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UNITED STATES
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NUCLEAR REGULATORY COMMISSION j ye i
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101 MARIETTA STREET. N.W.. SUITE 2900 l
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- p ATLANTA, GEORGIA 30323-0199
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JAN 231994 MEMORANDUM FOR: Ken Barr, RII Ken Clark, RII Larry Cohen, NRR Glen Salyers, RII i
William Sartor, RII FROM:
Fred Wright Emergency Preparedness Team Leader
SUBJECT:
FEBRUARY 9, 1994 ST. LUCIE NUCLEAR STATION EXERCISE This memo transmits the Exercise Scenario Package (Exercise Objectives, Narrative Summary, and Scenario Timeline) and provides work assigr.;;:ents and planning guidance for the St. Lucie Nuclear Station emergency preparedness exercise on February 9, 1994.
You are reminded that the Exercise Scenario Package contains confidential information and should be treated as such until i
after the exercise is terminated.
The work assignments are provided as Enclosure I to this memo, along with.the inspection requirements for your assigned emergency response facility as listed in Inspection Procedure 82301.
These assignments are for reference in your planning.
Last minute changes may necessitate some minor adjustments; however, the assignments should be consistent with your experience and interest.
The plant site is located near St. Lucie, Florida, with commercial air service available via West Palm Beach, Florida.
Lodging reservations are available at:
~
Holiday Inn Stewart-Jensen Beach, 3793 NE Ocean Blvd. (Hwy lAl) Jensen Beach, Florida, 34957.
The hotel telephone number is 407/225-3000 and the toll free reservation number is 1-800/ HOLIDAY, or j
Indian River Plantation Beach Resort, 555 N.E. Ocean Blvd.
Hutchinson Island. The hotel telephone number is 407/225-3700 and the toll free reservation number is 1-800/444-3389.
Please rep' ort to the site Monday, February 7, 1994.
The licensee contact at 4
St. Lucie will be Mr. Rick Walker. His business telephone number is (407) 465-3550 X3197.
The work location for the team onsite has not yet been determined. Report to the licensee's East Security and Main Badging Building (see Enclosure 2).
Contact Mr. Walker to determine working location and report there. is a' map of the highway route from West Palm Beach Airport to lodging, EOF, and site locations. is a map of the Site area and offsite Emergency Response Facilities.
9704070352 970325 I
~. -. ~ - - - -. - -. -
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I Multiple Addressees 2
Prelimina:y schedule of activities are summarized below:
j Monday 1:00 p.m.
Entrance Meeting 2/7/94 2:00 p.m.
Scenario Review With Licensee Scenario Developers 4:00 p.m.
Team Meeting Tuesday 6:45 a.m.
Team to Site 2/8/94 7:00 a.m.
Exercise Preparation and Emergency Facilities Tour 4:00 p.m.
. Team meeting Wednesday 6:15 a.m.
Team to Site 2/9/94 6:45 a.m.
Assume Positions At Assigned Facilities 7:00 a.m.
Exercise Starts 2:00 p.m.
Exercise Terminates Observe Player Critiques At Facilities Thursday 6:45 a.m.
Team to Site 2/10/94 7:00 a.m.
Prepare Findings for Exit 8:00 a.m.
Observe Controller / Evaluator Exercise Critiques
- 11:00 a.m.
Public Meeting 1:00 p.m.
Prepare Findings for Exit 4:00 p.m.
Team Meeting Friday 6:30 a.m.
Team to Site 2/11/94
- 9:00 a.m.
Formal Exercise Critique to Management
- 10:00 a.m.
NRC Exit 11:00 a.m.
Approximate Time for Team Departure from Site
- As of January 25, 1994, the licensee had not established a schedule for these meetings and they.may change.
If you have any questions or comments please contact me at (404) 331-3769.
A f
Fred Wright
Enclosures:
1.
Team Assignments 2.
Site Map 3.
Airport to Site Map 4.
Site Area and Emergency Response Facilities Map cc w/o encls:
(See page 3)
Multiple Addressees 3
cc w/o encis:
W. Cline K. Landis J. Norris R'.~ TrofinoWski 1
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l ENCLOSURE 1 TEAM ASSIGNMENTS 1
Observer Facility Work Assianment F. Wright Site Team Leader G. Salyers Control Room (a) facility management and-control; (b) analysis of plant conditions j
and corrective action (c) detection and classification of emergency events
)
(d)
' protective action decision-making l
(e) notifications and communications (f) implementation of protective i
actions (g) dose assessment (h) evaluation of post-accident sampling results (i) dispatch and coordination of monitoring teams W. Sartor TSC (a) staffing and activation of TSC (b) facility management and control (c) accident assessment and classification (d) dose assessment (e) protective action decision-making i
(f) notifications and i
rommunications (g) mplementation of protective
)
actions (h) assistance and support to Control Room (i) evaluation of post-accident sampling results (j) dispatch and coordination of monitoring teams i
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2 G. Salyers OSC (a) staffing and activation of the OSC (b) facility management and control (c) performance of support functions L. Cohen EOF (a) staffing and activation of the E0F (b) facility management and classification (c) accident assessment and classification (d) offsite dose assessment (e) protective dose assessment (f) notifications and communications (g) implementation of protective actions (h) interaction with.offsite officials, NRC, and other organizations K. Clark ENC (a) staffing activiation and facility control (b) processing and dissemination of information to the media n
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l ST. LUCIE NUCLEAR PLANT 1
SITE LAYOUT i
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PLANT: ST. LUCIE LOCATION: Ft. Pierce, FL -
UCENSEE: Florida Power & Light Co.
DIRECTIONS FROM WEST PALM BEACH f
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EOF LOCATICH:
Florida Power and Light 9001 West Midway Road Fort Pierce, Florida (Intersection of State Route 712 and I-95; approximately 10.5 miles west of the St. Lucie Plant)
JPIC LOCATION:
Florida Power and Light 9001 West Midway Road l
(
Fort Pierce, Florida j
FLORIDA POWER AND LIGHT COMPANY ST. LUCIE NUCLEAR POWER PLANT l
1994 EMERGENCY PREPAREDNESS i
EVALUATED EXERCISE FEBRUARY 9,1994
[
l 2.2 OBJECTIVES l
The St. Lucie Plant (PSL) 1994 emergency preparedness evaluated exercise objectives are based upon Nuclear Regulatory Commission requirements provided in 10 CFR 50, Appendix E, Emergencv Planning and Preparedness fo~ Production and Utilization Facilities. Additional guidance provided in NUREG.0654, FEM 1.-REP-1. Revision 1. Criteria for Preparation and Evaluation of Radiological Emergency Response Plans and Preparedness in Support of Nuclear Power Plants, was utilized in developing the objectives.
The exercise will be conducted and evaluated using a realistic basis for activities. Scenario
.:vems may escalate to a release of radioactive material to the environment.
The followmg objectives for the exercise are consistent with the aforementioned documents:
l l
A.
Accident Assessment and Classification 1.
Demonstrate the ability to identify initiating conditions, determme l
Emergency Action Level (EAL) parameters and correctly classify the j
cmergency throughout the exercise.
B.
Notification 1.
Demonstrate the ability to alert, notify and mobilize Florida Power and Light (FPL) emergency response personnel.
2.
Demonstrate appropriate procedures for both initial and follow-up notifications.
3.
Demonstrate the capability to promptly notify the U.S. Nucle:tr Regulatory Commission (NRC), State and Local Authorities of an emergency declaration or change in emergency classification.
4 Demonstrate the ability to provide accurate and timely information to State. Local and Federal Authorities concerning plant status, conditions and/or radioactive releases in progress, as appropriate.
1 l
5.
Demonstrate the ability to provide periodic plant status updates to State, Local and Federal Authonties.
FPUPSL
- ,2-1 94-EX/Rev.02/ll-22-93
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2.2 OBJECTIVES (Continued)
~ C.
Emergency Response 1.
Demonstrate staffing of Emergency Response Facilities (ERF)s.
' 2.
Demonstrate plannmg for 24-hour per day emergency response capabilities.
3.
Demonstrate the timely activation of the Technical Suppon Center (TSC) and Operational Support Center (OSC).
4.
Demonstrate the timely activation of the Emergency Operations Facility (EOF).
5.
Demonstrate the functional and operational adequacy of the Emergency Response Facilities, TSC, OSC, EOF and Emergency News Center (ENC).
6.
Demonstrate the adequacy, operability and effective use of designated emergency response equipment.
7.
Demonstrate the adequacy, operability and effective use of emergency communications equipment.
8.
Demonstrate the ability of each Emergency Response Facility Manager to mamtain command and control over the emergency response activities conducted within the facility throughout the exercise.
9.
Demonstrate the ability of each facility manager to periodically inform i
facility personnel of the status of the emergency situation and plant conditions.
10.
Demonstrate the precise and clear transfer of Emergency Coordinator (EC) responsibilities from the Nuclear Plant Supervisor (NPS) to designated senior plant management and transfer of Emergency Coordinator responsibilities to the Recovery Manager (RM).
11.
Demonstrate the ability to promptly and accurately transfer information between Emergency Response Facilities (ERF)s.
