ML20138K185

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-482/97-04

ML20138K185
Person / Time
Site:	Wolf Creek
Issue date:	05/06/1997
From:	Gwynn T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Maynard O WOLF CREEK NUCLEAR OPERATING CORP.
References
50-482-97-04, 50-482-97-4, NUDOCS 9705120236
Download: ML20138K185 (4)

See also: IR 05000482/1997004

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UNITED ST ATES

.,.m 71 NUCLEAR REGULATORY COMMISSION

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611 RY AN PLAZA DRIVE. SUITE 400

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MAY - 6 1997

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Otto L. Maynard, President and

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Chief Executive Officer i

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Wolf Creek Nuclear Operating Corporation

i P.O. Box 411

Burlington, Kansas 66839 l

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SUBJECT: NRC INSPECTION REPORT 50-482/97-04

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Thank you for your letter of April 23,1997, in response to our letter and Notice of

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Violation dated March 10,1997. We have reviewed your reply and find it responsive to

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.e concerns raised in our Notice of Violation. We will review the implementation of your

corrective actions during a future inspection to determine that full compliance has been

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, achieved and will be maintained.  !

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omas P. Gwy Jn, D' ect r

Division of Rea t oje ts

cc:

Chief Operating Officer

Wolf Creek Nuclear Operating Corp.

P.O. Box 411

Burlington, Kansas 66839

Jay Silberg, Esq.

Shaw, Pittman, Potts & Trowbridge

2300 N Street, NW

Washington, D.C. 20037 Ij

Supervisor Licensing

Wolf Creek Nuclear Operating Corp.

P.O. Box 411

Burlington, Kansas 66839

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9705120236 970506

gDR ADOCK 05000482

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Wolf Creek Nuclear -2- l

Operating Corporation l

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Chief Engineer

Utilities Division

Kansas Corporation Commission ,

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1500 SW Arrowhead Rd. l

Topeka, Kansas 66604-4027

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Office of the Governor  !

State of Kansas

Topeka, Kansas 66612 I

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Attorney General j

Judicial Center )

301 S.W.10th j

2nd Floor i

Topeka, Kansas 66612-1597 '

County Clerk l

Coffey County Courthouse I

Burlington, Kansas 66839-1798 l

Vick L. Cooper, Chief

Radiation Control Pron am j

Kansas Department

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Salth

arid Environment

Bureau of Air and Radiation

Forbes Field Building 283

Topeka, t'.ansas 66620

Mr. Frank Mc . sa

Division of Em 'e PrepatNness

2800 SW Topeka th

Topeka, Kansas 66611- 287

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Wolf Creek Nuclear -3-

Operating Corporation MAY - 6 1997

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DOCUMENT NAME: R:\_WC\WC704AK.JFR

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NUCLEAR OPERATING CORPORATION .*

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Richard A. Muench ' " ~ " * '

Vice Prescent Engineenng ' I a' ' '

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April 23, 1997 ~ ~ - ~ ~ ~ ~ ~ ' --

ET 97-0044

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U. S. Nuclear Regulentory Commission

ATTN: Document Control Desk

Mail Station F1-137

Washington, D. C. 20555 -

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Reference: Letter dated March 10, 1997, from A. T. Howell,

NRC, to O. L. Maynard, WCNOC

Subject: Docket No. 50-482: Response to Notice of Violations

50-482/9704-01, -02, -03,-04, and -07

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Gentlemen:

This letter transmits Wolf Creek N2 clear Operating Corporation's (WCNOC)

, response to Notice of Violations 50-482/9704-01, -02, -03,- 04, and -07.

Violation 9704-01 concerns the f al '.u re of a Shift Supervisor to recognize

conditions requiring entry into Technical Specification Action. Statement 3.6.3,

and failure to log that entry. Violation 9704-02 involved manipulation of a

turbine-driven auxiliary feedwater pump governor valve while troubleshooting an

inadvertent overspeed trip without correct work controls, and without correct

authorization. Violation 9704-03 concerns WCNOC's failure to establish

procedure SYS AL-124 adequately to control the test activity. Violation 9704-04 l

occurred when an operator f ailed to follow procedure direction when attempting  !

to trip the turbine-driven auxiliary feedwater pump. Violation 9704-07 occurred  !

when a revision to a flow chart in the Emergency Plan inadvertently resulted in

a decrease in the effectiveness of the plan, without prior NRC approval.

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This response letter is being submitted after the 30 day due date with the

concurrence of the Senior Resident Inspector a r, discussed at the 50-482/97-08

Inspection Exit Meeting.

WCNOC's response to these violations is in the attachment. If you have any j

questions regarding this response, please contact me at (316) 364-8831,

extension 4034, or Mr. Richard D. Flannigan at extension 4500.

