RBG-40146, Responds to Violation Noted in Insp Rept 50-458/93-28 Re Failure to Implement Corrective Actions Which Allowed Entry by Plant Into Condition Prohibited by Ts.Work Control Process Refined to Prevent Nonscheduled Work or Testing

Responds to Violation Noted in Insp Rept 50-458/93-28 Re Failure to Implement Corrective Actions Which Allowed Entry by Plant Into Condition Prohibited by Ts.Work Control Process Refined to Prevent Nonscheduled Work or Testing

ML20067C816
Person / Time
Site:	River Bend
Issue date:	02/18/1994
From:	James Fisicaro ENTERGY OPERATIONS, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
RBG-40146, NUDOCS 9403040243
Download: ML20067C816 (16)

Text

==-ENTERGY l""'r""2"""" * '"'

F'O Ocx 220 S: fW. uto. LA 70776 February 18,1994 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Subject:

Response to NRC Notices of Violation IR 93 28

Reference:

River Bend Station - Unit 1/ Docket 50-458/93 28 File Nos.: G9.5, G15.4.1 RBG- 40146 Gentlemen:

Pursuant 10CFR2.201, please find attached Entergy Operations response to notices of violation described in NRC Inspection Report (IR) 93 28. The inspection was performed by Mr. Ward Smith and other Region IV inspection personnel during November 7 through December 18,1993, of activities authorized by NRC Operating License NPF-47 for River Bend Station - Unit 1.

Should you have any questions, please contact me at (504) 336 6225. I Sincerely, l

• GT James J. Fisicaro Manager - Safety Assessment and Quality Verification JJF/jr enclosures cc: U. S. Nuclear Regulatory Commission, Region IV 611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011 i

NRC Resident inspector P. O. Box 1051 St. Francisville, LA 70775 9403040243 940218 ' l PDR ADOCK 05000458 Q PDR j

ATTACHMENT 1 REPLY TO NOTICE OF VIOLATION IR 9328 02 REFERENCE Notice of Violation - Lottor from A. B. Beach to John R. McGaha dated January 20,1994.

VIOLATION Failure to imolement correctivo ection which allowed entrv bv the olant into a condition orchib!?sd bv Technical Soocification Critorion XVI,10 CFR Part 50, Appendix B, requires, in part, that correctivo action shall be taken to provent recurrence of significant conditions adverso to quality.

On June 30,1993, the licensoo inadvortontly placed the plant in a condition prohibited by Technical Specification 3.5.1 which requires all three divisions of tho

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emergency core cooling system to be operablo when the plant is in Operational l Condition 1, and has no action statomont that allows the high pressure coro spray ]

to bo inoperabio with either of the other two amorgoney coro cooling system  !

divisions being inoperable at the same time. This is a significant condition adverso i to quality and dictates that action be taken within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> to shut down the plant ,

under the provisions of Technical Specification 3.0.3. J Contrary to the above, the licensoo failed to imptomont offective measures to  !

provent recurrence of the June 30 ovent and on November 4 while the plant was in Operational Condition 1, Residual Heat Removal Pump (RHR) B was declared inoperable while high pressure core spray was inoperablo.

REASON FOR THE VIOLATION The first event occurred on June 30,1993, when RHR loop "A" was placed in supprossion pool cooling (SPC) modo to lower the supprossion pool water level in accordance with the system operating procedures. Tho unit operator stamped the main control room (MCR) log book for entry into a short term limiting condition of operation (LCO). The short term LCO identified RHR loop "A" inoperable whilo in SPC mode. This action was not communicated to olther the shift supervisor (SS) or control operating foreman (COF) by the shift technical advisor (STA) or unit 1

oporator (UO). At the time this event took place, LCO 93-227 for HPCS was already activo due to HPCS pump motor circuit breaker repair. The SS and COF are the individuals who are primarily responsible for Technical Specification interpretation and complianco. The crew did not recognize entry into 3.0.3 due to the communication failure and did not consider alternative action (such as delaying SPC until the HPCS LCO paperwork had been cleared and restored to operable status).

