction .
with the NRC Office of Enforcement and other NRC Headquarters offices will reach an enforcement decision'. This process should take ; about four weeks to accomplish. 1
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Predecisional enforcement conferences are normally closed to the i public as is this conference. However, the Commission implemented a trial program in July 1992 to allow certain enforcement conferences to I be open for public observation. [ July 10,1992 - Federal Register] }}