ST-HL-AE-2977, Responds to NRC Re Violations Noted in Insp Rept 50-498/88-68.Corrective Actions:Phase B Isolation Requirements Incorporated in Emergency Operating Procedures & Team Formed to Conduct Enhancement Program

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Responds to NRC Re Violations Noted in Insp Rept 50-498/88-68.Corrective Actions:Phase B Isolation Requirements Incorporated in Emergency Operating Procedures & Team Formed to Conduct Enhancement Program
ML20235L293
Person / Time
Site: South Texas STP Nuclear Operating Company icon.png
Issue date: 02/14/1989
From: Vaughn G
HOUSTON LIGHTING & POWER CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
Shared Package
ML20235L297 List:
References
ST-HL-AE-2977, NUDOCS 8902270457
Download: ML20235L293 (7)


Text

I

.o-The Light company P.O. Box 1700 llouston, Texas 77001 (713) 228 9211 l

l Ilouston Lighting & Power ~.. ~ - -' - -

3,- ----.~~~-,4 February- 14, 1989  ;

ST-HL-AE-2977 File No.: G2.4 10CFR2.201 U. S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, DC 20555 South Texas Project Electric Generating Station Unit 1 Docket No. STN 50-498 Response to Notices of Violation 8868-02 and 8868-07 1

Houston Lighting & Power Company has reviewed Notices of Violation 8868-02 and 8868-07 dated January 9, 1989, and submits the attached responses pursuant to 10CFR2.201.

An extension to February 14, 1989 for submittal of this response was granted by Mr. E. Holler, Region IV on February 7, 1989.

If you should have any questions on this matter, please contact Mr. M. A. McBurnett at (512) 972-8530.

G. E. Vaughn Vice President Nuclear Operations GEV/RAF/n1 Attachments: 1. Response to Notice of Violation 8868-02

2. Comments on Paragraph 'a' - Notice of Violation 8868-02
3. Licensee Event Report 88-061
4. Response to Notice of Violation 8868-07
5. Response to NRC Generic Concerns 8902270<57 890214 '

ADOCK 05000498 O

PDR PDC O! l I

A Subsidiary of Ilouston Industries Incorporated i NL.89.030.03 g/ g l l

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a Ilouston Lighting & Power Company ST-HL-AE-2977 File No.: G2.4 Page 2 cc:

Regional Administrator, Region IV Rufus S. Scott Nuclear Regulatory Commission Associate General Counsel 611 Ryan Plaza Drive, Suite 1000 Houston Lighting & Power Company Arlington, TX 76011 -P. O. Box 1700 Houston, TX 77001 George Dick, Project Manager U. S. Nuclear Regulatory Commission INPO Washington, DC 20555 Records Center 1100 Circle 75 Parkway Jack E. Bess Atlanta, Ga. 30339-3064 Senior Resident Inspector-Unit 1 c/o U. S. Nuclear Regulatory Commission Dr. Joseph M. Hendrie P. O. Box 913 50 Be11 port Lane Bay City, TX 77414 Be11 port, NY 11713 J. I. Tapia Senior Resident Inspector-Unit 2 c/o U. S. Nuclear Regulatory Commission P. O. Box 910 Bay City, TX 77414 J. R. Newman, Esquire Newman & Holtzinger, P.C.

1615 L Street, N.W.

Washington, DC 20036 R. L. Range /R. P. Verret Central Power & Light Company P. O. Box 2121 Corpus Christi, TX 78403 R. John Miner (2 copies)

Chief Operating Officer City of Austin Electric Utility 721 Barton Springs Road Austin, TX 78704 R. J. Costello/M. T. Hardt City Public Service Board P. O. Box 1771 San Antonio, TX 78,296 Revised 12/21/88 NL.DIST

Inouston Lighting & Power Company Attachment 1 ST-HL-AE-2977 Page 1 of 4 South Texas Project Electric Generating Station Unit 1 Docket No. STN 50-498 Response to Notice of Violation 8868-02 I. Statement of Violation Inadequate Emergency Operating Procedures 10 CFR 50, Appendix B, Criterion V, requires that activities affecting quality shall be prescribed by documented instructions or procedures and shall include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished.