Ve tru y yours, j

Richard A. Muench

RAM /jad

Attachment I

cc: E. W. Merschoff (NRC), w/a

W. D. Johnson (NRC), w/a

J. F. Ringwald (NRC), w/a

J. C. Stone (NRC), w/a

9 r- C94o

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PO. Box 411/ BAngton, KS 6687 * hone: (316) 364 8831

g g'g_ An Eque Opportunety Einstoyer M F HC VET

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Attachment to ET 97-0044

Page 1 of 14

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Violation 50-482/9704-01: The Shift Supervisor did not recognize that a

Containment : solation Valve failure resulted in

entry into Technical Specification Action l

Statement 3.6.3, and failed to log entry into

Technical Specification Action Statement 3.6.3.

" Technical Specification 6.8.1.a states, in part, that written

procedures shall be established and implemented covering the applicable

procedures recommended in Appendix A of Regulatory Guide 1.33, Revision

2.

Regulatory Guide 1.33, Appendix A, Section 1.h, requires administrative

procedures for log entries.

Administrative Procedure AP 21-001, " Operations Watchstanding

Practices," Revision 4, Step 6.2.3.d, requirt- a log entry for entry

into Technical Specification action statements c.a to equipment failure.  ;

Contrary to the above, on July 28, 1996, at 5:15 p.m., the Shift

Supervisor logged a failure of Containment Isolation Valve EF HV0034 to

close on demand, but failed to recognize that this valve failure

resulted in entry into Technical Specification Action Statement 3.6.3

and failed to log entry into Technical Specification Action Statement

3.6.3."

Admission of Violation:

Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that

a violation of Technical Specification 6.8.1 occurred when the Shift

Supervisor failed to recognize that the EF HV0034 Containment Isolation Valve

l failure resulted in entry into Technical Specification Action Statement 3.6.3,

and f ailed to log entry into Technical Specification Action Statement 3.6.3.

All Limiting Concition for Operations (LCO) actions were adequately addressed

but not logged.

Reason for Violation:

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Two concerns were identified during the evaluation of the items identified in

violation 9704-01.

1. The Shift Supervisor did not enter Technical Specification 3.6.3 on July

l 26, 1996. He neglected to consider the containment isolation function of

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EF HV0034, instead he concentrated on the safeguards required position of

i the valve. (EF HV0034 is a motor operated containment isolation valve

i located within the containment structure.) The safeguards required

position is "open". The Shift Supervisor's concentratiot. on the "open"

safeguards position combined with: 1) Dual indication problems that

occurred in the " closed" position; 2) Technical Specification Table 3.6-1

( specifying "N/A" for the maximum EF HV0034 isolation time; and 3)

l Subsequent stroking of the valve that did not .:esult in problem recurrence,

l caused the Shift Supervisor to incorrectly determine that the containment

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isolation requirements of Technical Specification 3.6.3 did not apply.

The root cause for not entering Technical Specification 3.6.3 was personal

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error. The root cause of personal error by the Shift Supervisor appeared to

! be an isolated 'mstance, not having generic implications; however, on March

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6, 1997, two Fes.ormance Improvement Requests (PIR 97-0715 and PIR 97-0716)

were issued. Both PIRs dealt with the failure to either properly enter, or

to properly log the entry into, Technical Specification 3.6.3.

2. LER 96-010-00, wnich reported the failure of F.F HV0034 to properly operate

from March 10, 1996, through October 9, 1996, did not discuss operability

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Attacnment to ET 47-0044

Page 2 of 14

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Of EF MV0034 in relation to honnical Specification 3.6.3. LER 96-010-00

dic scuss events surrounding tne inoperability of E,F HV0034, but stated

tne cas s for reportacility was Tecnnical Spe :fication 3.7.4, which states

"At ' east two independent essential serviv water (ESW) loops shall be

operarle.' LER 96-010 did not consider noncompliance with Technical

Speci ication 3. 6. 3, which pertains to containnent isolation, and states:

"The containment isolation valves specifiea in Tacle 3.6-1 shall be

OPERABLE with is .ation t mes as shown in Table 3.6-1."

The root cause for failing to identify in LER 96-010 that Technical

Specification 3.6.3 was not properly entered was an incomplete

investigation of Performance Improvement Request (PIR) 96-2528. The root

cause for this problem was inadequate interface among organizations. This

event, and the LER reporting it, were mainly evaluated by WCNOC Engineering

without sufficient participation by Operations.

The failure of the PIR 96-2528 investigation to identify the failure to

address Technical Specification 3.6.3 was determined to have generic

implications. The generic implications are that a PIR, such as 96-2528,

has multiple issues af fecting various work groups. In the specific case of

PIR 96-2528, this PIR was evaluated by Engineering, and the issue of

Technical Specifications compliance was not given sufficient in-depth

attention.

