IR 05000271/1997004

Ack Receipt of 970729 Ltr Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-271/97-04. Enforcement Discretion Was Exercised in View of Staff Recent Implementation of CA

ML20217H106
Person / Time
Site:	Vermont Yankee
Issue date:	10/07/1997
From:	Cowgill C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Reid D VERMONT YANKEE NUCLEAR POWER CORP.
References
50-271-97-04, 50-271-97-4, NUDOCS 9710150031
Download: ML20217H106 (2)

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October 7,1997 Mr. Donald Senior Vice President, Operations Vermant Yankee Nuclear Power Corporation RD 5, Box 169 Ferry Road Brattleboro, Vermont 05301 SUBJECT: NRC INSPECTION REPORT NO. 50 271/97-04 - REPLY

Dear Mr. Reid:

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This refers to the July 29,1997 correspondence, in response to our letter dated July 3, 1997, regarding Vermont Yankee. This correspondence dealt with Notice of Violation 50-271/97 04 01.

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Thank you for informing us of your corrective actions. We have reviewed this matter in accordance with NRC Inspection Procedure 92901, " Followup - Plant Operations." Based upon our preliminary review of your staff's determination of the root and contributing causes for this violation, it appears that a self-critical examination of the circumstances involving the personnel errors has been conducted. The corrective actions you have taken or have proposed for this violation appear to have appropriately bounded the identified causes. These actions will be examined during a future inspection to assess their overall effectiveness.

As documented in our August 19,1997 letter forwarding inspection report 50-271/97 05,

additional examples of poor personnel performece in the conduct of plant activitics were identified. Enforcement discretion was exercised in view of your staff's recent implementation of corrective actions to address these types of personnel performance errors. We urge you and your staff to aggressively pursue implementation of your broad personnel performance improvement initiatives to preclude more significant performance 4 problems and consequences.

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Your cooperation with us is appreciated.

Sir:cerely, I I

' 3INAL SIGNED BY:

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MBERTJ SUMMERS FOR CD( ,

Curtis J. Cowgill, Ill, Chief 150002- erojects Branch No. 5 Division of Reactor Projects Docket No. 50-271

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9710150031 971007 ,

PDR ADOCK 05000271 .

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Mr. Donald cc w/ encl:

R. McCullough, Operating Experience Coordinator Vermont Yankee

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R. Wanczyk, Director, Safety and Regulatory Aff airs ,

- G. Maret, Plant Manager J. Duffy, Licensing Engineer, Vermont Yankee Nuclear Power Corporation J. Gilroy, Director, Vermont Public Interest Research Group, Inc.

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D. Tefit, Administrator, dureau of Radiological Health, State of New Hampshire Chief, Safety Unit, Office of the Attorney General, Commonwealth of Massachusetts D. Lewis, Esquire G. Bisbee, Esquire

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J. Block, Esquire T. Rapone, Massachusetts Executive Office of Public Safety State of New Hampshire, SLO Designee State of Vermont, SLO Designee Commonwealth of Massachusetts, SLO Designee D. Katz, Citizens Awareness Network (CAN)-. -

Distribution w/ encl:

Region i Docket Room (with concurrences)

PUBLIC Nuclear Safety Information Center (NSIC)

NRC Resident inspector W. Axelson, DRA C. Cowgill, DRP D. Bearde, DRP D. Screnci, PAO (2)

G. Morris, DRS

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Distribution w/enci (VIA E-MAIL):

W. Dean, OEDO K. Jabbour, NRR R. Eaton, NRR R. Correia, NRR

, F. Talbot, NRR Inspection Program Branch, NRR (IPAS)

DOCDESK DOCUMENT NAME: A:\novr9704.cpc To receive a copy of this document, Indicate in the box: "C"_ = Copy without attachment / enclosure "E" =

Copy with attachment / enclosure "N" = No copy OFFICE Rl/DRP R) A / l / l NAME- CJCOWGIL@db .

DATE: to' / $ ~7 10/ /97 ,,

OFFICIAL RECORD COPY

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VERMONT YANKEE

' NUCLEAR POWER CORPORATION

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.- Ferry Road, Brattleboro, VT 053017002 ment to

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ENGINEERING OFFICE 580 MAIN STREET

• BoLToN. MA 01740 (506) 779 4711 July 29,1997 BVY 97 96 United States Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D,C. 20555 References: (a) License No. DPR 28 (Docket No. 50 271)

(b) Letter, USNRC to VYNPC, NRC Inspection No. 50-271/97 04, NVY 97101, dated 07/03/97 (c) LER 97-008, Rev. 0 ' Plant Scram Due to Procedural Non-Compliance and FailuretoPerformSelf VerificationDuringNuclearinstrumentationCalibration",