a. Contrary to the above, South Texas Project Electric Generating Station Procedure OPOP01-ZA-0006, Revision 4, " Emergency Procedures Writers Guide and Verification," was not appropriate to the circumstances in that it did not require Emergency Operating Procedures (EOPs) be verified for technical adequacy by a multidiscipline team. This resulted in approximately six examples where the values provided in the E0Ps deviated form [ sic] the values provided in the site specific Set Point Document; numerous examples where the E0Ps deviated from the Westinghouse Owners Group (WOG)

Emergency Response Guidelines (ERGS) without providing adequate documented justification for these deviations; and at least one plant design change (addition of Phase B containment isolation) had not been incorporated into all applicable EOPs.

b. Contrary to the above, South Texas Proj ect Electric Generating Station Procedure OPGP03-AZ-0027 [ sic), Revision 4, " Emergency Operating Procedures Preparation, Approval, Implementation, and Revision," was not appropriate to the circumstances in that it did not require in-plant walkdowns as part of the E0P validation process. This resulted in equipment nomenclature was not accurately reflected in the E0Ps; locally posted equipment operating instructions were not in the immediate vicinity of the equipment to be operated; equipment requiring local operation was located inside containment and was not identified as such; solenoids required for local operation of the steam generator power operated relief valves were not labeled and caused confusion on the part of the operators during E0P walkdowns by the NRC inspection team; it was not l

identified that lack of emergency lighting could impede local actions required by the E0Ps; and it was not identified that environmental conditions (Radiation and/or temperature) could prevent local actions required by the E0Ps.

NL.89,030.03

e

. Ilouston 1.ighting & Power Company Attachment 1-ST-HL-AE-2977

~Page 2 of 4

c.  ; Contrary to the'above, EOF POP 05-EO-EC31, "SGTR With Loss of' Reactor

~

Coolant-Subcooled Recovery Desired" was not appropriate to the.

circumstances, in that'the word "OR".was missing between-Substeps.14.1 and 14.2. As. written, if the HHSI pump (s) was running L and the LHSI pump (s) was stopped, the operator would have incorrectly transitioned to Step 19, and omitted Steps 15, through

18. -This.would have resulted in radioactive reactor coolant water being forced into the steam generator via the ruptured tube (s) and into the atmosphere via the steam generator power operated relief valve (s) and/or' safety valves (s) l II. Houston Lighting and Power Position HL&P concurs.that the cited violation occured. We do however have a number of comments on paragraph 'a'. These comments are included.in Attachment 2.

The response to the generic concern expressed in Inspection Report 88-68 is addressed in Attachment 5.

III. Reason for Violation Paragraph 'a' With the exception of the last example cited in paragraph 'a',

please refer to the information provided in Attachment 2.

Regarding the failure to incorporateLa. design change into all applicable E0Ps, it has been determined that this was an oversight during the evaluation of the design change for EOP. impact.

Paragraph 'b' The failure to. require in-plant walkdowns during validation is attributed to not fully translating the guidance provided in NUREG-0899 into procedure OPGP03-ZA-0027, Emergency Operating Procedures Preparation, Approval,~ Implementation, and Revision.

Paragraph 'c' l 1

This portion of the violation has been previously addressed in Licensee Event Report 88-061, Emergency Operating Procedure Error Due to Inadequate Review, dated November 21, 1988, and is provided as Attachment 3.

I NL.89.030.03  !

Ilouston 1.ighting & Power Company Attachment 1 ST-HL-AE-2977 Page 3 of 4 IV. Corrective Actions Taken and Results Achieved EOP Specific