Corrective Steps Taken and Results Achieved:

• Perfcrmance Improvement Request (PIR) 96-2528 served as the basis for

information for the description, root cause, and corrective action for

the event reported in Licensee Event Report (LER) 96-10-00. The WCGS

Corrective Action Review Board (CARB) was not in existence when the

evaluation for significant ?;R 96-2528 was performed. The CARB now

provides upper level management and multi-discipline review of PIRs

involving significant issues, prior to the PIR's closure. The

procedurally required review by the CARB is now a practice that will

help ensure all applicable issues are evaluated when addressing

significant PIRs. Because LER content is based on significant PIR

evaluation, CARB review will aid in preventing inaccurate or incomplete

i LERs from being issued.

Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be

Achieved:

• Procedure AP 28A-001, Revision 6, " Performance Improvement Request,"

will be revised by May 10, 1997, to provide guidance for when a m21ti-

discipline team approa'h should be used to perform evaluations of

significant PIRs. This will ensure that knowledgeable organizations are

given the opportunity to provide input into the evaluation process for

significant issues.

• A rev13 ion to LER 96-C10-00 will be issued by April 30, 1997, to correct

the f ailure to identif y entry into Technical Specification 3.6.3.

ADDITIONAL EVENTS IDENTIFIED:

On March 5, 1997, at 0900, the "B" train Containment Cooler was isolated by

Clearance Order (C/0) 97-0302-EF to support abbreviated Valve Operation Test

and Evaluation System (VOTES) testing on EF HV0034. Technical Specification 3.6.3 requires an action when specific containment isolation valves, such as

EF HV0034, become inoperable. EF HV0034 became inoperaole during the

abbreviated VOTES testing, when the valve's operator rotor cover was removed;

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Page 3 of 14

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however, the Snift Supervisor did not enter Tecnnical Specification 3.6.3, as

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required.

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' misunderstanding occurred concerning the work scope. Interviews with the

Shift Supervisor revealed that he understood that the limit switch

compartment cover (rotor cover) would be removed, as is stated in the

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Maintenance Work Package Summary. However, the Supervising Operator did not

l understand that the cover would be removed. Although the Shift Supervisor and

l Supervising Operator each had a different understanding of the work scope,

! neither identified the need to enter Technical Specification 3.6.3. This is

due to the following:

1. The Shift Supervisor understood the cover was being removed as was stated

in the Work Package Summary. The Shift Supervisor did not enter Technical

Specification 3.6.3 because Clearance Order 97-0302-EF closed the outside

containment isolation valve (EF HV0032). The Shift Supervisor understood

that this met the action for Technical Specification 3.6.3 , and therefore

he thought it was not necessary to log entry of the Technical Specification

into the Shift Supervisor log.

2. The Supervising Operator misunderstood the scope of work and thought the

cover would remain installed. The Supervising Operator therefore had no

reason to believe operability would be affected and he subsequently did not

enter Technical Specification 3.6.3.

Based on the facts reviewed, the following were causes of the identified

problems:

1. There was no clear expectation of Equipment Out-of-Service Log (EOL) or

Control Room Log entries when a Clearance Order meets the Technical

Specification action. The Shift Supervisor and Supervising Operator to

believe that it was not necessary to log the Technical Specifications that

are considered whenever a Clearance Order satisfies the Technical

Specification action statement. At that time, Operations did not log all

Technical Specifications being considered when the Technical Specification

action statement was met by a Clearance Order. This is part of the pre-job

planning and satisfies the LCO. The expectations for the future will be to

log all Technical Specifications that apply and which are being considered;

including those Technical Specifications in which the action statement is

met by a Clearance Order. Logging of all applicable and considered

Technical Specifications will indicate that all appropriate Technical

Specifications have been considered.

l 2. Verbal and written communication resulted in the misinterpretation of the

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words "non-intrusive" and "cperability" used in the Work Package Task work

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Corrective Steps Taken to " ADDITIONAL EVENTS IDENTIFIED" and Results Achieved:

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• Control Room Log entries were amended.

• PIR 97-0716, which documents the description, root cause, and corrective

actions for this event, has been placed in Operations required reading .

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Attachment to ET 97-0044

Page 4 of 14

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Corrective Steps That Will Be Taken to " ADDITIONAL EVENTS IDENTIFIED" And The

Date When Full Compliance Will Be Achieved:

• Operations Management will issue a written expectation stating that, even

when an action statement is met, reference needs to be made in both the

control rocm logs, and in the EOL. This action will be completed by May 16,

1997

• Confusion surrounding the meaning of the words "non-intrusive" and

" operability" will be addressed in training. This training will develop a

consistent definition for each word that is acceptable to both Maintenance

and Operations. Training will alert personnel to the different

connotations words can carry and that words can have multiple definitions

based on the organizational perspective. Consideration to other words will

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also be given. This training will be given to both Maintenance and

Operations. Completion date for the training is July 5, 1997.

