IR 05000387/1997002
| ML18026A481 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 06/27/1997 |
| From: | JONES G T PENNSYLVANIA POWER & LIGHT CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-387-97-02, 50-387-97-2, 50-388-97-02, 50-388-97-2, PLA-4632, NUDOCS 9707090079 | |
| Download: ML18026A481 (17) | |
Text
CATEGORY1REGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ICCESSIO!<+NBR:9707090079DOC.DATE:97/06/27NOTARIZED:NODOCKETIACIL:50-387SusquehannaSteamElectricStation,Unit1,Pennsylva0500038750-388SusquehannaSteam'ElectricStation,Unit2,Pennsylva05000388AUTH.NAMEAUTHORAFFILIATIONJONESiG.T.PennsylvaniaPower6LightCo.RECIP.NAMERECIPIENTAFFILIATIONDocumentControlBranch(DocumentControlDesk)
SUBJECT: Respondstoviolationsnotedininsprepts50-387/97-0250-388/97-02.Correctiveactions:revisedSafetyTaggingSys,trainedpersonnelonnewsafetytaggingequipment&issuedhandsonbriefingpackageresignificanceofevent.DISTRIBOTIONCODE:IEOIDCOPIESRECEIVED:LTRIENCLISIZE:TITLE:General(50Dkt)-InspRept/NoticeofViolationResponseNOTES:RECIPIENTIDCODE/NAMEPD1-2PDCOPIESLTTRENCL11RECIPIENTIDCODE/NAMEPOSEUSNYICCOPIESLTTRENCI1105000387G0RINTERNAL:ACRSAEOD/~~+FILECENT~Eh'RR/DRIER/HHFBNRR/DRPM/PERBOEDIRRGN1FILE0122111111111111AEOD/SPD/RABDEDRONRR/DISP/PIPBNRR/DRPM/PECBNUDOCS-ABSTRACTOGC/HDS2111111111111DEXTERNAL'ITCOBRYCEPJHNRCPDRNOTES:11NOAC11NUDOCSFULLTEXT1111110NOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESKSROOMOWFNSD-5(EXT.415-2083)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEEDITOTALNUMBEROFCOPIESREQUIRED:LTTR21ENCL21
~~PennsylvaniaPower&.LightCompanyTwoNorthNinthStreet~Allentown,PA18101-1179~610/774-5151GeorgeT.JonesNcePresident-ivac/earOperations610/774-7602Fax:610/774-7797JUN271997U.S.NuclearRegulatoryCommissionAttn.:DocumentControlDeskMailStopPl-137Washington,D.C.20555SUSQUEHANNASTEAMELECTRICSTATIONRESPONSETONRCINTEGRATEDINSPECTIONREPORT50-387/97-02,50-388/97-02:NON-SAFETYRELATEDMAINTENANCEINDUCEDINCIDENTS.PLA-4632FILER41-2DocketNos.50-387and50-388Thepurposeofthisletteristoprovidetherequestedresponsetothenon-safetyrelatedmaintenanceinducedincidentsnotedintheNRCIntegratedInspectionReport50-387/97-02,50-388/97-02.ThefoureventsarebrieflydescribedinAttachmentA.Threeoftheeventshadthepotentialtoresultinpersonnelinjury;thefourthresultedinaplanttransientandposedachallengetooperations.PennsylvaniaPowerandLighttakesalloftheseeventsveryseriously.EachoftheseeventswasenteredintoourConditionReportprocess,hasreceivedanin-depthrootcauseevaluationresultinginspecificcorrectiveactionstopreventrecurrenceandidentificationofcommonissuesbetweentheevents.PP&Lreliesonthedefenseindepthprincipleforcontrolofevents.Thisprincipalconsistsofdesign,proceduresandpeople.Inthecaseofeachoftheevents,boththeprocedureandthepeoplebarriersbrokedowntosomedegree.ProceduresOurproceduresinsomecaseslackedclarityanddetail.Aprocedurewriter'sguidehasbeendeveloped.Itsintentistoachieveconsistentlywrittenproceduresthathavetherightlevelofdetail,areconcise,easytoreadandunderstand,and,mostofall,areaccurate.Anongoinginitiativeisinprocesstoimproveourprocedures97070900799706277PDRPDRADOCK0500038OG003"~lllllllllllllllllllllillillllllllllll
