ML17228B327

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Forwards Response to NRC Ltr Re Violations Noted in Insp Repts 50-335/95-15 & 50-389/95-15.Corrective Actions:Msis Was Blocked & Reset Immediately Following Event on 950802
ML17228B327
Person / Time
Site: Saint Lucie  NextEra Energy icon.png
Issue date: 11/15/1995
From: GOLDBERG J H
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-95-306, NUDOCS 9511210113
Download: ML17228B327 (23)
v • d • e


See also: IR 05000335/1995015

Text

RIGRITY1ACCELERATEDRIDSPROCESSING),REGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)r'ESSIONNBR9511210113DOC~DATE'5/11/15NOTARIZEDNOFACIL:50-335St.LuciePlant,Unit1,FloridaPower&LightCo.50-389St.LuciePlant,Unit2,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATIONGOLDBERG,J.H.FloridaPower&'ightCo.RECIP.NAMERECIPIENTAFFILIATIONDocumentControlBranch(DocumentControlDesk)

SUBJECT: ForwardsresponsetoNRCltrreviolationsnotedininsprepts50-335/95-15&50-389/95-15.Correctiveactions:MSISwasblocked&resetimmediatelyfollowingeventon950802.IDISTRIBUTIONCODE:IE01DCOPIESRECEIVED:LTRENCLSIZE:TITLE:General(50Dkt)-InspRept/NoticeofViolationResponseNOTESDOCKETN0500033505000389INTERNAL:RECIPIENTIDCODE/NAMEPD2-1PDACRSAEOD/SPD/RABDEDRONRR/DISP/PIPBNRR/DRPM/PECBOEDIRRGN2FILE01COPIESRECIPIENTLTTRENCLIDCODE/NAME11NORRIS,J2AEOD/DEIB1A'E.1FILECENTER1/'DRC8/HFB1NUDOCS-ABSTRACT1'GC/HDS31COPIESLTTRENCL11111111111111EXTERNAL:LITCOBRYCE,JHNRCPDR1111NOAC11iNOTETOALLRIDS"RECIPIEYTS:PLEASEHELPUSTOREDUCE4VASTE!CONTACTTHEDOCL'!iIEYTCO."iTROLDESK,ROOiiIPl-37(EXT.504-2083)TOELIiIINATEYOURNA!iIEFROiIDISTRIBUTIOY.LISTSFORDOCL'IiIEi'I'S5'OUDOi"I'L'LD!TOTALNUMBEROFCOPIESREQUIRED:LTTR19ENCL19 40'

0FloridaPowerLLightCompany,P.O.Box14000,JunoBeach,FL334080420NOV15$995L-95-30610CFR2.201U.S.NuclearRegulatoryCommissionAttn:DocumentControlDeskWashington,D.C.20555Re:St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15FloridaPowerandLightCompany(FPL)hasreviewedthesubjectinspectionreportandpursuantto10CFR2.201theresponsetothenoticeofviolationisattached.Verytrulyyours,J.H.GoldbergPresident-NuclearDivisionJHG/DAS/EJBAttachmentcc:StewartD.Ebneter,RegionalAdministrator,USNRCRegionIISeniorResidentInspector,USNRC,St.LuciePlant95ii210i13'it5iii5PDRADOCK050003359PDRanFPLGroupcompany FPLRESPONSETOINSPECTIONREPORT95-15SUMMARYNRCInspectionReport50-335/389/95-15consideredSt.LuciePlantperformanceduringthesix(6)weekperiodfromJuly30,1995throughSeptember16,1995.Theviolationsbelowoccurredduringarelativelyshortperiodoftime,asdescribedintheinspectionreport,andseveralofthecorrectiveactionswereinstitutedfollowingananalysisoftheevents,collectively.Thecorrectivestepstoavoidfurtherviolationswereinsomecasesdeterminedtobegenericfollowingthisanalysis,andarethereforerepeatedinanumberoftheresponses.TheInspectionReportidentifiedseven(7)violationswhicharelistedbelow.ViolationA:FailuretoFollowProceduresandBlockMSISActuationViolationB:FailuretoFollowProceduresDuringRCPSealRestagingViolationC:FailuretoFollowProcedureandDocumentAbnormalValvePositionintheValve,SwitchDeviationlogViolationD:FailuretoFollowProceduresduringAlignmentofShutdownCoolingSystemViolationE:FailuretoFollowProcedureandDocumentaDeficiencyonContainmentSprayValveSurveillanceTestProcedureViolationF:FailuretoInitialMaintenanceProcedureStepsasWorkwasCompletedViolationG:FailuretoFollowProceduresDuringVentingofECCSSystemResultedinContainmentSpraydownAdditionally,bothFloridaPowerandLight(FPL)andtheNRCevaluatedplanteventstoidentifycommonunderlyingthemes.FPLpresentedasummaryofeventstotheNRConAugust29,1995.Weaknessesidentifiedinthissummaryincludedprocedurecontentanduse,aswellasmanagementoversightofeguipmentperformance.FPL'sPlantoImprovetheOperationalPerformanceatSt.LuciewasdevelopedasaresultoftheAugust29,1995,meetingandsubmittedtotheNRConSeptember15,1995.Todate,FPLhascompletedtheactivitiesaccordingtotheimprovementplanschedul S=.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIONA:TechnicalSpecification6.8.1.arequiresthatwrittenproceduresbeestablished,implemented,andmaintainedcoveringtheactivitiesrecommendedinAppendixAofRegulatoryGuide1.33,Rev.2,February1978.AppendixA,paragraph1.dincludesadministrativeproceduresforproceduraladherence.ProcedureQI5-PR/PSL-1,Rev.62,"Preparation,Revision,Review/ApprovalofProcedures,"Section5.13.2,statesthatallproceduresshallbestrictlyadheredto.OP1-0030127,Rev68,"ReactorPlantCooldown-HotStandbytoColdShutdown,"required,inpart,thatoperatorsblockMainSteamIsolationSystem(MSIS)actuationwhenblockpermissiveannunciationswerereceived.ONOP1-0030131,Rev60,"PlantAnnunciatorSummary,"requiredthat,uponvalidreceiptofannunciatorsQ-18andQ-20,operatorsimmediatelyblockchannelsAandB,respectively.Contrarytotheabove,onAugust2,1995,duringacooldownofSt.LucieUnit1,validblock.permissiveannunciatorswerereceived,however,operatorsfailedtoestablishtherequiredMSISblocks,resultinginAandBchannelMSISactuations.RESPONSEA:REASONFORVIOLATIONTherootcauseofthisviolationwascognitivepersonnelerroronthepartofautilitylicensedoperatorwhofailedtoblocktheactuationofthemainsteamisolationsignal(MSIS)inaccordancewiththerequirementsoftheapprovedplantoperatingprocedure.2.CORRECTIVESTEPSTAKENANDTHERESULTSACHIEVEDA.Themainsteamisolationsignal(MSIS)wasblockedandresetimmediatelyfollowingtheeventonAugust2,199 St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-153.CORRECTXVESTEPSTOAVOXDFURTHERVXOLATXONSA.Thelicensedoperatorwhowasinvolvedintheeventwascounseledontheneedtofollowproceduresandreceiveddisciplineinaccordancewithplant'policy.B.AllOperationsNuclearPlantSupervisors(NPS)heldmeetingswiththeircrewssubsequenttothiseventtoreiterateFPL'sgoalforerrorfreeperformance.C.Thiseventwillbeincorporatedintolicensedoperatorrequalificationtrainingtoemphasizeproceduralcompliance,propercommunicationamongtheControlRoom'team,andtheimportanceofsupervision-inthecontrolroommaintaininganoverallawareness,ofactivities.ThisactionwillbecompletebyJanuary1,1996.D.St.LuciePlantadoptedverbatimcomplianceastheonlyacceptablemeansofprocedurecompliance.ThisrequirementhasbeenincorporatedintoplantQualityInstructionQI5-PR/PSL-1,"Preparation,Revision,Review/ApprovalofProcedures'~"4.FullcompliancewasachievedonAugust2,1995withthecompletionofitem2abov St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIONB:TechnicalSpecification6.8.1.arequiresthatwrittenproceduresbeestablished,implemented,andmaintainedcoveringtheactivitiesrecommendedinAppendixAofRegulatoryGuide1.33,Rev.2,February1978.AppendixA,paragraph1..dincludesadministrativeproceduresforproceduraladherence.ProcedureQI5-PR/PSL-1,Rev.62,"Preparation,Revision,Review/ApprovalofProcedures,"Section5.13.2,statesthatallproceduresshallbestrictlyadheredto.Contrarytotheabove,procedureswerenotadheredtostrictlyinthefollowingexamples:OP1-0120020,Rev.72,"FillingandVentingtheRCS,"precaution4.2,requiredthatReactorCoolantSystem(RCS)venting,describedintheprocedure,notbeattemptedifRCStemperaturewasabove200'F.OnAugust2,1995,ReactorCoolantPump(RCP)sealventing,performedinanattempttocorrectsealpackageleakageinthe1A2RCPinaccordancewithAppendixEofthesubjectprocedure,wasperformedwhileRCStemperaturewasapproximately370'F.Asaresult,designtemperaturesofRCPsealcomponentswereapproachedorexceeded.2.OP1-0120020,Rev.72,"FillingandVentingtheRCS,"AppendixE,"RestagingReactorCoolantPumpSeals,"requiredtheuseofRCPsealinjectionwhilerestagingwasattempted.OnAugust2,1995,restagingofthe1A2RCPsealpackagewasattemptedwithoutsealinjectionalignedtothesealpackage.Asaresult,designtemperaturesofRCPsealcomponentswereapproachedorexceeded.RESPONSEB:REASONFORVIOLATIONTherootcauseofthisviolationwascognitivepersonnelerroronthepartofautilitylicensedoperatorwhofailedtofollowanapprovedplantprocedurewhileperformingarestagingevolutiononaReactorCoolant'Pump(RCP)sealpackage.TheoperatordidnotstrictlyadheretotheconditionscontainedintheprocedurewhichrequiredthatRCStemperaturebenogreaterthan200'F,andthatsealinjectionbeinservic St.LucieUnits1and2DocketNos.50-335and50-389Reply'oNoticeofViolationInsectionReort95-152.CORRECTXVESTEPSTAKENANDTHERESULTSACHIEVEDA.TheRCP'estagingevolutionwasdiscontinued,andOperationscooledanddepressurizedtheReactorCoolantSystem(RCS)inaccordancewithapprovedplantproceduretolowerRCPsealtemperaturestowithintheacceptablerange.The1A2RCPwassecured.B.Thedamaged1A2RCPsealpackagewasreplacedpriortoreturningUnit1tooperation.3.CORRECTIVESTEPSTOAVOIDFURTHERVXOLATXONSA.Thelicensedoperatorinvolvedinthiseventwasdisciplinedinaccordancewithplantpolicy.B.TheprocedureappendixwhichwasusedforperformingtherestagingoftheRCPswasdeletedandisnolongeravailableforuse.C.PlantmanagementperformedanassessmentofthedecisionmakingprocessthatledtotherestagingoftheRCPsealundertheexistingplantconditions.Basedonthisassessment,Plantpolicy105,"PlantOperationBeyondtheEnvelopeofApprovedPlantOperatingProcedures",wasrevisedtorequireatechnicalreviewofprocedureswhicharebeingimplementedforthefirsttimeorforwhichplantconditionsaredifferentfromthosedescribedintheproceduresD.AllOperationsNuclearPlantSupervisors(NPS)heldmeetingswiththeircrewssubsequenttothiseventtoreiterateFPL'sgoalforerrorfreeperformance.E.St.LuciePlantadoptedverbatimcomplianceastheonlyacceptablemeansofprocedurecompliance.ThisrequirementhasbeenincorporatedintoplantQualityInstructionQI5-PR/PSL-1,"Preparation,Revision,Review/ApprovalofProcedures."4.FullcompliancewasachievedonAugust2,1995withthecompletionofitem2A,abov St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIONC:TechnicalSpecification6.8.1.arequiresthatwrittenproceduresbeestablished,implemented,andmaintainedcoveringtheactivitiesrecommendedinAppendixAofRegulatoryGuide1.33,Rev.2,February1978.AppendixA,paragraph1.dincludesadministrativeproceduresforproceduraladherence.ProcedureQI5-PR/PSL-1,Rev.62,"Preparation,Revision,Review/ApprovalofProcedures,"Section5.13',statesthatallproceduresshallbestrictlyadheredto.AP1-0010123,Rev99,"AdministrativeControlsofValves,Locks,andSwitches,"step8.1.6,required,inpart,thatallvalvepositiondeviationsbedocumentedintheValveSwitchDeviationLog.Contrarytotheabove,onoraboutAugust1,1995,HCV-25-1through7wererepositionedandleftintheclosedpositionwithouttherequiredentriesbeingmadeintheValveSwitchDeviationLog.TheValves'ositionscomplicatedalossofRCSinventory.RESPONSEC:REASONFORVIOLATIONTherootcauseofthisviolationwascognitivepersonnelerroronthepartofutilitylicensedoperatorswhodidnotproperlydocumenttheclosedstatusofthesubjectvalvesintheValveSwitchDeviationLog,asrequiredbytheapprovedplantprocedure.2.CORRECTIVESTEPSTAKENANDTHERESULTSACHIEVEDTheSafeguardsPumpRoomSumpIsolationvalves,HCV25-1throughHCV25-7,wererealignedtotheopenpositionimmediatelyfollowingthelossofRCSinventoryeventonAugust10,1995,whenControlRoomoperatorsdiscoveredtheclosedstatusofthevalve St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-153.CORRECTXVESTEPSTOAVOXDFURTHERVXOLATXONSA.AllOperationsNuclearPlantSupervisors(NPS)heldmeetingswiththeircrewssubsequenttothiseventtoreiterateFPL'sgoalforerrorfreeperformance.B.C.D.Theplanthasadoptedverbatimcomplianceastheonlyacceptablemeansofprocedurecompliance.ThisrequirementhasbeenincorporatedintoplantQualityInstructionQI5-PR/PSL-1,"Preparation,Revision,Review/ApprovalofProcedures."ManagementisconductingadailyreviewofControlRoomchronologicallogstoreinforcetheexpectationfordetailandcompleteness.IPlantadministrativeprocedureshavebeenrevisedtoprovideforincreasedreviewsbyplantstaffofthelogscontrollingvalverepositioning.FullcompliancewasachievedonAugust10,1995,withthecompletionofitem2abov St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIOND:TechnicalSpecification6.8.1.arequiresthatwrittenproceduresbeestablished,implemented,andmaintainedcoveringtheactivitiesrecommendedinAppendixAofRegulatoryGuide1.33,Rev.2,February1978.AppendixA,paragraph1.dincludesadministrativeproceduresforproceduraladherence.ProcedureQI5-PR/PSL-1,Rev.62,"Preparation,Revision,Review/ApprovalofProcedures,"Section5'3.2,statesthatallproceduresshallbestrictlyadheredto.OP1-0410022,Rev22,"ShutdownCooling,"step8.3.7,requiredthatV3652,theBShutdownCooling(SDC)hotlegsuctionisolationvalve,belockedopenwhileplacingtheBSDCloopinservice.Contrarytotheabove,onAugust29,acontrolroomoperatorfailedtoplaceV3652inalockedopenconditionwhileplacingtheBSDCloopinservice.Asaresult,the1BLowPressureSafetyInjectionPumpwasoperatedwithitssuctionlineisolated.RESPONSED:REASONFORVIOLATIONTherootcauseofthisviolationwascognitivepersonnelerroronthepartofautilitylicensedoperatorwhofailedtoproperlyverifythealignmentoftheshutdowncooling(SDC)systemflowpathinaccordancewiththeapprovedplantprocedure,priortostartingthe1BLowPressureSafetyInjection(LPSI)Pump.Thisresultedinthefailuretoopenthe1BLPSIPumpsuctionisolationvalve.2.CORRECTIVESTEPSTAKENANDTHERESULTSACHIEVEDA.TheControlRoomoperatorsnotedtheerrorinvalvealignmentandtheLPSIpumpwassecuredapproximately5minutesafterbeingstarted.Asubsequentinspectiondeterminedthatnodamagehadoccurredduringtheshortperiodofpumpoperation.B.ThesystemwasrealignedinaccordancewiththeapprovedprocedureandtheLPSIpumpwasrestarted.SubsequentoperationoftheLPSIpumpwassatisfactory.C.AnASMESectionXIcoderunwasperformedsatisfactorilyonthe1BLPSIPumpandasubsequentEngineeringassessmentconcludedthatpumpoperabilityhadnotbeenadverselyaffecte