12.
Demonstrate the ability of the TSC to request, prioritize and control Eraergency Response Teams (ERT)s in a timely manner.
i
- 13. - Demonstrate the ability of the OSC to assemble, dispatch and control ERTs in a timely manner.
i FPl>PSL 2.2 2 94-EX/Rev.02/ll-22-93
2.2 OBJECT 7VES (Continued)
C.
Emercency Response (Continued) 14.
Demonstrate the capability for development of the appropriate Protective Action Recommendations (PAR)s for the general public within the 10 Mile Emergency Planning 7nne (EPZ)..
15.
Demonstrate that the appropriate PARS can be communicated to State and Local Authorities within the regulatory time constraints.
D.
Radioloeical Assessment and Control 1.
Demonstrate the coordinated gathering of radiological and non-radiological (meteorological) data necessary for emergency response, including collection and analysis of in-plant surveys and samples, as applicable.
2.
Demonstrate the capability to calculate radiological release dose projections and perform timely and accurate dose assessment, as appropriate.
3.
Demonstrate the ability to compare onsite and off-site dose projections to Protective Action Guidelines (PAG)s and determine and recommend the appropriate protective actions.
4.
Demonstrate the ability to provide dosimetry t6 emergency response personnel as required and adequately track personnel exposure.
5.
Demonstrate the capability for onsite contamination control.
6.
Demonstrate the ability to adequately control radiation exposure to onsite emergency workers, as appropriate to radiological conditions.
7.
Demonstrate the decision making process for authorizing emergency workers to receive radiation doses in excess of St. Lucie Plant administrative limits, as appropriate.
8.
Demonstrate the ability to control and coordinate the flow of information regarding off-site radiological consequences between radiological assessment personnel stationed at the TSC and EOF.
9.
Demonstrate the ability of field monitoring teams to respond to and analyze an airborne radiological release through direct radiation measurements in the environment. as appropriate.
FPUPSL 2.2-3 94-EX/Rev.02/ll 22-93
i 2.2 OBJECTIVES (Continued)
D.
Radiological Assessment and Control (Continued) 10.
Demonstrate the collection and analysis of air samples and provisions for effective communications and recordkeeping, as appropriate.
t 11.
Demonstrate the ability to control and coordinate the flow of information regarding off-site radiological consequences with State radiological assessment personnelin the EOF.
E.
Public Information Program 1.
Demonstrate the timely and accurate response to news inquiries.
(
2.
Demonstrate the ability to brief the media in a clear, accurate and timely manner.
b 3.
Demonstrate the ability to coordinate the preparation. review and release of public infonnation with State and Local Government Agencies as appropriate.
'F.
Medical Emernency l.
Demonstrate the ability to respond to a radiation medical emergency in a timely manner.
2.
Demonstrate the capability of the First Aid and Personnel Decontamination l
Team to respond to a medical emergency, administer first aid and survey for contamination on a simulated contaminated injured individual.
i I
3.
Demonstrate the capability to arrange for and obtain transportation and off-site medical support for a radiological accident victim.
4.
Demonstrate the ability of Martin Memorial Hospital personnel to treat an injured and/or contaminated patient.
G.
Evaluation l
1.
Demonstrate ability to conduct a post-exercise critique to determine areas requiring improvement or corrective action.
'The medical emergency poruon of the 1994 Exercise may not be performed concurrently with the Exercise.
The Medical Emergency Objecuves will be uulized for the Medical Emergency sub-drill in any case..
FPlJPSL 2.2-4 94-EX/Rev.02/11-22-93 e
i 2.2 OBJECTIVES (Continued) l e
H.
Exemotions Areas of the PSL Emergency Plan that will NOT be demonstrated during this exercise include:
)
1.
Site evacuation of non-essential personn:1 i
2.
Onsite personnel accountability 3.
Actual shift turnover (long term shift assignments will be demonstrated by rosters).
4.
Actual drawing of a sample utilizing the Post-Accident Sampling System (PASS).
5.
Real time activation of the Emergency News Center (ENC).
1 i
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FPUPSL 2.2 5 94-EX/Rev.02/11-22-93
I 5
CONFIDENTIAL ru.m e 46=>
l FLORIDA POWER AND LIGHT COMPANY i
ST. LUCIE NUCLEAR POWER PLANT 1994 EMERGENCY PREPAREDNESS l
EVALUATED EXERCISE FEBRUARY 9,1994 3.1 NARRATIVE
SUMMARY
The scenario begins with Unit 2 operating at 100% power. De 2B High Pressure Safety Injection (HPSD pump is tagged out of service (OOS) for maintenance. A 5 gallon per minute (gpm) leak develops on a cold leg weld in the Unit 2 Reactor Coolant System (RCS) piping.