FILER41-2,PLA-4632DocumentControlDeskHumanPerformanceWehaverecognizedthatineachevent,therewasafailureinthehumanperformanceaspectoftheactivities.Thisisthemostsignificantissuetocomeoutofthereviewoftheseevents.ItisanestablishedNuclearDepartmentgoaltoachieveanevent-freeenvironmentfromahumanperformancestandpoint.WehaveahighpriorityDepartmentinitiativetoimprovehumanperformanceandreducethenumberofhumanperformanceerrors.PP&Lhasaddressedthehumanperformanceimprovementissuefromtwo'perspectives:thesupervisor'sroleandtheindividual'srole.NuclearDepartmentmanagementhasemphasizeditsexpectationstothesupervisors.Trainingisbeingmodifiedtoincludeformaltrainingandonthejobtraining,whichspecificallyaddressesadministrativeandhumanperformanceconcerns.Wehavealsoinstitutedafieldreviewchecklistwithemphasisonhumanperformance.Eachmaintenanceworkcrewisbeingtrainedinthenextroundofcrewtrainingtotakeadvantageofthecrew/foremanteamconcept.Thetrainingwillreinforce/emphasizethateachmemberofthecrewneedstobeproficientingoodhumanperformancetechniques.Inadditiontocrewtrainingandforemanspecifictraining,allmaintenanceforemenaretargetedtoattendLeadershipAcademytraining.Thiswilldirectlyenhancetheirabilitytoeffectivelyinfluenceandleadtheircrews.Wehavelookedattheseeventsindividuallyandcollectively.WehavealsoevaluatedourrecentexperienceagainstindustryexperienceaswellaspreviousSusquehannaexperience.Wehaveidentifiedweaknessesinourpriorreviewofsimilarevents.Theseweaknessesareunderstoodandtheappropriateactionshavebeentaken.Theseissuesinclude:rootcauseanalysis,changemanagement,andtrainingandqualifications.Asstatedearlier,PP&Ltakesalloftheseeventsveryseriously.Webelievethatthecorrectiveactionsidentifiedinthisletterwillprovidelongtermsolutionsthatwillpreventrecurrenceoftheidentifiedconditions.Wetrustyouwillfindthisresponsecompleteandadequateforyourreview.PP&LwelcomestheopportunitytodiscusstheinitiativesnotedabovewiththeNRC,shouldtheNRCfeeltheneedforadditionalinformationisnecessary.AnyquestionsonthisresponseshouldbedirectedtoMr.J.M.Kennyat(610)-774-7535.Verytrulyyours,G.T.JoAttachment
-3-FILER41-2,PLA-4632DocumentControlDeskcopy:NRCRegionIMr.C.Poslusny,Jr.,NRCSr.ProjectManager-OWFNMr.K.M.Jenison,NRCSr.ResidentInspector-SSES ATTACHMENTATOPLA-4632PageIof6Eventl:PersonnelWorkinginCondenserWaterboxwithInadequateSafetyBlockingPersonnelwereworkinginthecondenserwaterboxeswithinappropriateindustrialsafetyblocking,(blockingreferstotheuseofpermitandtagsystemtocontrolthestatusofplantcomponentsforpersonnelsafetyprotection).Whilepersonnelwereworkinginthewaterbox,valveswererequestedtobemanipulatedtoreducewaterleakage.Thesevalveswerenotpartofthepermitboundarybutrepresentedtherealboundarybetweenthewaterfilledlineandthedrainedportionoftheline.Theoperatorresponsibleforissuingthesafetypermitidentifiedthatanunsafeconditionexistedinthatpeoplewereallowedtoworkinthepipebeforetheentiresystemwasdrained.Nopersonnelinjurywasincurredalthoughthepotentialexistedforasignificantpersonnelsafetyincident.SummaryofRootCauseThekeyissuethattherootcauseevaluationpointstoisalackofprocessesorprotocolforhandlinghazardswithinapermittedboundary.Thispointstotheneedfortrainingandknowledge/experiencefortheinvolvedindividualstoestablisheffectivehumanperformanceasthelastbarriertopreventerrorthatputpeopleatrisk.SummaryofKeyCorrectiveActionsAsaresultoftheinvestigationintothiseventanumberofcorrectiveactionshavebeenorarescheduledtobetaken.Thoseofsignificanceinclude:RevisiontotheSafetyTaggingSystem.oTrainingpersonnelonthenewsafetytaggingequipment.Issueanallhandsbriefingpackagediscussingthesignificanceoftheevent,theneedtousegoodhumanperformancetechniques,andtheimpactthatcommunicationsplayedintheevent 0