BVY 97 70, dated 05/23/97 Subject: Reply to a Notice of Violation Inspection Report No. 50-271/97 04

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This letter is written in response to Reference (b), which documents that certain of our actMtles were not conducted in full compliance with NRC requirements. This violation, classified as Severity Level

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IV, was identified during an NRC inspection conducted from April 20 to May 31,1997. Our response to the Violation is provided below:

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VIOLATION:

Technical Specification 6.5, " Plant Operating Procedures,' states that detailed written procedures, involving nuclear safety operations, surveillance, and testing requirements, shall be prepared, approved, and adhered to.

Vermont Yankee Operating Procedure (OP)-4406, "LPRM Calibration and Functional Check,'

Revision 13, dated October 18,1996, requires in part, a proper sequence of actions in order to restore the APRMs to a normal mode of operation from the bypass mode used for this periodic calibration.

Contrary to the above, at 9:10 AM on April 24,1997, the Vermont Yankee personnel failed to indhere to written procedures when conducting OP 4406, in that they improperly left the " A" and

"D" APRM mode switches in the "ZERO" position and fallod to make necessary adjustments to the APRMs prior to their being removed from bypass, resulting in a reactor scram event.

RESPONSE:

Reason For The Violation Vermont Yankee does not conte.t this violation. The event was caused by personnel error during performance of Local Power Range Monitoring (LPRM) System calibration, in that a failure to complete a procedural step resulted in the Average Power Range Monitoring (APRM) System Mode Switches for

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' U.S. Nuclear Regulatory Commission' * VERMONT YANKEE NUCLEAR POWER CORPORATION

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O i'A' and 'D* channels being left in the "ZERO" position Ins,ead of the ' OPERATE * position.

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Following the calibratiot, ?f the t.PRM detectors, the procedure directed that the affected APRM output j be adjusted to indicate cota thermal power. Since. the restoration of the APRM Mode Switches was

omitted,- the APRM output wss unable to be adjusted. Without resolving this unexpected response, -i

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- the Irwolved personnel prrceeded with the activity. When requested, the licensed operator removed -

J the APRM channels 'A' and "D*. from the bypass condition without uhing proper self-cnocking *

i practices. When both APRM's were removed from bypass, each provided a half scram input to their

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roepective Reactor' Protection System (RPS) trip channels and a reactor scram occurred. An .

. - Independent formal root cause was subsequently performed and documented in Vermont Yankee Event -

[ Report 97 0413. Since multiple barriers failed in order for the event to occur, a t.*71er assessment was

performed during the formal root cause evaluation. The multiple barriers the N M included pre job

' briefing, procedure quality, procedure development and review process, wmmunications, work j practices, knowledge and skill, and alarm response.

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l Root causes of this event were personnel errors in work practices and verbal communications.

1.- Work Practices

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[ a. Failure to follow procedure:

F 1) - The Reactor Engineer (RE) failed'to direct the Instrument and Control (l&C)

! Technician to perform the fourth action contained in a step.

l 2) The RE when unable to perform the verification / adjustment to the APRM l channels, moved on to the next step. This was contrary to a statement in the

!- - step itself, VY procedural use and adherence requirements and management expectations for use of self-checking techniques. '

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b. Inadequate application of STAR (Stop, Think, Act, Review) techniques: .The operator

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did not verify the correct system response between each APRM bypass switch l rrnnipulation. '

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- 2. Verbal Communications

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The RE failed to stop the calibration and communicate the questions / uncertainties he l  : encountered when unable to verify the APRM response, f:

! The contributing causes of this event were inadequate procedure and cognitive human error resulting from lack of skill / knowledge.

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F 1. Inadequate Procedure L- One step was written in a manner such that all actions were not clearly visible and easily performed.' A missed action was imbedded in a multiple action step.

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l 2. Skill / Knowledge >

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A lack of' knowledge on system / switch functions was evident by the RE decision to restore the APRM channels to service in order to get a power meter reading.

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= Cor octive Steps That Have Been Taken And The Results Achieved

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j Immediatellnterlm: The following actions have been completed.

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U.S. Nucle:r Reguttory Commission VERMONT YANKEE NUCLEAR POWER CORPOR ATION

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July 29,1997 ,

Page 3 l 1, After the scram, operators placed the plant in a stable state using the appropriate plant operating procedures.