1. Phase 'B' isolation requirements have been incorporated into affected E0Ps. (paragraph 'a')
2. A manual cross reference of 'like' steps has been developed to minimize the possibility of a change not being incorporated into affected E0Ps (paragraph 'a').
3. Westinghouse has provided a Design Difference and Analysis Applicability Document and a Step Deviation / Justification Document for STPEGS, based on Unit 2 EOPs and Rev. 1 ERGS. While there will be some differences between Unit 1 and Unit 2, this document will be utilized as the Interim Step Deviation / Justification Document for both units until the completion of the E0P enhancement program described in IV.6.
4. An in-depth review of Unit 2 EOPs to identify and correct editorial errors was completed prior to Unit 2 Fuel Load. This review will also be conducted for both Unit 1 and Unit 2 as part of the EOP enhancement program. (paragraph 'b')
5. The missing -OR- was incorporated into EOPs 1 POP 05-EO-EC31 and 2 POP 05-EO-EC31, SGTR with Loss of Reactor Coolant-Subcooled Recovery Desired, (paragraph 'c').
6. HL&P has developed a comprehensive program to enhance the quality of the STPEGS Emergency Operating Procedures. The principal elements of this program area o The evaluation and revision of the administrative control procedures for writing, verifying, validating and implementing E0Ps. This is to include the incorporation of the guidance of NUREG 0899 and appropriate comments / recommendations of the NRC E0P inspection team, o The establishment of a team of five(5) dedicated individuals familiar with Westinghouse Pressurized Water Reactors, to conduct the enhancement program. (Note: There will be a six week period when only two will be available because of training commitments. Upon completion of this training the group will return to full strength).

NL.89.030.03

lbston Lighting & Power Company Attachment 1 ST-HL-AE-2977 Page 4 of 4 o The revision of Unit 1 and Unit 2 EOPs to conform to the new administrative requirements and to incorporate: Revision lA of

the ERGS, approved changes to the Setpoint Document, and appropriate comments / recommendations of the NRC E0P inspection team.

o The verification and validation of the revised E..es.

o The training of operating crews on the revised E0Ps prior to implementation. i l

Because completely revised EOP's will be put in place at the completion of this effort, the final Step Deviation / Justification Document will not be available until August 1990. Until that time the document described in IV.3 will be utilized.

i V. Corrective Action to Preclude Recurrence The Letions taken in Section IV should preclude recurrence VI. Full Compliance The current revision of the EOPs are adequate to perform their intended function.- The concerns raised by the NRC inspection team will be addressed with the completion of the program enhancement described in Section IV. This activity is scheduled to be complete by August 31, 1990.

NL.89.030.03

t

' ilouston Lighting & Power Company .

Attachment 2 ST-HL-AE-2977-

> Page 1 of 3 SOUTH TEXAS PROJECT ELECTRIC GENERATING STATION 1 UNIT 1 JDOCKET NO. STN 50-498 COMMENTS ON PARAGRAPH 'a'-Notice of Violation 8868-02 i

HL&P has the following comments on specifie' excerpts.from paragraph 'a' of Violation 8868-02. .

First Excerpt -l

... Procedure OPOP01-ZA-0006, revision 4, " Emergency Procedure Writers Guide and Verification", was not appropriate to the circumstances in ,

that it did not require Emergency. Operating Procedures.(EOP's) be {

verified'for technical adequacy by a multidiscipline team."

Comment, Not all the requirements _ for the review of: EOP's are contained in-procedure'OPOP01-ZA-0006, " Emergency Procedures Writers Guide'and

-Verification"; this procedure contains the internal department review. -i The : requirements for other reviews are found in procedure i OPGP03-ZA-0027, " Emergency Operating Procedures Preparation; Approval, .!

Implementation, and Revision". Revision 4 of this procedure, effective I 8/22/88, required each revision of an'EOP be reviewed by Plant Staff- j which consisted of reviews by Plant Engineering, Support Engineering or -!

Nuclear Engineering, Plant Operations, Nuclear Training and other I affected departments. Prior to Revision 4 it was not required that  ;

either Support Engineering or Nuclear Engineering be included'in the j review process.

l

) Second Excerpt j

"...This resulted in approximately six examples where values provided )

in E0Ps deviated form [ sic) the values provided in the site specific Set 1 Point Document;..."

Erample

'I "In accordance with the setpoint document, the charging flow is 32 l gpm. In FRII, Step 2.3, the charging flow is given as between 30 and 35 gpm in one place and 30 gpm in another place within the same j step. This same error occurs in FRI2, Step 3.4 and in FRI3, )

Step 2.4". ,

'l l

l NL 89.030.03

e libuston Lighting & Power Company Attachment 2 ST-HL-AE-297)

Page 2 of 3 ,

1 l

Comment These deviations from- the Setpoint Document had been documer ..d and 1 evaluated. At the time of the inspection, approved justificat. ions were in place explaining that these changes provided the operators l with allowable operational tolerances. This action is consistent i with the Westinghouse Owners Group Emergency Response Guidelines (ERG) requirements and the South Texas Project Electric Generating Station (STPEGS) Writers Guide.