• The Superintendent of Operations will discuss with the operating crews the

importance of clear, concise and detailed communication with Maintenance

personnel. Operating crews will be reminded that different terms can have

different meanings to various organizations. Clear communication ensures

that the sender and receiver each have a common understanding. These

discussions will be completed by May 16, 1997.

• Procedure AP 21F-001, " Equipment Out-Of-Service Control," shall be changed

to reflect that if a Clearance Order meets the requirements of a Technical

Specification action statement, the Equipment Out-of-Service Log (EOL) must

state this, se it is understood that the Technical Specification is not

being violated. This revision will be completed by May 16, 1997.

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Attachment to ET 97-0044

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Violation 50-4s2/9704-02: A System Engineer manipulated the turbine-

driven auxiliary feedwater pump governor

valve FC FVO313 while troubleshooting an

inadvertent overspeed trip without a work

package task and without authorization

from the Shift Supervisor, and control

room operators manipulated the speed of

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the turbine-driven auxiliary feedwater

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pump to below 3850 rpm.

" Technical Specification 6.8.1.a states, in part, that written

procedures shall be established and implemented covering the applicable

procedures recommended in Appendix A of Regulatory Guide 1.33, Revision

2.

Regulatory Guide 1.33, Appendix A, Section 9, requires procedures for  ;

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performing maintenance that can affect the performance of safety-related

equipment.

Administrative Procedure AP 16C-002, " Work Controls," Revision 4,

Attachment C, Step C.2.1, requires workers to perform troubleshooting

activities using a work package task with authorization from the Shift

Supervisor.

System operating Procedure SYS AL-124, " Venting the Turbine-Driven

Auxiliary Feedwater Pump Oil System," Step 6.1.4, requires operators to

open Valve FC HV0312, a turbine-driven auxiliary feedwater pump trip-

throttle valve, until the turbine operates between 3850 and 3900 rpm,

then slowly open the valve while verifying that the governor valve

maintains control of the turbine.

Contrary to the above, on January 24, 1997, system engineers failed to

comply with procedures for performing maintenance. Specifically:

1. The system engineer manipulated Valve FC FV0313, the

turbine-driven auxiliary feedwater pump governor valve while

troubleshooting an inadvertent overspeed trip without a work

package task and without authorization from the Shift

Supervisor.

2. Under the direction of the system engineer, control room

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operators manipulated the speed of the turbine-driven

l auxiliary feedwater pump to below 3850 rpm."

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Adatission of violatig

i Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that

a violation of Technical Specification 6.8.1 occurred when a System Engineer

failed to comply with procedures for performing maintenance by manipulating

valve FC FV0313, without a work package task, and without authorization from

the Shift Supervisor. WCNOC also agrees that, under the direction of the

l system engineer, Control Room operators manipulated the speed of the turbine-

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driven auxiliary feedvater pump to below 3850 rpm.

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Reason for Violation 9~04-02:  ;

Two examples were identified for Violation 9704-02. These two examples are

addressed separately below. l

Reason for Violation --- Example One

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The root cause for this inappropriate action by the system engineer was the I

system engineer's mindset to identify and resolve the Turbine Driven Auxiliary

Feedwater Pump (TDAFWP) overspeed trip problem, at the expense of his duties

as Team Leader. The system engineer did not consider the procedural direction

provided in AP16C-002, " Work Controls," that defines the limits of

investigation. ]

Following overspeed trip of the TDAFW P, the system engineer became fully

engaged with resolving the trip. The system engineer discussed concerns about  ;

the possible cause of the trip with the Shift Supervisor. The Shift Supervisor

understood that the system engineer was planning to visually investigate the

cause of the trip, but the Shift Supervisor was unaware that the system  ;

engineer would actuate components. The system engineer's responsibility to  !

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identify the cause of the overspeed trip became his primary focus, and being  !

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aware of the need to check for Governor Control Valve (GVC) binding while the )

equipment was still warm, and the time constraint associated with the Limiting

Condition For Operation (LCO), he acted inappropriately.

The system engineer felt that because the system was out of service, and he

thought he had the Shift Supervisor's permission, no further controls were

necessary. The system engineer, being inexperienced in the area of

troubleshooting, responded inappropriately by not stopping and considering the

procedural requirements identified in AP16C-002 as they relate to

troubleshooting. Additional investigation, documented in PIR 97-0363,

provides evidence that the problen at hand is not global within the system

engineering organization.

It was also identified that the Shift Supervisor delayed AR initiation later

than the " Work Controls" procedure allcws. This conclusion is based on the

interview with the Shift Supervisor which revealed that he was attempting to

determine the cause for the trip for information prior to AR initiation. The

Shift Supervisor is knowledgeable of the work controls process, but did not

know this level of activity is outside of the limits for investigation. The

Work Controls procedure is a " reference use" category procedure which requires

it to be readily available, but not in hand. The Shift Supervisor did not

consult the procedure before making his decision.