2. A post trip review was conducted by Operations Department.

3. A review and revision of the LPRM Calibration and Functional Check procedure was conducted prior to subsequent use. Two LPRM callbrations have been performed without incident since the scram. l i

4. Lessons learned were presented to all Licensed Operators, Reactor Engineers and instrument and Control Technicians prior to plant restart.

i 5. An independent Root Cause investigation was conducted. '

6. The need for procedural compilance was reinforced to Reactor Engineering Personnel.

7. A plant staff meeting for al: departments was held to discuss human performance aspects of this event. Management's expsetations for procedural adherence and prompt communication of problems when they arise was reinforced.

8. Operations standard for self verification (STAR Stop, Think, Act and Review) was subsequently developed and issued June 29,1997.

Additionally, station management has increased oversight of reactivity management actMtles to ensure management expectations are clearly understood and reinforced. Reactor Engineering self-assessment activities have increased in the area of reactivity manage 11ent. Particular emphasis is being placed on self checking, pre-evolution briefings, communications and orocedure adherence. The need to anticipate and verify expected system and plant response, and aevelop contingency actions for potential unexpected responses is also emphasized. Prior to the last LPRM calibration which was performed on June 26,1997, a partial revision to the procedure was performed to further improve quality since the barrier assessment performed in the root cause analys!s identified the vulnerability to a full scram by testing two channels at the same time. Specifically, the procedure was revised to perform steps for one APRM channel at a time and separate individual actions within one step into separate steps, in addition, as part of the long term corrective actions noted below, the LPRM calibration procedure will undergo a complete review, and be revised as necessary, along with other Reactor Engineering procedures.

Corrective Actions That Will Be Taken To Avoid Further Violations Long Term:

1. Vermont Yankee will review all RE procedures that, if performed incorrectly, could cause a half or full scram. Vermont Yankee will designate such procedures "Conthuous Use" procedures.

Vermont Yankee willverify that such procedures contorm to the requirements of procedure AP 0037, Appendix B, Vermont Yankee Procedure Writer's Guide. The anticipated completion is October 31,1997.

I 2. The LPRM Calibration and Functional Check and other similar RE procedures are being evaluated for possible assignment to the E&C Department. Reactor Engineering would then provide assistance to E&C, as needed. The anticipated completion is October 31,1997.

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U.S. Nuclear R:gulatory Commission VERMONT YANKEE NUCLEAR POWER CORPORATION

- July 29,1997 Page 4 3. Training will be provided to Reactor Engineering personnelin the areas of Neutron Monitoring and Reactor Protection Systems. The anticipated completion is September 30,1997.

4. The Operations Standard for Reactivity Management will be revised to document existing management expectations for returning bypassed instrumentation to service. The anticipated completion date is September 1,1997.

5. A new training module for Licensed Operator Requalification and Auxiliary Operator Requalification will be developed and presented reinforcing self-verification (STAR) techniques.

The anticipated completion is December 31,1997.

In the course of reviewing events per the ER process, human performance, procedure quality, c:mmunications, and work practices have been recently identified and acknowledged as areas needing increased management oversight and involvement. Although the scram occurred due to human performance error, Verm 7t Yankee does not believe the recent performance issues identified are Indicative of an overall adverse performance trend where human performance errors have resulted in significant plant challenges or transients. Station management has fosiered a low threshold for initiating Event Reports (ERs). Consequently, the quantity of ERs has increased significantly and has resulted in identifying an adverse precursor performance trend similar to those identified in Reference b). Senior station management has and continues to provide strong day-to-day involvement in the corrective action prccess resulting in early identification of adverse performance trends and development of commensurate corrective actions.

Senior plant management is currently developing an action plan for improving human performance at Vermont Yankee. Input into the action plan was discussed with all VY managers in a workshop on July 23-24, 1997. Anticipated programmatic changes include Improved pre-evolution briefings and post-evolution critiques. The Vermont Yankee Observation Program is also being modified to emphasize human performance during field observations. We have also recently developed and implemented a Stop, Think, Act and Review (STAR) laboratory. This training has been provided to limited plant staff.

'Ne anticipate wider use of this important training in the future. We are confident these continued performance improvement laitiatives will result in improved human performance. We will continue to Id:ntify trends and implement corrective actions focused on improving human performance using the Event Report process.

Date When Full Compilance Achieved Vermont Yankee achieved full compliance when the LPRM Calibration was performed correctly in accordance with the procedure on May 19,1957.

WJ trust that the enclosed Information is responsive to your concems; however, should you have any questions or require additional pertinent information, please do not hesitate to contact us.

Sincerely, Vermont Yankee Nuclear Power Corporation

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% Donald A. R '

Senior Vice President, Operations cc: USNRC Region i Administrator USNRC Resident inspector VYNPS USNRC Project Manager- VYNPS

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