The second event occurred at approximately 2232 on November 4,1993, when loop B of the low pressure coolant injection (LPCI) system residual heat removal (RHR) system (train B) was inadvertently rendered inoperable while the high pressure core spray system was out of service to support unrelated testing. This condition, HPCS and LPCI- B inoperable, is not specifically addressed by Technical Specification 3.5.1, "ECCS - Operating", and thus required entry into Techrical Specification 3.0.3.

Prior to the second event, corrective maintenance had been performed on loop B RHR valvo 1E12*MOVF0068. A tracking LCO had been writton to track maintenanco and retest requiromonts. A valve stroke was performod as part of the correctivo maintenance procedure and was completed at 1415. A portion of the surveillance test procedure (STP) for loop B RHR valve operability was also specified for rotest of the valvo, but was believed to be redundant to the previous valvo stroke test ano therefore, was not performed at that time. At 1510, the HPCS system was declared inoperable in support of unrotated motor-operated valvo signature testing. The Operations crew believed that the operability requirements for 1E12*MOVF006B had boon satisfied at 1415, following corrective maintenance on the valve and the subsequent stroke test.

Prior to shift turnover at 1800, based on review of plant priority items, it was revealed that the STP was specified for rotest of the valvo. Following a discussion with Electrical Maintenance personnel at 2200, a copy of the STP was obtained by the STA and approved for work by the COF. The STP was given to the UO to be performed. The first stop in the applicable section of the STP is to close valvo 1E12*MOVF0048, which isolates the suction to the RHR B pump, thereby rondoring the LPCI function of RHR B loop inoperable. This action was taken by the UO. Immediately after the UO placed the switch for this valve in the closed position, he and the control room operations crew realized that both HPCS and RHR B were inoperable, a condition requiring entry into TS 3.0.3. After the valve had fully closed, the UO immediately reopened it. The length of time that the valve was closed was approximately 2 minutes.

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Investigation of the second event rovoaled that the COF inappropriately approved the STP for work, since the HPCS system was inoperable at the timo. In addition, a caution in the proceduro reminds the operator that closing the RHR B pump suction valve will randor the loop inoperable and thus, the operator must ensure that at least the minimum number of ECCS systems are operablo. This caution was misinterpretod by the UO.

The root cause of the second event was personnel error. The results of the root cause analysis revealod the following:

• The COF failed to recognize that the STP would ronder RHR B inoperablo and thorofore inappropriately approved the STP for work.

The UO failed to correctly interpret and act upon the caution in the procedure. He incorrectly belioved that the caution applied only to low pressuro ECCS systems and not HPCS.

Contributing factors to the second event were as follows:

The STA failed to maintain propor oversight of the job by getting directly involved with its performanco. This was contrary to the responsibilities of the STA as stated in ADM-0044, " Shift Technical Advisor Program."

• The methodology for signing-in work in the plant had recontly changed. The use of a work managomont contor outsido of the main control room was implomonted approximately one month prior to this event. However, the work management contor is only used betwoon 0600 and 1800, Monday through Friday. At all other timos, work is signed-in at the main control room. This change in normal operation could havo contributed to the occurrence of the second event.

• Work responsibilitios of the shift supervisor and the control oporating foreman had recently changed. As a result of soveralidentified deficienclos, the COF was relocated to within the at the controls area and work was now approved by the SS. In this second event, the SS did not approve the proceduro and was not mado aware of the performance of the STP until after the RHR loop was rondered inoperable.

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• During the shift briefing, the fact that the HPCS system was 4

Inoperable was discussed; however, the implications of having this

! system inoperable were not brought out (i.e., with HPCS inoperable, l no work should be performed on any other ECCS system or the RCIC l system).

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• Surveillance test procedure (STP) 204-6304 was listed as an l

3 outstanding item on the tracking limiting condition for operation

] (TRLCO) for E12*MOVF006B. This TRLCO was listed as a high

! priority item for the plant workers to accomplish. The perceived need

! to complete this task may have projected undue schedule pressure j onto the Individuals involved.

• Had the control room crew properly used the short term LCO tracking i sheet that had been put in place after the first event, the SS would have been aware that the partial STP was to be performed and would not have allowed the RHR valve stroking while the HPCS was inoperable.