Discussions with other Shift Superviscrs have indicated that they would not

have allowed this troubleshooting to occur without initiation of an AR and

subsequent approval of a Work Package. This provides evidence that this lack

of understanding is not global to all Shift Supervisors. The root cause for

the inappropriate action by the Shift Supervisor was an error in Judgment

concerning the limits of investigation provided in AP16C-002, " Work Controls".

Corrective Steps Taken and Results Achieved For Violation 9404-02 --- Example

One

• Immediate corrective action resulted in appropriate counseling and

discipline of System Engineering personnel by System Engineering

management.

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Attachment to ET 97-G044 l

Page 7 of 14 1

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• Following this event, ne saperintendent :. f Operations met with all

cperating crews and re-ccmmunicated the req.irements identified in the work l

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co r.t r o l process, emphasicing proceaural, compliance, the limitations of

investigation, requi:ements for Shift Supervisor initiation, and the l

thresnold of troubleshooting as defined in AP16C-002.

• The Manager of System Engineering reviewed issues associated with )

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procedures AP15C-002, " Procedure use and Adherence," and AP16C-002, " Work

Controls," and discussed issues related to this event with all System

Engineers. This action was ccmpleted on April 22, 1997. I

Corrective Steps That Will Be Taken and the Date When Full Compliance Will Be 1

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Achieved For Violation 9704-02---Example One:

• The Manager System Engineering will develop a qualification standard to

include specific training, as a minimum, on procedure AP15C-002, " Procedure

Use and Adherence" and procedure AP16C-002 " Work Controls". This standard

will ensure the pertinent information of each procedure is understood as it

applies to System Engineering responsibilities. Training to this standard

will be completed by July 1, 1997.

• Additional interim corrective action requires the Manager Syste.m

Engineering to review this event with other Engineering Managers for

identification of information that relates to other engineering groups.

This review will determine the need for a qualification standard for other

engineering groups. This action will be complete by May 30,1997.

• The Manager Integrated Plant Scheduling 'IPS) will collect information

relative to Team Leader responsibilities and ensure that it is included in

an existing procedure, or a new procedure. Those persons acting as Team

Leaders will be qualified only after meeting the requirements for these

roles as specified in the procedure. The Manager IPS will maintain and

update the qualified list of personnel who can fulfill the role. These

actions are to be complete by May 30, 1997

Reason for Violation 9704-02 --- Example Two

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The root cause of the second example was inadequate work practices in the

use of procedure SYS AL-124. The system engineer and the Supervising ,

Operator made judgment errors in the use of the procedure. Contributing )

causes included ineffective communications between the system engineer and '

the Shift Supervisor, failure to perform a second pre-job brief of the

procedure, and a procedure that was inadequate to the task.

The system engineer had been involved with SYS AL-124 in the past. The

system engineer also thought that some operator intervention of lowering

the speed control had taken place in past runs. This condition has been

substantiated during a previous run of SYS AL-124, in December of 1996. ,

The system engineer was also aware that what he recommended was not

specifically in the procedure, but felt that the procedure was being

followed.

The Operations group was responsible for performing SYS AL-124. The

Supervising Operator, when presented with the decision at completing step

6.1.4.3, had two options: continue with the procedure as written, possibly

resulting in anotner overspeed trip, or halt the procedure and place the

equipment in a safe condition. The Supervising Operator chose to intervene

by lowering the spee1 controller setpoint, avoiding another possible ,

overspeed trip, rather than tc ilt the procedure and notify the Shift )

Supervisor.

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j ':t is evident that botn the system engineer and the Supervising . Operator

. were. cognizant of .their procedural: perfortnance responsibilities. They both .

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knew: that manipulation of the speed controller was not specifically

. addressed by procedure step 6.1.4.3. They were aware of management

j expectations regaroing procedure use, but did not perform- to this

expectation,

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( Corrective Steps Taken and Resultis Achieved For Violation 9404-02 --- Example

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'*- Immediate corrective action ,resulted in appropriate. counseling and

', discipline of Operations and System Engineering personnel' by their

!' management.

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i * Tollowing- this event, the Superintendent of Operatict;s met with all

j operating crews and re-emphasized his expectations for procedural

compliance. These meetings were completed by March 15, 1997.

• The Manager of System Engineering conducted a training session with the

system engineers to emphasize the tole of the Shift Supervisor in regards

to-direction and performance of work in the plan. Special emphasis was

placed on effective three-way communication between the requester and the

Shift Supervisor, ' prior to the start of any activity.

_

This action was

completed on April 22, 1997.