St.LucieUnits.1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-153.CORRECTIVESTEPSTOAVOIDFURTHERVIOLATIONSA.Thelicensedoperatorinvolvedinthiseventwasdisciplinedinaccordancewithplantpolicy.B.OperationsimplementedprocedurechangeswhichrequiretheuseofadedicatedprocedurereadertoassistintheimplementationofSDCrelatedevolutions.C.AllOperationsNuclearPlantSupervisors(NPS)heldmeetingswiththeircrewssubsequenttothiseventtoreiterateFPL'sgoalforerrorfreeperformance.D.Theplanthasadoptedverbatimcomplianceastheonlyacceptablemeansofprocedurecompliance.ThisrequirementhasbeenincorporatedintoplantQualityInstructionQI5-PR/PSL-1,"Preparation,Revision,Review/ApprovalofProcedures."E.Thiseventwillbeincludedintolicensedoperator,requalificationtraining.ThisactionwillbecompletedbyJanuary1,1996.4.FullcompliancewasachievedonAugust29,1995withthecompletionofitem2Aand2Babov St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIONE:TechnicalSpecification6.8.1.arequiresthatwrittenproceduresbeestablished,implemented,andmaintainedcoveringtheactivitiesrecommendedinAppendixAofRegulatoryGuide1.33,Rev.2,February1978.AppendixA,paragraph1.dincludesadministrativeproceduresforproceduraladherence.ProcedureQI5-PR/PSL-1,Rev.62,"Preparation,Revision,Review/ApprovalofProcedures,"Section5.13.2,statesthatallproceduresshallbestrictlyadheredto.QI16-PR/PSL-2,Rev.1,"St.LucieActionReport(STAR)Program,"requiredthatSTARsbeinitiatedforQualityAssuranceauditfindingsandindependenttechnicalreviewrecommendations'ontrarytotheabove,aSTARwasnotgeneratedwhenaQualityAssurancereviewofaninadvertentUnit1containmentspraydown,documentedininterofficecorrespondenceJQQ-95-143,identifiedthepracticeofprelubricatingFCV-07-1A,ContainmentSprayheaderAflowcontrolvalve,whenperformingvalvestroketimetesting.RESPONSEE:1.REASONFORVIOLATIONTherootcauseofthisviolationwascognitivepersonnelerroronthepartofutilityQualityAssurance(QA)personnel.QApersonnelwereintheprocessofconductinganindependentreviewfocusingonthecontributingfactorsassociatedwithaUnit1containmentspraydownevent.Thepracticeofpre-lubricatingContainmentSprayheaderflowcontrolvalveFCV-07-lApriortosurveillancetestingwasidentifiedduringthis.review,butwasnotdeterminedtobeacontributingfactortothisevent.RecommendationstocorrectthisdeficiencywerethereforenotcontainedintheresultingQAreport,norwasaSt.LucieActionRequest(STAR)generatedinatimelymanner.2.=CORRECTIVESTEPSTAKENANDTHERESULTSACHIEVEDA.ASt.LucieActionRequest(STAR951048)wasgeneratedonSeptember7,1995todocumentthedeficientpracticeofpre-lubricatingUnit1andUnit2containmentsprayflowcontrolvalvespriortosurveillancestroketimetesting.B.TemporarychangeswereissuedtoplantsurveillanceproceduresonSeptember2,1995toremovethepracticeof'pre-lubricatingvalvespriortosurveillancetesting.10 St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-153.CORRECTIVESTEPSTOAVOIDFURTHERVIOLATIONSA.B.C.AmeetingwasheldonSeptember13,1995betweentheVicePresidentofNuclearAssuranceandallSt.LucieQualityAssuranceandQualityControlpersonnel.Duringthismeeting,clearexpectationswereprovidedregardingthethresholdforidentificationanddocumentationofdeficienciesbyQualitypersonnel.EOnOctober25,1995,asecondmeetingwasheldbetweenthesiteQualityManagerandSt.LucieQApersonnel.Duringthismeeting,therequirementsoftheQualityInstructionQI16-PR/PSL-2,"St.LucieActionReport(STAR)Program"werereviewed.TheresponsibilityofQApersonnelfortimelyidentificationanddocumentationofdeficienciesinaccordancewiththisprocedurewasreinforced.Permanentchangeswillbemadetoplantsurveillanceprocedurestodiscontinuethepracticeofpre-testlubricationofthevalvespriortosurveillancetesting.ThisactionwillbecompletedbyDecember1,1995.4.FullcompliancewasachievedonSeptember7,1995withthecompletionofitem2Aabov