The corrective actions taken for the June 30 event were designed to prevent recurrence of the event by ensuring that at least one of the senior licensed operators on shift was informed of the (LCO) condition. This notification was designed to occur before the action was taken to actually enter the LCO. This action provided a barrier to the human error occurring due to incomplete or absence of communications.

The behavioral factors contributing to the second event were fundamentally different from the June 30 event. The second event occurred due to a misjudgment error on the part of the crew which allowed a habit intrusion to influence crew performance. Where the crew had been very thorough in using the l short term LCO in other situations, they allowed their familiarity with the systems and the procedure in this event to influence the manner in which they implemented the short term LCO form. Failure to document the intended action and obtain the required acknowledgements on the short term LCO form prior to manipulating the-controls prevented the deliberate review for which the form was designed. This, compounded by the failure of the STA to provide the appropriate oversight and inadequate job scoping prior to the surveillance being transmitted to the control room, allowed the second event to occur.

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1 CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED Correctivo actions taken included returning the B loop of the RHR system to operable status within minutos by opening valvo 1E12*MOVF0048. Additionally, the operations supervisor and the assistant plant managor-operations woro notified l of this event within one hour of its occurrence and a condition report (CR) was initiated.

A team which included the individuals involved and an additional nuclear control operator was formed to datormino the root causes of the event, any additional contributing factors and develop correctivo actions to provent recurrence. The Operations Department hold a mooting with the parties involved in accordance with OSP-0018, " Operations Accountability Review," to support the development of the root cause and correctivo actions to provent recurrence. The results of thoso reviews revealed the following:

• The River Bond Station administrative procedures governing conduct of operations and the STA program woro reviewed and found to adoquatoly address the responsibilities of each crow member.

• The caution in the surveillanco tost proceduro (STP) for loop B RHR valvo operability was dotorminod to be adoquato to provant recurrence. The investigation revealed that if the unit operator had asked the COF if the minimum number of ECCS systems wore operable, rather than if it was nocessary to ontor a short-term LCO, a more thorough review of plant configuration would have resulted.

• Additional training was considorod as a possible correctivo action for this event. Operations training -initial, licenso and roqualification training, all stress the fact that the ECCS systems include HPCS, LPCS, RHR-LPCI and the automatic depressurization system (ADS).

Every licensed operator and STA, who is SRO cortified, knows this to be the caso. Based on the investigation of this event, Operations concluded that the existing training was both adequato and sufficient, 5

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. Personnel changes woro made to the crew involved in the second event and management expectations regarding appropriato implomontation of the short term LCO form woro relayed to all Operations Department shift supervisors, control operating foremen and shift technical advisors. i l

Allindividuals involved have been counseled on the significance of this event j and the possible consequences of an event of this type, included in this '

counseling was emphasis on the nood to increase sensitivity to inoperable equipment, and the implications of having equipment such as ECCS systems inoperable. In addition, this counseling includod a review of the responsibilities of each crew membor. Disciplinary actions were taken by Operations management. Night orders consisting of the CR response documenting this ,

event, were initiated to implomont required reading for all operations personnel, i CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIQRS Correctivo stops that will be taken to avoid further violations are as follows:

i Discussion of this event will be included in the operator roqualification l training module with an estimated completion date of April 1,1994.

The work control process will continue to be refined to prevent inclusion of non-schedulod work or testing. The work control process providos additional reviews of work and testing by senior licensed individuals to ensuro conflicting activitios are not schedulod simultaneously. When the June 30 ovent occurred, the process had recently undergono a chango, and the functional responsibilities of the SS/COF had boon revised. The second event then occurred when an unscheduled item was allowed to be included in the shift's schodulo without the bonofit of the full review process.

Operations belloves the work control process will now provent a repoat of an unscheduled tost causing the operating crew to fool an urgency to complete an activity when it only aids in closure of a work item that could be reviewod and scheduled under the normal process.