This should produce a declaration of a Notification of Unusual Event (NUE). The RCS leak escalates to 65 gpm. His should produce a declaration of Alert and a down power on the j
reactor. During the reactor down power, when the in-house electrical loads are transfened to the Startup (S/U) Transformers (Xformers), the 2A3 4160 Volt (4.16 KV) bus will lock out on differential cunent when the "A" 4.16 KV S/U breaker is taken to close. The leaking cold leg weld fails. resulting in a shear break in the piping. This should produce a declaration of a Site Area Emergency (SAE). When the Recirculation Actuation Signal (RAS) occurs, the 2B I.aw Pressure Safety Injection (LPSI) pump shuts down and will not restari. He large break Loss of Coolant Accident (LOCA) with no Emergency Core Cooling System (ECCS) flow to the reactor l
vessel allows the reactor core to become uncovered and fuel damage results. A leak develops in the Contamment sump piping allowing sump water to be released into the Safety Injection (SI) pipe tunnel and the Unit 2 Reactor Auxiliary Building (RAB) basement. The released activity is picked up by the running 2B ECCS ventilation system and transported to the environment i
through the 2B ECCS vent stack on the Unit 2 RAB roof. A General Emergency (GE) should l
be declared. The 2B LPSI and/or HPSI pump is restored and ECCS flow is initiated to the reactor. This will exacerbate the core damage and increase release to the Containment at first until rewetting and cooling of the core can 6:e effect.
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i CONFIDENTIAL (v.s a2a>w>
FPl>PSL 3.1 1 94-EX/Rev.01/11-30-93
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i CONFIDENTIAL (u.s aum, l
FLORIDA POWER AND LIGHT COMPANY ST. LUCIE NUCLEAR POWER PLANT 1994 EMERGENCY PREPAREDNESS EVALUA'IED EXERCISE FEBRUARY 9,1994 3.2 SCENARIO TIMELINE TIME EVENT 0700 Player briefing, shift turnover and initial conditions establish Unit 2 operating at 100% power, in the middle of core life. Power history has been full power operation for the last 180 days. Unit 1 is in day 42 of a 45 day scheduled refueling outage. Demand on the system is modernie with an anticipated peak of 10,000 MW,. Service area conditions are normal. De 2B High Pressure Safety Injection (HPSI) pump is out of service (OOS) for outboard seal and bearing replacement. De 2B HPSI pump was placed on clearance at 1600 on February 8,1994. The pump bearing and seal work continued on the previous peak and mid shifts.
The completion of installation and testing is anticipated by the middle of the day. He Hot Ring-Down (HRD) and National Warning System (NAWAS) phone systems are both OOS in the Unit 2 Control Room (Simulator). Weather has been 4
sunny and mild for the last week. Forecast is for clear skies, temperatures in the upper 70's.' Current temperature is 75' with winds from the Northeast (45") at 3_-4 mph.
0715 Full Length Control Element Assembly (FLCEA) testing is begun on Unit 2 in accordance with Operating Procedure OP-2-0110050, Control i
Element Assembly Periodic Exercise.
0800 A 5 gallon per minute (gpm) leak begins from a faulty weld in the Reactor Coolant System (RCS) 2A1 Cold Leg. A NOTIFICATION OF UNUSUAL EVENT (NUE) should be declared based upon Emergency Plan Implementing Procedure (EPIP) 3100022E, Classification of Emergencies, greater than 1 gpm unidentified leakage.
The Nuclear Plant Supervisor (NPS) should assume the duties of the Emergency Coordinator (EC).
(
CONFIDENTIAL ru.m anm FPI/PSL 3.2-1 94-EX/Rev.07/12-03-93 l
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CONFIDENTIAL <u emm) l 3.2 SCENARIO TIMELINE (Continued)
TIME EVENT 0805 Reactor Cavity leakage alarm, Charging / letdown mismatch, Reactor Cavity sump levels and Containment atmosphere indications are utilized to validate the RCS leakage. Operators should enter ONOP 2-0120031, Excessive Reactor Coolant System Leakage and perform a leak rate calculation using AP-2-0010125A, Surveillance Items, Data Sheet 1.
0815 (Approx.)
ne Nuclear Plant Supervisor (NPS) may order a power Containment entry at this time to investigate the RCS leak. (Entry team activity will be allowed up to the point of actual Containment entry, which will be simulated.)
0830 (Approx.)
Contingency message for the Notification of Unusual Event declaration.