• Interim corrective action resulted in "On the Spot Change" (OTSC)97-024 to

procedure SYS AL-124. This procedure change was .ef fective 'in preventing

recurrence of an overspeed trip

• The Manager of Operations provided long-term corrective. action by revising i

.SYS AL-124, to provide an optimal way of regulating the TDAFWP control

system. This procedure change was completed April 22, 1997.

Corrective Steps That Will Be Talren And The Date When Full Compliance Will Be

Achieved For Violation 9704-02---Example Two:

• AP15C-002, Revision 8, " Procedure Use and Adherence" will be revised

to include a definition for literal compliance to better aid personnel

in the field. The PSRC Chairman (Manager IPS) is responsible for

incorporating this definition into the procedure. This action will be

complete'by May 8, 1997.

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Attachment to ET 97-0044

Page 9 of 14-

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Violata.on 50-402/9704-03: Pe r s orme l - failea to properly est & ish procedure

SYS AL-124. Specifically the procedure failed to

define icw speec and oi. pressure parameters, and

failed to specify actions sboald those parameters

be exceeoed. In addition, a change was made to SYS

AL-124 that required operators to manually open the

trip-throttle valva and control turbine speed at

approximately 2500 rpm. This could not be

accomplisned due to the design of the ramp

a

generator circuit.

" Technical Specification 6.8.1 a states, in part, that written

procedures shall be established and implemented covering the applicable

procedures recommended in Appendix A of Regulatory Guide 1.33, Revision

2.

Regulatory Guide 1.33, Appendix A, Section 9, requires procedures for

performing maintenance.

System operating Procedure SYS AL 124, " Venting the Turbine-Driven

Auxiliary Feedwater Pump 031 Syrtem," i<evi s ion 1, provides guidance for

post maintenance testing of the turbine-driven auxiliary feedwater pump.

'

Contrary to the above, on January 24, 1997, licensee personnel failed to

properly establish Procedure SYS AL-124. Specifically:

1. The procedure contained a precaution to closely monitor the

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bearing oil pressure when operating the turbine at low

speeds, but failed to define low speeds and low oil

pressure, and tailed to specify what actio,ns were to be

taken when low oil pressure was reached. S

2. On-The-Spot Change 97-0023 to the prNedure required

operators to manually open the trip-throttle valve and

control turbine speed at approximately 2500 rpm. With the

governor controller set at the normal position of

approximately 3850 rpm, this could not be accomplished due

to the design of the ramp generator circuit tnat attempted

,

to accelerate the turbine from approximately 1100 rpm t> the

s normal setting of the controller, 3850 rpm."

Admission of Violation:

Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that a

violation of Technical Specificat; on 6.8.1 occurred when licensee personnel

failed to properly establish procedure SYS AL-124 by failing to define low

speed and oil pressure parameters, and failing to specify actions should those

parameters be exceeded. In addition, personnel it. correctly established and

attempted to implement a change to SYS AL-124 that could not be accomplished

due to the design of the equipment.

Reason for Violation:

The 2: cot cause of these two examples war failure to recr;gnize t:e correlation

between LIMIT SWITCH 6 (LS-6), TTV position, and the speed of the TDAFWP

resulted in selection of an unachievable speed. This resulted in additional

idle speed operation, not anticipated by the procedure change, and subsequent

normal low oil pressure (above the low pressure alarm) due to idle operation.

The Manager Operations placed a stop work order on future performances of SYS ,

AL-124, to remove any perceived time constraint pressure associated with J

completion of the LCO. A group, consisting of the Central Work Authority

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Attacnment to ET 97-0044 i

P arie 10 of 14

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( CNM , Ih. tit Supe r v:. s o r , v/ sten Engineering Sacer.71sor, Operations Procedures

? W.n te r , System Engineer, ano 15C, was then tasked with changing the procedure.

A Centrol Rocr cr:ef 't tre cnangea procedure was then conducted by the system  !

enginee:. The system enaineer would be tne local lead test performer with the

4 Supervising Operator ' c eing me responsible lead with the procedure.  ;

,

LS-6 actuation is at a tn:cttle position aoove 3000 rpm. Below this position, I

the control circuitry controis at idle speed of 1100 rpm. The change thus

caused longer operation ut idle speec, because achieving 1500 rpm was not

obtainable. This resulteu in subsequent idle speed oil pressure The OTSC

would have been snecessful if LS-6 were located lower in the throttle position

' of the TTV. This was not known by the group that changed the procedure, nor

, is this key information captured by any documantation.

Had the procedure change recogni:'ed the correlation of LS-6 and TTV position, l

prolonged idle speed operation would not have oc-curred. The unanticipated

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prolonged idle speed gave tne appearance that the oil pressure concern was not

'

addressed. The caution had no explicit speed for low oil pressure. The

procedure performers, conscious of the caution, took the appropriate action.

.This operation time at idle had no adverse affect on the TDAFWP.

