IR 05000483/1992020

Discusses Insp Rept 50-483/92-20 & Forwards Notice of Violation.Insp Reviewed Circumstances Surrounding Loss of CR Annunciator Event.Violation Not Being Issued for Failure to Declare Alert as Required by Emergency Plan

ML20128D542
Person / Time
Site:	Callaway
Issue date:	02/04/1993
From:	Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Schnell D UNION ELECTRIC CO.
Shared Package
ML20128D545	List: IR 05000483/1992020 ML20128D665
References
EA-92-215, NUDOCS 9302100174
Download: ML20128D542 (5)

Text

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'% ***** #*e February 4, 1993 Docket No. 50-483 License No. NPF-30 EA 92-215 Union Electric Company ATTN: Mr. Donald Senior Vice President - Nuclear Post Officer Box 149 - Mail Code 400 St. Louis, Missouri 63166

Dear Mr. Schnell:

SUBJECT: NOTICE OF 'IOLATION (NRC INSPECTION REPORT NO. 50-483/92020(DRP))

This refers to the special NRC inspection conducted during the period of October 26 through October 30, 1992, at the callaway Plant. The inspection included a review of the circumstances surrounding the loss of control room annunciator event which occurred on October 17, 1992. The initial NRC review of this event was performed by an Augmented Inspection Team (AIT). The report documenting the AIT findings was sent to you by letter dated November 10, 1992. The report documenting this inspection was sent to you by letter dated November 18, 1992. An enforcement conference was held on November 24, 1992, to discuss the findings of the inspection and your corrective actions. The report summarizing the conference was sent to you by letter dated December 4, 1992.

At 1:00 a.m., on October 17, 1992, all four annunciator field contact power supply output fuses blew after replacement of a failed power supply. This resulted in the loss of all main control board annunciators. However, because only 371 of 683 annunciators lit, the control room staff incorrectly believed that those annunciators which had remained dark were operable.

Upon replacement of the output fuses at 1:56 a.m., 519 of the annunciators were restored to service. Due to an inadequate post-maintenance test, plant personnel failed to recognize that full operability of 164 annunciators had not been restored.

Apparently, the power supply failure caused a voltage spike that blew an additional ten fuses, which the retest failed to detect.

The plant staff subsequently identified and replaced the failed fuses later that day. The plant had been operating at 100 percent power throughout the event.

CERTIFIED MAIL RETURN RECEIPT REQUESTED l

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Union Electric Company -2 -

February 4, 1993 A number of factors contributed to this event, including inadequate knowledge of the annunciator system by plant personnel, including licensed operators, instrumentation and control personnel, and engineers; inadequate teamwork and communications; poor work control practices; the lack of a questioning attitude or complacency by plant personnel; inadequate system design; and failure to learn from previous events.

We recognize that the annunciator system is not safety-related nor considered in any of the. plant's safety analyses. We also recognize that safety-related instrumentation remained available to monitor plant parameters, automatic safety systems were unaffected, and no significant systems were out-of-service.

However, the control room operators routinely rely upon the annunciator system to assist them in operating the plant and will only rely solely on safety-related instrumentation when they recognize the anr.unciator system is unavailable. The failure of your staff to recognize the status of the annunciator system (Violation A), as well as their failure to perform an adequate retest to ensure the system's operable status (Violation E), make this matter a significant regulatory concern. The initial response of plant personnel to the loss of annunciators did not meet our expectations and was not consistent with your plant's past good performance.

We acknowledge your event specific corrective actions which include training, development of off-normal and system troubleshooting procedures, improved-work controls, improved annunciator system design, and improved emergency action criteria. We also acknowledge your generic corrective actions which include a review of other important nonsafety-related systems for similar problems; improved management controls; steps to improve procedural adherence, teamwork, and communications; and improvements to the corrective action program.

In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," (Enforcement Folicy) 10.CFR Part 2, Appendix C, Violations A and B in the enclosed Notice have been categorized as-a Severity Level III problem. After consultation with the Director, Office of Enforcement, and the Deputy; Executive Director for Nuclear Reactor Regulation, Regional Operations and Research, I have decided that a civil penalty will

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not be issued in this case in recognition of your identification I of the root causes, your broad and comprehensive corrective actions, and your plant's overall good past performance. It is expected that based on your past performance your actions will ensure that these failures will not recur.

A violation is not beina issued for the failure to declare an ALERT as required by the emergency plan for the loss of

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Union Electric Company -3 - February 4, 1993 annunciators, which was the apparent violation discussed at the enforcement conference. In reaching that decision,.we concluded that such a citation would not address our primary concerns, which are discussed above. Additionally, we considered the reduced significance of the failure to declare an ALERT given that, Revision 3 of Regulatory Guide 1.101 (August 1992) accepted the new guidance for developing emergency action levels contained in NUMARC/NESP-007, Revision 2. Under most circumstances the new guidance requires declaration of an ALERT for a loss of all control room annunciators only if such a loss is concurrent with a significant plant transient or loss of compensatory non-alarming indications. Although you have not incorporated NESP-007 into your program, declaration of an ALERT _would not have been required for the October 17th event under the new guidance had your staff recognized the-loss of annunciators.

In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice,"

a copy of this letter will be placed in the NRC Public Document Room.

Given the extent of the corrective actions that were discussed at the enforcement conference no response to the enclosed Notice is required. However, should you wish to respond, please submit that response in accordance with the directions contained in the enclosed Notice.

Sincerely, I

W A. Bert Davis Regional Administrator Enclosure: Notice of Violation cc w/ enclosure:

G. L. Randolph, Vice President, Nuclear Operations J. V. Laux, Manager, Quality Assurance Tom P. Sharkey, Supervising Engineer, Site Licensing DCD/DCB(RIDS)

OC/LFDCB Resident Inspector, RIII Region IV Resident Inspector, Wolf Creek K. Drey cc w/ enclosure: See Next Page

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February 4,1993

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Chris R. Rogers, P.E.

Utility Division, Missouri

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Public Service Commission

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Gerald Charnoff, Esq.

Thomas Baxter, Esq.

R. A. Kucera, Deputy Director,

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Department of Natural Resources

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