0845 he RCS leakage increases to 65 gpm. Within minutes, Reactor Cavity Ixak High goes off scale (12 gpm) as a result of the increased leakage.
Containment pressure, temperature and radiation levels are increasing and RCS pressure and level are decreasing.
An ALERT should be declared based upon Emergency Plan
- ntiemenung Procedure (EPIP) 3100022E, Classification of i
Emergencies, greater than 50 gpm leakage.
4 The Technical Support Center (TSC) and Operations Support Center (OSC) should begin activation. The Emergency Operations Facility (EOF) should be staffed and activated by the initial responders. (The Emergency Control Officer (ECO) may fully activate the EOF at any time after this point if he deems it necessary.)
Operators should begin a downpower at 10 MW,/ min, enter OP 0030125, Turbine Shutdown Full Load to Zero Load and utilize OP 0030123, Reactor Operating Guidelines During Steady-State and Scheduled Load Changes 0915 (Approx.)
Contingency message for the Alert declaration.
CONFIDENTIAL <uma mw>
FPldPSL 3.2 2 94-EX/Rev.07/12-03-93 l
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CONFIDENTIAL <umm e.ioee>
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3.2 SCENARIO TIMELINE (Continued)
TIME EVENT i
0930 (Appmx.)
Dunng the course of the downpower, if the operations crew attempts to transfer house electrical loads to the Startup Transformers, the 2A3 4.16 KV bus will lock out on differential current when the "A" 4.16 KV Startup breaker is taken to "close". (If operators have not taken this action voluntarily, the bus will lock out on the reactor trip.) Operators enter ONOP-2-0910054, Loss of Safety Related Bus. Operators stabilize the plant and request assistance from the TSC and OSC. Operations and electrical personnel are dispatched to investigate.
1000 The RCS 2A1 cold leg weld fails and the line shears resulting in a large
}
break Loss of Coolant Accident (LOCA).
A SITE AREA EMERGENCY uld be declared based upon a LOCA greater than available charging capacity. De full activation of the Emergency Operations Facility (EOF) should begin at this time if not previously done so.
SOf (Approx.)
he reactor and turbine are tripped. After standard post-trip actions, the operations crew enters Emergency Operating Procedure (EOP) 2-EOP-03, LOCA. On the trip, or earlier when aligning loads, the 2A3 4.16 KV bus locks out. Operators stabilize the plant and request assistance from the TSC and OSC. Operations and electrical personnel are i
dispatched to investigate.
ne TSC and OSC should be staffed and activated by this time. De i
I EC duties should be turned over to Plant Management in the TSC by this time. The Reactor Vessel Level Monitoring System (RVLMS) l indicates head voiding. Safety Injection Tanks (SITS) are injecting.
1030 (Approx.)
Contingency message for the Site Area Emergency declaration.
1100 Recirculation Actuation Signal (RAS) occurs. The 2B LPSI pump trips and will not restart. A le,ak develops in the Containment Sump piping allowing sump water to be released into the Safety Injection (SI) pipe tunnel and the Unit 2 Reactor Auxiliary Building (RAB) basement. The
. released activity is picked up by the running 2B ECCS ventilation system and transported to the environment through the 2B ECCS vent
' stack on the Unit 2 RAB roof.
CONFIDENTIAL <u.a a2ao oe>
FP1JPSL 3.2-3 94-EX/Rev.07/12-03-93
CONFIDENTIAL tu.maus o 4
3.2 SCENARIO TIMELINE (Continued) i i
TIME EVENT 1130 As the reactor vessel level drains down and the core uncovers, fuel l
damage begins.
'Ibe EC abould declare a GENERAL EMERGENCY based upon verified fuel damage with IDCA and loss of containment integrity.
Protective Action Recommendations (PAR)s are generated based upon i
plant conditions.
1140 (Approx.)
Recovery of 2B LPSI and/or HPSI allows reflooding of the core. This will exacerbate the core damsge and increase release to the Containment at first until rewetting and cooling of the core can take effect.
Contam' ment water is still being released to the basement of the Unit 2 11eactor Auxiliary Building (RAB) through the ECCS pipe tunnel. The released radioactive material enters the environment through the monitored 2B ECCS vent exhaust.
1200 (Approx.)
Contingency message for the General Emergency declaration.
Emergency Core Cooling Systems (ECCS) have covered the core.
Containment radiation, temperature and pressure have stabilized.
1300 Cooldown, depressurization and/or Law Pressure Safety Injection (LPSI) have refilled the reactor vessel. Field radiation readings have declined.
Field monitoring activities continue. The emergency response teams continue to stabilize the reactor, initiate long-term cooling, verify safe l
shutdown and evaluate containment integrity.