ATTACHMENTATO'PLA-4632Page2of6Event2:12TonGroveCraneTippedOverIInthiseventthecranetippedoverduetooverextendingtheboomwhenrotatedtoanearlyperpendicularpositionwithreferencetothecrane.Theboomwasunloadedatthetimeoftheincident.Onememberoftheriggingcrewwasinthepathoftheboomasitwasfallingandhadtojumpoutofthewaytoavoidbeingstruck.Noinjurytopersonneloccurred.SummaryofRootCauseTheeventreviewthatfollowedidentifiedanumberofkeycontributortotheevent.Theindividualhadlimitedexperienceoperatingcranes.Hisinitialtrainingwasgenericinnature,wasnotassociatedwithINPOAccreditedTechnicalTrainingPrograms,andalsowasnotspecifictothismodelorvintagecrane.'ewasnotawarethatthecranecouldbetippedwithnoloadontheboom,andthereforedidnotrefertothe"loadchart".Finally,theindividualonthegroundhadhisbacktothecranewhenittipped,reflectingalackofexperienceonhispartwhenworkingaroundacrane.SummaryofKeyCorrectiveActionsAnumberofsignificantcorrectiveactionsareinplace.Theyinclude:Sitewidetrainingontheeventhasbeencompleted.Reviewofallcraneoperatorstrainingandexperience.Intheabsenceofsubstantialexperience,appropriateactionsaretaken.Traintheriggingcrewonsafetywhenoperatingaroundacrane,establishingexpectationsregarding"eyesontheboomandhook."Inaddition,thereareactionsscheduledforfuturecompletionwhichenhanceandcomplementtheactionsnotedabove:Continuefollow-uptrainingandcoachingoncranesafetyatregularintervals.Reinforcethehumanperformancetoolsofself-checkingandriskassessment.Revisecraneoperatortrainingtoincludestructuredon-the-jobtraining,sufficientminimumpracticestandards,andtaskcertification.~EvaluateotherNon-SusquehannaTrainingCenterTrainingforsimilardeficiencie ATTACHMENTATOPLA-4632Page3of6Event3:SDHRPVCPipingRuptureApipingfailureoccurredinthetemporaryportionoftheSupplementalDecayHeatRemoval(SDHR)SystemimmediatelyfollowingthestartoftheP2pumpduringpre-operationalchecks.SDHRisusedtoprovidealternatecoolingwatertothefuelpoolheatexchangersduringunitrefuelingoutagestoallowservicewater(normalcoolingwatersupply)toberemovedfromservice.InthiseventthePVCpipingonthepumpdischargerupturedimmediatelyfollowingthestartofthepump.Asareactiontotherupture,thePVCpipemovedenoughtostrikeanindividualinthelegcausingaminorinjury.SummaryofRootCauseAmoredetaileddescriptionofthiseventisnecessarytounderstandtheconclusionsreached.Anearlyidenticalarrangementhadbeenusedduringthepreviousoutage.Betweenoutages,thevendorthatsuppliedthepumpskidmadechangesthathebelievedwouldenhancethepumpoperation,andwereofminornature.Thesechanges,whichincludedtheadditionofspringmountsforthepumps.resultedinallowingthetorsionexperiencedduringthepumpstarttobetransmittedtothePVCpipe,causingtherupture.Thefactthatthepipingwasnotcompletelyventedcontributedtotheeventbyallowingthetorquecomponenttoincreaseunderstartupconditions.Thisequipmentisinstalledeachoutage,andassuchisassembledanddisassembledeachoutage;thereforethefit-upisnotthesameforeachevolution.Thevendormadechangestotheskidtoallowbetteroperation.Inhisviewthesewereminorchangesbuttheyresultedintwosignificantdifferences.Thefirst,discussedabove,resultedintransmittingtorsiontothepiping.Thesecondconsequencewasthattheadditions/changeschangedtheoverallelevationoftheskidmakingthefit-upmoredifficult.Theengineeringteaminvolvedknewofthechangesbutfailedtoidentifytheirsignificance.Therootcausesoftheeventinclude:theuseofPVCpiping,poorinitialfit-upofthepiping,poorventingofthepiping,andthespringsmountedtotheframeofthepumpskid.Inaddition,theinjuredworkerdisplayedpoorhumanperformanceskillsinthathefailedtomove"outofharm'sway"duringthepumpstar