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A quality action team (QAT) bogan mooting January 3,1994 with the specific goal of identifying root causes and correctivo actions for human performanco issuos in general at River Bond Station. The QAT's mission is to focus on causes of human performance orrors including cultural and behavioral issues, in addition, the QAT is expected to provido recommendations that when imptomonted will croato a cultural shift toward zero human performanco errors. The results of this offort will also be applicable to other violation responsos identified in those attachments.

The long term corrective action that will also help provent recurrence will be the implomontation of Improved Technical Specifications (ITS). The ITS, unlike current Technical Specifications, presents tho information in a clear and conciso mannor in a two column format for ease of understanding and interpretation.

DATE WHEN FULL COMPLIANCE WILL B_li. ACHIEVED Full compliance was achloved when RHR B was immediately restored, after discovery, to an operable status.

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ATTACHMENT 2 REPLY TO NOTICE OF VIOLATION IR 9328 03 REFERENCE Notico of Violation - Lotter from A. B. Beach to J. R. McGaha dated January 20, 1994.

VIOLATION Technical Specification 6.8.1 requires, in part, that written proceduros shall be established, implomonted, and maintained covering the applicable proceduros recommanded in Appendix A of Regulatory Guido 1.33, Revision 2, February

1978.

l Regulatory Guido 1.33, Appendix A, states that maintenance that can affect the performance of safoty-related equipment should be proporly proplanned and performed in accordance with written proceduros, documented instructions, or drawings appropriate to the circumstances.

Contrary to the above, maintenance that affected the performanco of safoty-related equipment was not performod in accordance with written proceduros, in that:

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l Example 1 l

On November 22,1993, the instructions for the work performed in accordanco with Maintenance Work Order R137896 required that the foreman check and initial ,

each individual's training matrix. The foroman who signed this shoot did not initial l any of the individuals' training matrix.

Examolo 2 ,

On December 3,1993, Stop 7 of Maintenance Work Order R137897 required an inspection of the motor pinion and key of Valve E22*MOVF012 for proper "as-found" installation, using Correctivo Maintenanco Procedure CMP 1253, "Limitorque Motor Operated Valves," Revision 9, and the vendor technical manual which required that the key be secured in position by staking the end of the motor shaft keyway. The inspection stop was completed and signed off as

" Satisfactory," when in fact the key was not secured in position by staking the

! and of the motor shaft keyway.

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IN RESPONSE TO EXAMPLE 1:

REAS.ON FOR THE VIOLATION The refurbishment and signature testing of motor operated valvos (MOV) are performod by tho Systems Engineering Valvo Group. All work is performed under the control of the applicablo maintenanco proceduros and systems engincoring )

procoduros. During the performanco of work in the plant, the MOV test engincor performs those functions applicable to the maintenance foreman, j Prior to porforming work, in accordance with Maintenance Work Order (MWO)

R137896, the MOV test engineer, as foreman, performod the required pro-job briefing and upon completion, the tost engincor initiated each Individual's training matrix. However, he did not sign as the foreman in the applicable block. Prior to the start of work in the field, a second MOV test engincor assigned to this job and who was present at the pro-job briefing, reviewed the MWO briefing shoot and l noted that the first test engincor (or foroman) had not signed the applicable block.

l At that time the second tost engincor( who was actually the load test ongincor),

l signed, in error, the briefing shoot.

l The reason for the violation was due to personnel inattention to detail during the performanco of work.

CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED Test personnel recolved instructions on Docomber 6,1993, stressing the requiroments of the briefing shoot. Additionalinstructions woro given to test personnel on December 7,1993, stressing the standards and expectations on proceduro compliance.

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i i IN RESPONSE TO EXAMPLE 2:

j flEASON FOR THE VIOLATION j

j On Docombor 3,1993, MOV tost personnel were schedulod to inspect and replace i the motor pinion key on valvo 1E21 *MOVF012. The motor pinion key was being i inspected to ensuro proper installation per Limitorque Maintenance Update Bulletin l 891. The replacement of the key was being performed as the result of l Information Notice 92-83. Prior to the start of work, the technicians performing j the work were briefed on the scope of work, including drawings, and were given

specific instructions concerning the proper installation of the motor pinion key. I 1

Upon removal of the motor, the motor pinion key installation was marked 4 " Satisfactory" based on initial inspections. However, during subsequent I j replacement of the motor pinion key, test personnel determined that the original l key inspection was not satisfactory and the first disposition was revised.