St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIONF:TechnicalSpecification6.8~1.arequiresthatwrittenproceduresbeestablished,implemented,andmaintainedcoveringtheactivitiesrecommendedinAppendixAofRegulatoryGuide1.33,Rev.2,February1978.AppendixA,paragraph1.dincludesadministrativeproceduresforproceduraladherence.ProcedureQI5-PR/PSL-1,Rev.62,"Preparation,Revision,Review/ApprovalofProcedures,"Section5.13.2,statesthatallproceduresshallbestrictlyadheredto.ADM-08.02,Rev7,"ConductofMaintenance,"Appendix5,step5,requiredthatproceduresbepresentduringworkandthatindividualstepsbeinitialedonceperformed.Contrarytotheabove,inspectionofworkinprogressrevealedthatindividualstepswerenotinitialedonceperformeduponcompletionforworkconductedinaccordancewithPlantChange/Modification11-195.RESPONSEF:1.REASONFORVIOLATIONTherootcauseofthisviolationwascognitivepersonnelerroronthepartofanElectricalDepartmentjourneymanwhofailedtoproperlydocumentthecompletionofstepswhileperformingworkactivitiesassociatedwiththetripsolenoidsonthe1BEmergencyDieselGenerator(EDG).Thestepswerenotinitialedastheywerebeingperformed,inaccordancewithapprovedplantprocedure.2.CORRECTIVESTEPSTAKENANDTHERESULTSACHIEVEDA.ThestepsofthemaintenanceprocedurebeingworkedweresignedoffbythejourneymanimmediatelyfollowingthecompletionoftheworkonAugust31,1995,andthecompletedprocedurewasreviewedbythechiefelectricianandElectricalsupervisor.B.TheEDGcircuitrywassubsequentlytestedfollowingcompletionoftheworkonAugust31,1995,andperformedsatisfactorily.12 0

St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-153.CORRECTIVESTEPSTOAVOIDFURTHERVIOLATIONSA.MeetingswereheldfollowingthiseventwithElectricalMaintenanceemployeestoreviewthisincidentandemphasizemanagementexpectationsregardingthedocumentationofw'orkactivities.B.SupervisorsfromeachMaintenancedisciplinehaveconductedmeetingswiththeiremployeestoreinforcetheneedforstrictadherencetotheadministrativerequirementsrelatedtoprocedureuse.C.Theplanthasadoptedverbatimcomplianceastheonlyacceptablemeansofprocedurecompliance.ThisrequirementhasbeenincorporatedintoplantQualityInstructionQI5-PR/PSL-1,"Preparation,Revision,Review/ApprovalofProcedures."4.FullcompliancewasachievedonAugust31,1995withthecompletionofitem2Aand2Babove.13 St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15VIOLATIONG:10CFR50AppendixB,CriterionV,"Instructions,Procedures,andDrawings,"requires,inpart,thatactivitiesaffectingqualityshallbeprescribedbydocumentedproceduresofatypeappropriatetothecircumstances.Contrarytotheabove,onAugust18,1995,ventingoftheLowPressureSafetyInjection(LPSI)Systemwasconductedinaccordancewithaprocedurewhichwasinappropriatetothecircumstances.Specifically,OP1-0420060,Rev.0,"VentingoftheEmergencyCoreCoolingandContainmentSpraySystems,"didnotrequireaverificationthattheportionsofthesystembeingventedwerehydraulicallyisolatedfromadjacentsystemsandflowpaths.Asaresultofthisfailuretoestablishproperinitialconditions,waterdrivenbythe1ALPSIpumpwasinadvertentlydirectedtotheATrainContainmentSprayheader,resultinginaspraydownoftheUnit1ReactorContainmentBuilding.RESPONSEG:REASONFORVIOLATIONTherootcauseofthisviolationwasproceduraldeficiencyinthattheECCSventingprocedure,OP1-0420060,didnotstatetheplantconditionsrequiredtosuccessfullyventtheECCSbutreliedupontheRCSheatupproceduretosetplantconditions.Specifically,theventingproceduredidnotrequireoperatorstoverifythatthepropercontainmentsprayheaderisolationvalveswereclosedpriortorecirculatingthewaterintheSDCsystem.AcontributingfactortothiseventwasthattheoperationspersonnelperformingtheECCSventingproceduredidnotrecognizethattheexistingplantconditionswouldresultinflowtothe'A'ontainmentsprayheaderwhenflowwasalignedthroughtheShutdownCoolingHeatExchanger.AsecondcontributingfactorofthiseventwasthatFCV-07-1AwasplacedintheopenpositionbecausethisvalvehadfaileditsASMEstroketimetest.Plantmanagementmadethedecisiontodeferthevalverepairandpositionthisnormallyclosedvalvetoitsengineeredsafeguardsopenpositioninlieuofrepairingthevalvepriortostartup.14 St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-152.CORRECTIVESTEPSTAKENANDTHERESULTSACHIEVEDA.Operatorssecuredthe1ALPSIPumpandisolated,theflowpathtothecontainmentsprayheaderfromtheLPSIPump.TheReactorCavitysumpwasdrainedtotheWasteManagementSystem.B~Followingtheevent,allnonessentialworkatthesitewasplacedonhold,andUnit1wasmaintainedstableinMode3whileseniorplantmanagementconductedmeetingswithallavailablesitepersonneltostresstheneedforworkervigilanceandattentiontodetail.Theneedtoreduceequipmentdeficienciesthatimpactoperationswasalsodiscussed.C.Unit1wascooleddownanddepressurizedtoMode,5andaninspectionanddecontaminationofcontainmentwasthenconducted.TheeventwasevaluatedunderanEngineeringevaluation,whichresultedinacomprehensiveinspectionofcomponentsinsidecontainmenttoensurefuturecomponentreliability.D.Operatingprocedure,OP1-0420060,"VentingoftheEmergencyCoreCoolingan'dContainmentSpraySystem",wasrevisedSeptember1,1995toincludetheplantconditionsrequiredtobepresentduringventing.3.CORRECTIVESTEPSTOAVOIDFURTHERVIOLATIONSA.Plantpolicy105,"PlantOperationBeyondtheEnvelopeofApprovedPlantOperatingProcedures",wasrevisedtorequireatechnicalreviewofprocedureswhicharebeingimplementedforthefirsttimeorforwhichplantconditionsaredifferentfromthosedescribedintheprocedure.B.TheMaintenanceDepartmentestablishedateamcomposedofplantstaffandengineeringpersonnel,todeterminetherootcausefortheContainmentSprayheaderisolationvalverepeatfailuresanddeterminecorrectiveactionstoeliminatethisoperatorworkaround.FCV-07-1AwasrepairedpriortoreturningUnit1toservice.15 St.LucieUnits1and2DocketNos.50-335and50-389ReplytoNoticeofViolationInsectionReort95-15C.Existingplantdeficiencieswerereviewedbyseniorplantmanagement.AdditionaldeficiencieswhichcouldimpactoperationswereaddedtotheworkscopeoftheUnit1shutdown.Thesedeficiencieswerecorrectedpriortoreturningtheunittoservice.D.Administrativeprocedure,AP-0010147,"AssessmentofAbnormalPlantConfigurationsorSignificantMaterialDeficient'ConditionsonPlantOperation",wasdevelopedtoenhanceoutagescopereviewandensurethatequipmentdeficienciesarerestoredinatimelymanner.E.St.Luciemanagementinstitutedaweeklyreviewofappropriateperformanceindicatorsandworkbacklogstatus,includingtheageofopenitemsandoperatorworkarounds.F.AllOperationsNuclearPlantSupervisors(NPS)heldmeetingswiththeircrewssubsequenttothiseventtoreiterateFPL'sgoalforerro'rfreeperformance.G.Thiseventwillbeincorporatedintolicensedoperatorrequalificationtraining.ThisactionwillbecompletebyJanuary1,1996.4.FullcompliancewasachievedonAugust18,1995withthecompletionofitems2A,2Cand2Dabove.16

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