ATTACHMENTATOPLA-4632Page4of6SummaryofKeyCorrectiveActionsThecorrectiveactionsforthiseventarebothshortandlongterm.Theshorttermactionshavebeencompleted,andincluded:ReplacementofthePVCpipe.Chockingthespringmounts.Installingsufficientvents.oProceduralchangestostartpumpswithdischargevalveclosed,andtoincludingrequiringallpersonneltostandclearwhenstartingequipment.Thelongertermactionsinclude:Raisingtheawarenessofplantpersonnelofpersonalsafetyandatrisksituations.Ensuringadequatestepsaretakentoensureproperpipefit-u ATTACHMENTATOPLA-4632Page5of6Event4:CoreBoringResultedinOffgasIsolationandReactorManualScramCoreboreactivitieswerebeingperformedperaWorkAuthorization(WA)inUnit1.ThescopeoftheWAwastoexcavatea36"diameterholethroughthefloorslabwithacoredrill.Thefloorthicknessisapproximately4'7"atthelocationofthecorebore.Thecoredrillingprocessrequiredtheuseofwaterasalubricationandcoolingmedium.Acollectionsystemwasinplacefortheslurrycreatedbytheexcavationprocess.IThecoredrillcutpartiallythroughthemetaldeckingundertheconcreteslabandreleasedaslurryofwaterandconcretedustthroughthecut.Afunnelwasinstalledontheelevationbelowthecutinordertocapturetheslurry.Theslurryfilledthefunnelandoverflowedduetocloggingofastrainerinthethroatofthefunnel.Theslurrythensplashedontothetopoftheshoringscaffold.TheslurryranoffoftheshoringscaffoldontoanadjacentpipethatrunsdirectlyovertheUnit1OffgasRecombinerHydrogenAnalyzerPanel.Thewater/concretedustslurrydrippedfromthepipeontotheHydrogenAnalyzerPanelandanadjacentinstrumentpanel.ThemixturewettedtheHydrogenAnalyzerelectronicslocatedinthepanel.Thewettedelectronicsforthe"A"ChannelHydrogenAnalyzercausedaHi-HiHydrogensignaltobegenerated'whichinitiatedan"IsolateOffgas"signal.Thissignalclosedthesteamjetsuctionvalvesperdesign.AttemptsweremadetorestoretheoriginalsystemconfigurationandplacetheCommonRecombinerbackintoservice.Theseactionswerenotsuccessful,andwithMainCondenservacuumdeteriorating,themodeswitchwasplacedinShutdownwhichinitiatedaReactorScram.SummaryofRootCauseInadequatepre-planningoftheriskassociatedwiththeworkactivity.ItisPP&L'sexpectationthatallworkisapproachedinamannerthatexpectssuccess,butplansforfailure.ProceduralinadequaciesfortheOffgassystemrequiredtheoperatortomakeinterpretationsontheguidanceprovidedwhichresultedinabnormalsystemrespons ATTACHMENTATOPLA-4632Page6of6SummaryofKeyCorrectiveActionsThiseventshouldbeviewedintwoaspects,oneofmaintenancewhichinitiatedthetransient,andoneofoperationinresponsetothetransient.Correctiveactionshavebeenidentifiedforbothworkgroupsanddelineatedbelow.MaintenanceActivities:Reinforceourworkpracticestandardwithallsupervision(expectsuccess,planforfailure).Reviewallmajormodificationworkforrisk.Makechangesrequiredbeforeallowingworktocontinue.Reviseworkpackageprocedurestoincludeguidanceforriskassessment.OperationResponseReviseoperatingandoff-normalprocedures.Re-evaluatetrainingfrequenciesforoperatorsontheOffgasSystem.oDeveloptraininginresponsetothiseventfordistributionplantwide,describingtheconditionleadinguptothetransient,theoffgasresponse,andtheimportanceofoffgastoplantoperation.