Examples "In accordance with the setpoint document, .the adverse containment value for narrow range (NR) steam generator (S/G) level is 21 percent, EOP ES11, Steps 1.0 [ sic], 16.1 [ sic), and 16.2 [ sic] list this value as 27 percent. In E000, Step 21.b, the correct value, 21 percent, was used".

"In accordance with the setpoint document, the adverse containment value for pressurizer level is 40 percent. EOF ES11 Conditional Information page Steps 1.0 and 2.0 and procedure, Steps 6.2 and 24.2

[ sic} lists this value as 44 percent".

Comment Revision 2 of the procedures in question was in effect when requested by the NRC. By the time the. inspection team arrived on site, Revision 3 of those same procedures was approved. This revision corrected the Adverse Containment setpoints. The inspection team was provided with the revised procedures when the problem was identified. Also note that Step-1.0 should be Conditional Information Page Step 1.0 and that 16.1 and 16.2 should be 17.1 and 17.2 respectively.

Example "In accordance with the setpoint document, the containment sump level is 5 foot 10 inches or 70 inches. E0P Status Tree F00 [ sic]

lists this value as 69 inches".

Comment The setpoint of 69 inches in EOP Status Tree F005 was used based upon an Engineering identified discrepancy in the Setpoint Document.

Notification of this error was made by Operational Advisory Letter l

ST-HS-P2-0453 which in effect is a change to the Setpoint Document,

! This change was necessary because the closest sensor, taking into l account error, is at 69 inches. This setpoint change has been incorporated into Revision 3 of the setpoint document which is currently in review.

i l

l NL.89.030.03 l

llouston 1.ighting & Power Cornpany Attachment 2 ST-HL-AE-2977 Page 3 of 3 Third Excerpt

" ... numerous examples where the E0P's deviated from the Westinghouse Owners Group (WOG) Emergency Response Guidelines (ERGS) without providing adequate documented justification for these deviations. . ."

Comment HL&P agrees the deviation documentation is incomplete, however, at the time of the inspection, HL&P was working toward meeting a commitment previously made to the NRC regarding this issue. In Inspection Report 87-08 the following Open Item was initiated:

"...However, many deviations from the WOG ERGS were not documented and justified on SJ/V forms and there were inadequate basis and justification for some of the deviations which were documented on SJ/V forms. Pending licensee resolution, the lack of documentation of deviations from the WOG ERGS will be tracked as an open item (498/8708-61)."

HL&P responded to this open item at the request of the NRC. In letter ST-HL-AE-2268 dated June 22, 1987 the following response was provided:

" Confirmatory Item 27, Staff review of the procedures generation package, is currently under NRC review. Telephone discussions,...,

indicate the following:

HL&P is planning to assemble documentation of deviations from and additions to the WOG ERGS that will meet the intent of section 3.3.2 Appendix A of SRP 13.5.2. We further stated that we would complete this effort prior to the first refueling outage for Unit 1. Subsequent conversations have indicated that the NRC Staff concurs with this completion schedule."

Additionally, in response to concerns raised during inspection 88-52, HL&P proposed additional actions to speed the above process. Letter ST-HL-AE-2779 provided a commitment to have Westinghouse perform a detailed step-by-step comparison of Unit 2 EOPs with the ERGS and to provide step deviation justifications. This information was then to be used to develop the same documentation for Unit 1 E0Ps.

NL.89.030.03

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I Ifouston Ughting & Power Company Attachment 4 ST-HL-AE-2977 Page 1 of 2 1 l

l South Texas Project Electric Generating Station l Unit 1 Docket No. STN 50-498 Response to Notice of Violation 8868-07 I. Statement of Violation Inadequate Audits 10 CFR 50, Appendix B, Criterion XVIII, requires a comprehensive system of planned and periodic audits to verify compliance and to determine the effectiveness of all aspects of the quality assurance program.