Corrective Stops Taken and Results Achieve _d1

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• Procedure SYS AL-124 was revised. The procedure revision included

information detailing the actuation of LS-6 while manually opening the TTV,

4 mixed with 4w omatic GCV function. The procedure re visi on also reviewed

the oil pressure prc:;autions as they relate to idle speed operation. This

revision was completed on April 22, 1997.

• * Manager of System Engineering has supplemented the TDAFWP instruction

manual, I/M M-021-00086, via the Vendor Engineering Techr,1 cal Information

Program (VETIP), to clarify manual TrV operation, mixed with automatic GCV

control of the TDAFWP.

.

• Review of the OTSC process identified the process to be prudent and

appropriate. No programmatic deficiencies were identified, therefore no

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additional corrective action is warranted.

Corrective Steps That Will Be Taken And The Date When E'ull Compliance Will Be

Achieved:

1

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• Training, detailing the actuation of LS-6, while manually opening the TTV,

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mixed with automatic GCV function, will be included in the Operator

Training Instructions. This training will apply to both initial and re-

i qualifications and include ooth licensed and non-licensed operators. Re-

qualification training will be completed by June 30, 1997. Initial

training will be completed by January 30, 1998.

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Att~.cnment to ET 97-0044

Page 11 of 14

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Violation 50-402/5 04-04: An cpe:ator unsuccensfully atcempted to trip the  !

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i taroine-ariven auxillary feedwater pump cy pulling j

On the trip linkage. j

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"Tecnnical Specification 6.8.1.a states, in part, that written j

procedures shall be estaclished and implemented covering the l

applicable procedares recommended in Appendix A cf Regulatory l

l Guide 1.33, Be n s ion ') . j

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Regulatory Guide 1.33, Appendix A, Section 3.1, requires l

procedures 'or operation of the auxiliary feeddater system.

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dystem Operating krocedure SYS AL-124, " Venting the Turbine Driven

j Auxiliary Feedwater Pump Oil System," Step 6.1. 5, requires the

l operator to trip tre turbine driven auxiliary feedwater pump using  ;

the manual tric lever.  ;

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Contrary to the above, on January 24, 1997, the operator I

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unsuccessfully attempted to trip the turbine-driven auxiliary )

feedwater pump by pulling on the trip linkage, causzng the turbine  !

speed to increase."

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Admi.csion of Violat. ion:

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l Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees that

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a violation of Technical Specification 6.8.1 c ': cu r red when an operator

attempted to trip tne turbine-dtiven auxiliary feedwater pump by pulling on  ;

,

the mechanical overspeed connecting rod (trip linkage).

.

Reason for Violationt

. On January 24, 1997, during the third performance of SYS AL-124, a decision

was made to trip the TDAWP. When the Shift Supervisor entered the pump room,

d.

he directed the Nuclear Station Operator !NSO) to trip the TDAFWP. The NSO,

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controlling speed manually with the TTV, attempted to trip the TDANP by

p:alling on the mechanical overspeed cennecting rod. He chose this method

based on his physical location in the room, and also due to congestion in the

4 rcam. This attempt was not successful. A second NSO who was in the room,

4 made his way to the manual trip cush button, located on the other side of the

{ pump, and tripped the TDAFWP.

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i Operators were taught to use the mechanical push button to trip the TDAFWP.

The method to utilize the connecting rod was used successfully in the past

- Evidence from interviewc indicates that tripping the pump by the connecting

j rod method was informally introduced during field training. The TDAFWP manual

. only discusses asing the trip button, and does not instruct the user to pull

3

on the connecting rod. A review of old lesson plans did not identify

instruction for utilizing the connecting rod method. Subsequently, it was

. determined that the Electrical Trip / Reset on the FC219 panel was also an

acceptable method for tripping the TDAFWP.

The root cause of this event was inappropriate field training that fostered

the use of an ad hoc non-proceduralized trip method. A contributing factor

that fostered the use of the ad hoc method is the physical lay out of the

room and the d',fficult access tc the trip puch buttan. It was easier to

utilize the ad hoc rathod than to climb over, around, and through the

equipment in the room to access the mechanical trip push button.

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Attachment to ET 97-0044

Page 12 of 14

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• Correccive Steps Takea and Results Achieved:

• The Shift Supervisors, Superv.tsing Operators, as well as thtir operating

^

crews, were i.nediately informed of the proper methods for tripping the

TDAEWP.

- * Essential Reading was developed for Operating crews instructing tnat

! only the mechanical trip push button, or the electrical trip / reset

4 button on the FC219 panel, are acceptable methods to be used to trip the

TDAFWP. This Essential Reading was initiated on April 10, 1997.

a

Corrective Steps That Will Be Taken And The Date When Full Compliance Will Be

Achieved:

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• Additional communication to appropriate personnel that ad hoc operation l

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is unacceptable, and that equipment is to be operated per procedures, or

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per design will be completed by June 30, 1997

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Attachment to ET 97-0044

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Page 13 of '4.