! A review of the sequence of events revealed that if the motor pinion key had not I been required to be replaced that the improperly installed key would have been I considorod satisfactory and the valve would have boon returned to service.

Evaluation of this event indicated that the following factors contributed to the failure to properly inspect the motor pinion key installation.

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. The drawings utilized during the pro job briefing were not at the jobsito at the 1 time of work.

. At the time the MWO was released for work, the test personnel felt that they

( woro under pressure to hastily perform the work.

1 The reason for this violation is the failure of test personnel to have appropriato proceduros at the jobsite to perform the work which is a failure to follow proceduro.

CORRECTIVE. STEPS THAT HAVE BEEN TAKEN AND_RESULTS ACHIEVED Condition Report 93 0841 was written to address the improper installation of tho motor pinion key.

in response to both examples, the human performanco issues were addressed by conducting the following briefing sessions on datos indicated, to instruct MOV test l

personnel on the following subjects.

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12LQDLQ3 Pro Job Briefina Reautrements  !

Subjects covered woro:

Worker responsibilities under ADM-0028 to have an understanding of the job plan and a commitment for following the job plan safely.

The latest procedures and drawings are to be used to perform work.

Propor sign off, by the foreman, of training requirements for each worker.

Sign off of the foreman's signaturo block shall be completed by the foreman  !

who completos the training matrix block on the briofing shoot. l l

12/07/93 Standards and Exooctations Subjects covered woro:

1 Strict procedural compliance and, if applicable, procedure rovision prior to 1 performing any work stop.

All the necessary drawings, proceduros, and vendor manuals with work packago shall be at the jobsito.

Schedulo pressure is not an excuso for poor worker performance. Workors will stop work and consult with their supervision if unrealistic scheduto j performanco is expected. I 12/10/93 Procer Installation of Motor Pinion Kovs and How to identity i Unsatisfactorv Conditions l Subjects covered woro:

Propor methods for identification of acceptablo motor pinion key installation.

Proper installation of motor pinion key por Limitorquo Updato 891.

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CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER VIOLATIONS The firm of Failure Provention and Investigation International (FPI) was contacted l In late December of 1993 to provide a root cause analysis of recent events that involved personnel errors at River Bond Station (RBS). Even though this event l specifically was not selected for review, approximately 180 condition reports from

! the year 1993 involving human error were selected for review and evaluation. The resultant data was validated by interviews with RBS personnel. The analyses and interviews were focused as to the type of errors that occurred and why, the data of which was compared to licensee event reports from the same period.

t l FPI will also assess the corrective actions taken and make further l recommendations. The results of their analysis are expected in a formal report late l February,1994. The report should provide insight as to underlying causes of the l human errors that have occurred at RBS, e.g., organizational or programmatic j weaknesses, inadequate training or skills, misjudgment and etc. The benefits of the report will also be applicable to other violation responses described in these attachments.

l Other corrective steps to avoid further findings have been completed as described above.

l l DATA WHEN FULL COMPLIANCE WILL BE ACHIEVED l

Full compliance has been achieved.

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ATTACHMENT 3 REPLY TO NOTICE OF VIOLATION IR 9328 04 i REFERENCE

) Notico of Violation - Letter from A. B. Beach to J. R. McGaha dated January 20, 1994.

VIOLATION Technical Specification 6.8.1 requires, in part, that written procedures shall be j established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.

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Regulatory Guide 1.33, Appendix A, states that maintenance that can affect the por;formance of safety-related equipment should be properly proplanned and 2

performed in accordance with written procedures, documented instructions, or

. drawings appropriate to the circumstances.

Contrary to the above, on November 17,1993, while conducting troubleshooting activities on the reactor core isolation cooling control circuits in accordance with Maintenance Work Order R178922, the work instructions failed to provido a stop that would place the appropriate switch in bypass to provent a reactor water cleanup system isolation. As a result, an inadvertent roactor water cleanup system isolation occurred.