Contrary to the above, the licensee failed to perform comprehensive audits of the South Texas Project Electric Generating Station EOPs.

This was evidenced by the fact that of the four audits and five surveillance reviewed, none of the generic issues identified by the NRC inspection team had been identified by quality assurance. The basic reason, in part, that audit and surveillance activities were not identifying generic issues was the objectives of these activities. The emphasis of these activities was being placed on process compliance rather (sic] on the quality of the product.

II. Houston Lighting & Power Position Houston Lighting & Power does not contest the violation.

III. Reason for Violation This violation occurred because of an inconsistent understanding within the Audit Group organization, of those attributes that determine the effectiveness of a procedure development program.

IV. Corrective Actions Taken and Results Achieved "his Notice of Violation has been discussed with personnel in the Audi) Jroup. This discussion included the importance of properly identifying inspection attributes.

An audit of Instructions and Procedures will be completed during February 1989. This audit will focus on tts products of the Procedure Program. This will ensure that any generic implications of this finding, with respect to other procedure types, are identified.

NL.89.030.03

,~ c .

' Ifouston Lighting & Power Company Attachment.4.

ST-HL-AE-2977 Page 2 of 2-V. Corrective Action to Prevent Recurrence.

Existing audit scope documents have been reviewed to ensure.that they reflect performance and results based auditing. Six audit scopes were determined to require enhancement. These audit scopes will be revised prior to the next performance of the applicable audit during 1989.

For the 1989 audit cycle Department Managers of audited organizations will be asked, during the planning' process, to provide the Audit Team Leader with the attributes that they feel provide an indication of successful and' effective implementation. This information will be factored'into the audit plan as appropriate.

The surveillance reporting process has been modified to allow QA surveillance personnel more flexibility in documenting observations and recommendations relative to improving work processes, modifying procedures, etc. These observations and recommendations will be included, as appropriate, in the monthly summary of QA surveillance .

activities which, is issued to the management of affected organizations.

Following the completion of the Emergency Operating Procedure (EOP) enhancement program (refer to Attachment 1, Response to Notice of

. Violation 8868-02), Nuclear Assurance will conduct an assessment of the EOPs that will include. desk top reviews, plant and control room walkdowns, observation of simulator exercises, and a review of the EOF training program. Following this assessment, additional assessments will be scheduled as required, based on Emergency Operating Procedures program activities.

VI. Full Compliance The audit program at the South Texas Project is in full compliance with applicable regulations at this time. The enhancements described in Section V will be implemented throughout the course of 1989.

NL.89.030.03 I

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ __ _ _ i

Ilouston Lighting & Power Company Attachment 5 ST-HL-AE-2977 Page 1 of 2 SOUTH TEXAS PROJECT ELECTRIC GENERATING STATION UNIT 1 DOCKET NO. STN 50-498 RESPONSE TO NRC GENERIC CONCERNS Statement of Concern We [NRC] are concerned that the weaknesses in your [HL&P] verification i and validation efforts, as described in paragraph 2.2.2 of the enclosed

[ Inspection) report, allowed the procedural inadequacy described in paragraph 2.4.1 to remain undetected until discovered by the inspection team. This procedural inadequacy is cited as Violation 1.c [8868-02).  ;

In your response to this violation, you are roquested to address the 1 specific actions you have taken or planned, to assure that the l appropriate resources (in number, experience, and level of effort) are applied to the review and evaluation of procedures, instructions, and other documents which communicate your expectations and guidance for the performance of safety-related activities.

Clarification of the Concern On.or about January 18, 1989, a telephone conversation was conducted between Mr. W. H. Kinsey (HL&P) and Mr. E. Holler (NRC) regarding the statement of concern. During this conversation it was indicated by Mr. Holler that the statement relating to resources i.e., number, experfence, and level of effort, applied to the Emergency Operating Procedures. l Resources for EOP development are discussed in Attachment 1, Response to Notice of Violation 8868-02.