1400 (Approx.)
Termination of Exercise Play CONFIDENTIAL (u.m anS*9 FPUPSL 3.2 4 94-EX/Rev.07/12-03 93
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)
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ST. LUCIE MAINTENANCE EVALUATION - OCTOBER 1996 A.
Assessment: The licensee experienced 9 cases of equipment failure including a i
repeat of a previous Unit 2 manual Reactor trip resulting from high generator H2 temp due to failed TCV, along with a number of examples of personnel error and failure to follow procedures, inadequate procedures, or weak procedures. The problems i
associated with TCV failures may indicate a weakness in determining root cause. The number of problems related to personnel errors and procedure problems indicate i
weaknesses, possibly attitude problems, in the Maintenance Program. Additionally, the Unit 1 Steam Generators have a significant portion of tubes plugged (1A 25.3% &
18-21.5%). Replacement of these Steam Generators is scheduled for the spring of 1998.
B.
Basis:
1.
Last SALP Rating:
Category 2 (1/2/94 - 1/5/96)
Next Period End:
04/15/97 2.
Maintenance Backloa:
Corrective Maintenance Work Reauest Backloa - 1101 Non-outage work orders were open at the beginning of September,1996, no significant changes since beginning of year. Licensee has not met their goals of reducing backlog.
Overdue Preventive Maintenance Backloa - 30 Maintenance PMs were late during the third quarter of 1996 (no prior trending information).
3.
Power Reduction / Trios Caused by Eauipment Failures:
Unit 2 01/05/96 Manual reactor trip resulting from high generator H2 temp due to failed TCV.
Unit 1 02/22/96 Manual trip / shutdown following dropped / unrecoverable CEA.
Unit 1 04/29/96 - 07/23/96 Refueling Outage.
j Unit 2 04/20/96 Turbine Stop Oil onfice blockage.
i Unit 2 04/09/96 Downpower due to Circ Water Piping leakage.
Unit 2 05/24/96 Downpower due to CEDM problems.
Unit 2 05/31/96 Downpower due to MSR TCV closure due to blown fuse.
Unit 2 06/06/96 Manual reactor trip resulting from high generator H2 temp due to failed TCV.
Unit 2 06/22/96 Downpower due to 2B FRV Controller problems.
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4.
Licensee Self-Assessment: A licensee audit in the area of implementation of Maintenance Rule requirements performed during July 1996 was thorough, comprehensive and considered a strength.
5.
Maior Enforcement Issues: Since January 1,1996, violations were identified, associated with: lack of controlled procedure at jobsite; failure to verify current procedure at jobsite; inadequate independent verification; unattended freeze seal; failure to adhere to CEDM coil resistance test criteria; documentation of f
as-found & as-left data; failure to properly implement procedural usage requirements in work planning process.
6.
Strenaths: Predictive monitoring program, development of equipment unavailability risk determination matrix were noted as strengths during Maintenance Rule Baseline inspection. Additionally, increased predictive maintenance of CEDM System has resulted in a reduction in CEA drop events.
1 C.
Future inspections:
4-man weeks of inspection in the maintenance area (Regional initiative), focus l
on outage activities BOP and EDG maintenance (2-man weeks). procedure adequacy and safety system performance (2-man weeks).
i 1
Conduct (1-man week; ISI { core inspection).
1 Integrated S/G Inspection i
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ST. LUCIE MAINTENANCE EVALUATION - OCTOBER 1996 A
Assessment: An increase in personnel errors and equipment problems was noted.
)
The majority of the equipment problems are BOP related. For the most part the licensee considered safety in establishment of goals and for monitoring of systems and components in the maintenance rule. The maintenance program is adequate.
B.
Basis:
i The maintenance area was rated good overall the last SALP period. The last PPR indicated a problem with EDGs and procedure problems.
The plant matrix indicates 12 equipment failures,12 personnel errors and 3 procedure problems during the last 6 months. Examples of personnel errors were:
- 8/31/96 Improper use of M&TE for meggering NI cables
- 8/3/96 Freeze seat left unattended
- 7/30/96 3 of 4 linear NI channels found miswired
- 7/20/96 2 charging pumps tripped due to erroneous level signal Power Reduction caused by Equipment Failures in the last 6 months:
i
- 4/20/96: Unit 2 - Turbine Stop Oil orifice blockage.
- 4/09/96: Unit 2 - Downpower due to Circ Water Piping leakage.
- 5/24/96: Unit 2 - Downpower due to CEDM proble.ns.
- 5/31/96: Unit 2 - Downpower due to MSR TCV clusure due to blown fuse.