REASON FOR THE VIOLATION While performing the rotost phase of maintenanco work order (MWO) R178922 I (RCIC isolation Investigation) the K172 relay picked up and consequently resulted in an isolation of the reactor water clean-up (RWCU) system. A job stop to place the (1E31 A-S1 A) by-pass switch in the by-pass position was not included in the job plan which, if performed, would have proctudod the RWCU isolation. The i reason the by-pass switch was not included in the job plan was due to tha failure of both the planner and the system ongineer to follow the relay schematic to its final contact on the one-lino diagrams. The RWCU circuitry was completely missed, and therefore, an isolation occurred during subsequent testing. The reason for the violation is lack of attention to detail during the preparation of the MWO package.

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i An additional causal factor is that the surveillance test proceduro (STP) covoring i the required testing was not found -- although it did oxist -- during tho ,

development of the MWO package. This was duo to the relay not being listed on i i the STP cross reference matrix. Had this STP boon found, a now rotest proceduro i

!' would not have boon required and the existing written procedural stops from the STP could have boon incorporated into the MWO.

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_q0RRECTIVE STEPS TAKEN AND RESULTS ACHIEVED j i j

• The planner / system engineer received immodlato counseling on the failuro to I follow the relay circuitry to the final contaa t.

• The relays that woro replaced were successfully rotested por MWO R178922.

• The MWO job plan has boon revised to ensure STP-207-4240 is the rotest 1 1

.! specified, should replacement of this relay be required in the future. l 1

CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER VIOLATIONS )

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] Drawing change notico (DCN) 93-0631 was submitted by System Engincoring for

approval on November 24,1993. Once approved, the DCN will provido information that the K3A and K3B relays provido not only a main steam line isolation, but also a reactor water clean up isolation as well. This omission of j rolovant information was also considorod as a causal factor during the i investigation of the root cause. DCN 93-0631 was initiated to provido a moro

, obvious indication that the K3A relay also causes a RWCU isolation. This action will be completed by June 1,1994.

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} A request was mado to the Maintenance Support Group to add the 1E51 A*K100 i relay to the "STP to Mark Number Cross Reference List" for STP-207 4240. This i cross reference report will provide the users the ability to datormine if an applicable STP exists to rotest a component in llou of writing now specific test instructions. The Maintenanco Support Group will add the K100 relay to the STP-

207 4240 component cross reference list by February 28,1994. The completed cross reference list associated with the logic system functional test (LSFT)

program upgrade, will not officially be issued until December 1994, i

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Maintenanco previously committod to review the maintonanco rotost program l comparing it to the INPO good practicos, NMAC guidelinos and processos in uso at i other sites. (Reference Violation IR 9327-02) This review, when completed, will result in recommandations that will strengthen the existing program. An ovaluation of the maintenance rotost program and resulting recommendations will be completed by February 18,1994. Once the scope has boon identified, a program implementation schedule will be developed.

During the transition period between establishing an enhanced rotest program and developing the LSFT cross reference to STP list, Maintenance will provido an interim policy that: 1) definos the role of system ongineering as it relates to MWO reviews and approvals,2) provides direction and guidance for identifying support i required on back shifts,3) defines what constitutes high risk work ovolutions and I the appropriate design documents required as reference in order to identify I applicable retests. This policy and required training will be completed by March 16,1994.

As a result of this event and other events involving inadequate technical review of test packages, RBS managers havo been meeting to determino additional action needed to develop concreto Interim stops to provant recurrence of similar events.

Their goal is to guarantee the identification and correction of inadequate proceduros, and to assure procedural complianco, in addition, management at RBS is currently developing a long term performance improvement plan (LTPIP) to achlove continuing improvement in station performanco areas. More specific, as it applies to those violation responses, the LTPIP addresses: 1) planning and performance management, 2) loadorship, 3) work process officiency, and 4) problem identification and resolution; all of which contain the human performance element, improvement in those performanco areas once implomonted, will result in a permanent acceptable lovel of human performanco achievements.

DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED ,

Full compliance was achieved the same day (11/18/93) when the system was returned to normal and the test completed. Additional corrective actions will be completed as specified above.

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