Responses As stated by your concern, this issue was a result of the EOP inspection team identifying a procedural inadequacy that was of a safety significant nature. HL&P has addressed this specific concern in the response to Violation 8868-02. The Emergency Operating Procedures, however, are unique in the realm of operational procedures in that with the exception of the procedure governing reactor trips, these procedures are used infrequent.ly. This is in contrast with procedures used for normal operation and maintenance of a unit which are used on a regular basis by different personnel, making it unlikely that an error of the msgnitude identified in the EOPs would go undetected. While there are improvements that hsve been and will continue to be made in Station Procedures, it is Houston Lighting & Power's position that, as a whole, the procedures at S'IPEGS, by demonstration, are adequate to perform intended functions without compromising safety, quality, or the health and safety of the public.

NL.89.030.03

a llouston 1.ighting & Power Company Attachment 5 ST-HL-AE-2977 Page 2 of 2 SOUTH TEXAS PROJECT ELECTRIC GENERATING STATION UNIT 1 DOCKET NO. STN 50-498 RESPONSE TO NRC GENERIC CONCERNS Previous actions taken at STPEGS include:

1. The incorporation of an independent technical review for all new and revised procedures. This review requires the use of a checklist which is provided in OPGP03-ZA-0002.
2. The establishment of a biennial review of station procedures to ensure they remain current over the life of the plant.
3. Tne development of a mechanism (Procedure Request Form) for plant personnel to identify problems with or recommend improvements to procedures.

In addition, an overall enhancement program will be implemented to incorporate applicable lessons learned from the EOP inspection for procedures used for the operation, maintenance, and testing procedures.

Operating procedures will be completed by December 31, 1993. Other procedures (e.g., maintenance and' surveillance) will be enhanced as the procedures require major revision or through the biennial review process.

NL.89.030.03

n-ATTACHMENT 3 I . Tha Ligh= t . ST-HL.AE. 2 97 7 gg g PAGE I 0F S Houston Lighting & Power P.O. Box l'/00 Houston, Texas 77001 (713) 228 9211 November 21, 1988 ST-HL-AE-2861 File No.: G26 10CFR50.73 U. S. Nuclear Regulatory Commission Attention: Document Control Desk

Washington, DC 20555 South Texas Project Electric Generating Station Unit 1 Docket No. SIN 50-498 License Event Report 88-061 Regarding Emergency Operating Procedure Error Due To Inadeouate Review Pursuan,t to 10CTR50.73, Houston Lighting & Power (HL&P) submits the attached Licensee Event Report (88-061) regarding an emergency operating procedure error due to inadequate review. This event did not have any adverse impact on.the health and safety of the public.

If you should have any questions on this matter, please contact Mr. C.A. Ayala at (512) 972-8628.

T G. E. Vaughn Vice President Nuclear Plant Operations GEV/BEM/rh

Attachment:

LER 88-061 r

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A Subsidiary of ouston Industries Incorporated

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ATTACHMENT' 25 Houston Lighting & Poser Company

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~~~~31-HL-AE-2861 File No.: G26 10CFR50 73 Page'2-cc:

' Regional Administrator, Regio- IV -Rufus S. Scott Nuclear Regulatory Commission Associate General Counsel 611 Ryan Plaza Drive, Suite 1000 Houston Lighting & Power Company Arlington, TX. 76011 P. O. Box.1700 Houston, TX 77001 George - Dick, Proj ect Manager U. S.' Nuclear Regulatory Commission INPO Washington, DC' 20555 Records Center 1100 Circle 75 Parkway Jack E. Bess- . Atlanta, Ga. 30339-3064

~ Senior Resident Inspector / Operations e/o U. S. Nuclear Regulatory Commission Dr. Joseph M. Hendrie P. O. Box 910- 50 Be11 port Lane Bay City, TX 77414 Be11 port, NY 11713 n

-J. I, Tapia Senior Resident Inspector / Construction c/o U. S. Nuclear _ Regulatory' Commission P. O. Box 910 Bay City, TX 77414

. J. R. Newman, Esquire i'

Newman & Holt =inger,'P.C.

1615 L Street,-N.V.

Washington, DC 20036 R. L.' Range /R. P Verret Central Power & Light Company P. O.. Box 2121 .