- 6/06/96:
Unit 2 - Reactor trip resulting from high generator H2 temp due to failed TCV.
- 6/22/96: Unit 2 - Downpower due to 2B FRV Controller problems.
- 7/23/96: Unit 1 - Manual trip due to turbine maintenance.
Maintenance Backlog:
- Non-outage corrective maintenance backlog: 1101 items, no significant
' changes since beginning of year.
- Overdue Preventive Maintenance Backlog: 30 Maintenance PMs were late Maintenance Rule A(1) systems: 6 systems
- EDG governors, EDGs,4.16 KV AC safety related breakers, PORVs, C AFW, and RCP seals.
C Future Inspections:
- Maintenance Rule follow-up: 62703 (RI) - 1 man-week
- ISI inspection: 73753 (core) - 1 man-week
- Integrated S/G Inspection: 73753 (RI) - 3 man-weeks
Pre astEEiiEEii3:.-
3 Semiannual Plant Performance Assessment St. Lucie 1 and 2 Current SALP Assessment Period: 1/7/96 through 3/97 i
Last SALP Rating Previous SALP Rating i
1/2/94 - 1/6/96 5/3/92 - 1/1/94 Operations 2
1 i
Maintenance 2
1 Engineering 1
1 Plant Support 1
1 i
INP0 assessment July 1995 - Category 1 j
I.
Performance Overview Since July 1995, there have been a series of events that led to cuestioning the plant's overall performance. An NRC root cause effort cetermined that, in addition to procedural adherence / adequacy weaknesses, the licensee suffered from weaknesses in both interfaces across organizational lines and corrective actions: The SALP board concluded that performance in the areas of Operations and Maintenance had declined to level 2.
Since the SALP board, additional examples of i
declined performance were noted.
These have included:
Significant operator inattentiveness which resulted in the e
overdilution event on January 22, 1996, highlighted the recent large number of personnel errors and lack of command and control in the control room (SL3. CP).
I e
On February 22. 1996, a dropped CEA and an ensuing Unit 1 shutdown resulted in the declaration of an unusual event.
During the shutdown, main feedwater regulating valve instabilities resulted in operators manually tripping the unit.
On February 24. a containment radiation monitor was rendered e
inoperable for two days due to an improper valve lineup following a grab sample.
As a result, the unit was started up without this TS-required component available.
Several instances of failure to follow procedures and operatcr inattention led to the extended period of inoperability (SL4).
.e On May 7. an inspection indicated that a significant number of shifts had been worked with fi,re brigade members which were not medically qualified. A breakdown in the tracking of this data resulted from a key individual being laid off, On May 12. fuel movement was commenced on Unit I without only 1 of 4
e 2 wide range N1 channels available.
Operators performing a surveillance test on the inoperable channel did not coordinate i
l
with the refueling center properly.
Additionally, the fuel offload was commenced without incorporating requirements from the spent fuel pool heat load calculation into the appropriate operational procedures.
e On June 6. Unit 2 s manually tripped due to high generator gas temperature.
Root cause was a screw which vibrated loose and resulted a temperature control valve feedback arm falling free of its connection.
This failure mode had been encountered before.
On June 16, an inspection identified that 56 individual violations e
of overtime guidelines had occurred on the part of 4 individuals over a 30 day period.
Evidence also existed that employees were regularly working lor.ger hours than those reported on their timesheets.
On July 20. Unit 1 experienced a loss of charging flow when, due '
e to a mispositioned board selector switch, both operating pumps stopped on a faulty indication of high pressurizer level, caused by I&C errors.
A number of engineering-related problems have been identified. to e
include:
A number of annunciator response procedures which were e
inaccurate due to a failure to update them when design modifications took place.
Four similarly miswired nuclear instrumentation channels due e
to errors in control wiring diagrams implemented during a modification.
The condition was identified at full power and resulted in an entry into TS 3.0.3.
Nonconservative errors were identified in auxiliary e
feedwater actuation system setpoints due to a failure to incorporate as-built data in instrument calibration calculations.
l Maintenance overtime usage was found excessive in that four e
individuals were responsible for 56 examples of non-approved exceedences of Technical Specification overtime guidelines.
On August 14. glue was found in key lock switches on both units' e
hot shutdown panels, rendering the switches inoperable.
The tampering instances appeared to be additional examples of padlocks and door locks which were identified in July.
In addition to the inspection findings above. the inspectors have noted a general, low state of morale.
A great number of both management and non-management employees have expressed concern with regard to the company's ongoing downsizing effort.
The general feeling is that, unlike Turkey Point. which was afforded the budget and time to improve prior to downsizing. St. Lucie is expected to improve AND downsize simultaneously.