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viciation 50-482/9704-07: A change was made to the Emergency Plan, which

resulted in a decrease in the effectiveness of the

plan without prior NRC approval.

"10 CFR 50.54 (q) permits the licensee to make changes to tne

emergency plans without prior Commission approval only if the j

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changes do not decrease the e f fc ctiveness of plans and meet the i

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standards of 10 CFR 50.47(b),

, Contrary to the above, on February 23, 1996, the licensee changed

the emergency plan, which resulted in a decrease in the

effectiveness of their plan without prior NRC approval in tnat an

emergency action level form that would have previously classified I

a particular event as a site area emergency was changed to 1

classify it as an Alert."

Admission of Violation:

Wolf Creek Nuclear Operating Corporation (WCNOC) acknowledges and agrees

that a violation of 10 CFR 50,54 (q) occurred when an editorial error

'

during a revision procees inadvertently resulted in redirecting the flow

path of one decision box to the potential decla ra t. ion of an ALERT,

instead of leading to the intended declaration of a SITE AREA EMERGENCY

(SAE).

Reason for the Violation

This incident occurred because an error was made during a change to the

" Safety System Failure or Malfunction" page of the Emergency Action

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Level (EAL) flow charts. As part of this change, several. decision boxes

were re-sized and realigned.

During the process of reorganizing and changing this flow chart page, an

editorial error inadvertently resulted in redirecting the flow path of

one decision box from leading to a SAE to leading to an ALERT. This

error was not identified during the review and approval process.

Consequently, there was a reduction in the effectiveness of the

Emergency Plan without prior NRC approval.

.

The results of subsequent evaluation and interviews identified the root

cause to be inadequate reviews performed by the initiator and the

qualified reviewer.

There were two contributing factors:

a The guidance in AP 15C-004, Revision 9, " Preparation, Review, and

Approval of Documents," was unclear, and allowed for various

interpretations. This led to an inconsistent understanding and

application of the expectations concerning the required level of

de'. ail to be applied *" the document review process.

• AP 15C-004 also did not provide clear guidance on how to perform a

review of a flow chart. Compounding this, there was no tool

available which would allow the initiator, or other personnel

reviewing tne EALs, to verify that the logic for the blocks that led

to each level of classification was correct, and had not been

inadvertently changed on any of the EAL flow charts.

Interviews indicated that individuals involved in this review process

varied in their perception of procedural and management expectations

concerning the level of detail required. The evaluation also determined

that there was a disparity between the perceived expectations of

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4 Attachment to ET 97-0944

Page 14 of 14

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creparers and reviewers. This :. s Potentially a generic issue with the

' review process, extendina beyo:a ' 235 the review of Emergency Planning

Procedures.

The Inspection Report cover letter ana "Ob s e rva t l.o ns and Findings"

section of the inspection report did icentify that tne Shift Supervisor

was not notified in a timely manner. The root cause of this failure to

effect a timely notification of the Shift Supervisor was the incorrect

celief by Emergency Planning personnel that other EAL emergency action

classification trees would have caused the correct classification of

this event scenario. This belief was corrected in discussions with the

Senior Resident Inspector on January 21, 1997. A demonstration of the

effectiveness of corrective actions to this concern about timely

notification was given on January 23, 1997, when another error in the

EALs was identified. The inspection report " Observations and Findings"

section identified that immediate notification and corrective action

occurred .in this instance.

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Corrective Steps Taken and Results Achieved

• The error in the " Safety System railure or Malfunction" page of the

Emergency Action Level (EAL) flow charts was corrected on January 22,

1997.

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* A matrix detailing all possible logical flow paths was developed.

5

Each classif2 cation has every possible combination of blocks listed.

2 This will allow a reviewer to ensure there are no undocumented a

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changes which would alter an EAL classification. This matrix was

completed March 28, 1997

• The initiator of the form revision and the qualified reviewer were

given job performance counseling in accordance with the Management

Action Response Checklist (MARC) program. This action was completed I

on March 26, 1997

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Corrective Steps That Will Be Taken And The Date When Full, Compliance

Will Be Achieved

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e A new section is being added to procedure AP 15C-004, Attachment D,  !

idenrifying the EAL matrix discussed above. The section will also

direct that the matrix be used to perform the review of the flow

chart in order to review each possible emergency classification.

! These changes will be incorporated by April 30, 1997 Until the

change is incorporated, the Ma na'je r Emergency Planning will assure

that the matrix is used for any revisions to the EALs.

• Information on possible generic issues, including the disparity in

perceptions of preparers and re"iewers about procedural requirements

< and management expectations concerning the level of detail required j

in raviews, wi '.1 . presented to the PSRC c.n April 23, 1997. j

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