Corpus Chr.isti, TX 78403 R. John Miner (2 copies)

. Chief Operating Officer City of Austin Electric Utility

'721 Barton Springs Road Austin, TX 78704-R. J. Costello/M. T. Hardt' City Public Service Board P. O.' Box 1771 San Antonio, TX 78296 Revised 08/24/88 NL.DIST

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( On October 27, 1988 Unit I was in Mode 1 at 100% power. During an NRC special I inspection of Emergency Operating Procedures (EOP's), a procedure step was found which could have caused an operator to skip actions which are required to limit the consequences of a steam generator tube rupture accident. During j development of a procedure revision the word "or" was omitted between two j procedure steps. This omission was not detected in subsequent reviews. The cause of this event was inadequate review of the EOP. No other safety significant errors or omissions were identified by the NRC. The procedure has been revised to correct the error.

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ATTACHMENT 3~-

DESCRIPTION OF OCCURRENCE: . ST.HL AE My

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PAGE 'l 0F o j .On October 27, 1988 with Unit 1 in Hode 1 at 100%~ power, an NRC special l inspection of Emergency Operating Procedures (EOP's) was in progress. This.

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inspection included tabletop review of all EOP's and walk through and simulator exercise of selected EOP's to determine their adequacy. During the table top review of the " Steam Generator Tube Rupture With Loss of Reactor Coolant Subcooled Recovery Desired" procedure, the NRC identified a step which would have caused an operator to skip actions which are required to limit the consequences of a steam generator tube rupture accident. Based on this discovery, the NRC purposely specified an accident scenario for simulator exercise which required the use of the deficient procedure to test operator response. When the plant operator demonstrating the procedure reached the erroneous step, he immediately idt:ntified'the error to the NRC inspectors.

This procedure was written based on guidance included in.the Westinghouse Owners. Group Emergency Response Guidelines (ERG's). It originally. included steps to ver.ify the status of the High Head Safety Injection (HMSI) pumps and to secure them if they were running. This action is required to limit the primary-to-secondary leakage'through the tube rupture. In August of 1988, HL&P revised the procedure based on changes to the ERG's. The revision included additional steps to ensure that the Low Head Saf ety Inj ection (LHSI) pumps are also secured if. running. However, the issued revision did not include the word "or" between two steps. This omission would have caused an operator to bypass procedure steps which secure the HHSI r-d LHSI pumps.

This condition was determined to be reportable on October 28, 1988 and the NRC was notified pursuant to 10CFR50.72 at 1023 hours0.0118 days <br />0.284 hours <br />0.00169 weeks <br />3.892515e-4 months <br />.

CAUSE OF OCCURRENCE:

The cause of this event was determined to be inadequate review of the EOF revision prior to its issuance. It could not be determined if this event occurred during transposition from the ERG or during typing.

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WIC Fra 3844 U.S. NUCLEA2 REQULATO3Y COMMBE3 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION mmoveo oMe No. siso-om ExFeRES BfJ1E5 F ACILITY NAMS (1) DOCERT NUMGER (2l Lgg guMegg se, pggg ggg YEam '? 3 8,0yl,',4 6 {; :.j gae ves South Texas, Unit 1 v m ,, - ., m _-4 o l5 l0 lo l0 l4 l9 l 8 8 l8 -

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ANALYSIS'OF EVENT: 4GE 5 OF f FSAR Chapter 15 and.the Westinghouse ERG's identify termination of LHSI and HHSI as required actions in the mitigation of a steam generator tube rupture accident. Should a main steam relief valve stick open, this action would also be required to minimize the release of radioactive material. Failure of an EOP to require the termination of LESI and HHSI is reportable pursuant to 10CFR50.73(a)(2)(v).

This event was discovered by the NRC during the table top review of this procedure. During a subsequent simulator exercise, the operator performing the procedure realized that it was wrong and identified the error to the NRC inspectors. This demonstrates a thorough understanding of the principles of accident mitigation by the operators.

No other saf.ety significant errors or omissions were identified by the NRC inspection.

CORRECTIV2' ACTION The deficient EOF has been corrected for both units to comply with the Westinghouse. Emergency Response Guidelines.

ADDITIONAL INFORMATION:

As a result of the NRC i..apection, an enhancement program will be implemented to ensure the accuracy and consistency of the EOP's. This program will be tracked as a corrective action for NRC Inspection Report 88-068.

There have been no previous reports regarding inadequate EOP's.

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