- ~ -
l i
II.
Functional Area Assessment - Ooerations A.
Assessment Performance in Operations appears to have leveled. At the time of the last PPR, o>erator errors and operational events were on the increase.
In tie past six months, examples of improved operator attention to detail and conservative decision-making have been identified. Strong performance was identified in the area of reduced inventory operation. Weaknesses were identified in the areas of procedural quality and operability maintenance and decision-making.
Improvements in control room environment, formality, and communications have been noted.
The licensee has appeared to make inroads in the areas of operator self-assessment and documentation of adverse conditions.
B.
Basis 1.
Attention to Detail and Conservative Decision-Making Non-licensed operators were successful in identifying e
two cases of inadvertent containment radiation monitor inoperability and a breach in a fire-rated assembly.
e After a non-conservative decision which resulted in a late declaration of an NOUE for CVCS system leakage.
operators have declared three NOVEs for similar i
circumstances (CVCS leakage outside containment which could not be quickly quantified).
Management has been effective in encouraging conservative decision-making.
e Entry into a shutdown action statement when 4 Unit 2 control rods would not respond electrically.
Five entries into reduced inventory during the period e
without error.
Timely trip of Unit 1 due to apparent gas buildup in e
the IB transformer, e
Terminating a Unit 1 startup due'to predictions that xenon decay would invalidate the estimation of critical conditions.
2.
Weaknesses in Procedures and Maintenance of Operability Numerous errors identified in annunciator response e
procedures.
e Full core offload began on Unit I without incorporating requirements from the fuel pool heat load calculation into operational procedures.
Operator aids ~found in the field did not agree with e
procedural requirements for the tasks they described.
Unit 1 fuel movement began without the required'2 e
operable channels of wide range nuclear instruments due to the performance of a surveillance test.
Clearance hung during the Unit 1 outage resulted in e
inoperability of audible count rate in containment.
3.
Other Observations Good performance was noted during a Unit 2 downpower e
due to low turbine auto-stop oil pressure, a Unit 2 trip due to a failed turbine cooling water valve.
several startups, and fuel movements in Unit I containment.
Poor performance was noted in the use of a single e
o)erator for fuel movement in the spent fuel pool, in tie control of keys for PORV operation outside of the control room, in the control of backup charging pump selector switch position, and in performing a test of a turbine-driven AFP which resulted in a pump trip.
Equipment failures continue to challenge operators, e
with the occurrence of two manual trips per unit this calendar year due to equipment failures.
C.
Future Inspections The high number of allegations and an increase in resident involvement with engineering activities has reddeed the available time for core Operations inspections. The site has been brought' to an N+1 staffing level: however, qualification of the new.
resident is not anticipated until February, 1997. Additionally, both assigned Resident Inspectors will be attending CE training at TTC for three weeks in October / November. An acting resident has been arranged for the period; however, inspection at the N+1 level will not be possible until the end of the current SALP cycle (March 1997).
Consequently. Senior Resident and Resident inspectors objectivity visits, involving control room observations are planned. Additionally. DRS inspections of the licensee's procedure development and approval process, which has recently changed in an effort to improve procedure quality. are planned.
III.
Functional Area Assessment - Maintenance A
Assessment: An increase in personnel errors and equipment problems was noted. The majority of the equipment problems are BOP related.
For the most part the licensee considered safety in establishment of goals and for monitoring of systems and
- ~ - - -.-
4 components in the maintenance rule. The maintenance program is adequate.
B.
Basis:
i The maintenance area was rated good overall the last SALP period.
J The last PPR indicated a problem with EDGs and procedure problems.
The plant matrix indicates 12 equipment failures.12 personnel errors and 3 procedure problems during the last 6 months.
Examples of personnel errors were:
- 8/31/96 Improper use of M&TE for meggering NI cables
- 8/3/96 Freeze seal left unattended 1
- 7/30/96 3 of 4 linear NI channels found miswired
- 7/20/96 2 charging pumps tripped due to erroneous level signal Power Reduction caused by Equipment Failures in the last 6 months:
- 4/20/96: Unit 2 - Turbine Stop Oil orifice blockage.
- 4/09/96: Unit 2 - Downpower due to Circ Water Piping leakage.
- 5/24/96: Unit 2 - Downpower due to CEDM problems.
- 5/31/96: Unit 2 - Downpower due to MSR TCV closure due to blown fuse.
- 6/06/96: Unit 2 - Reactor trip resulting from high generator H2 temp due to failed TCV.
- 6/22/96: Unit 2 - Downpower due to 28 FRV Controller problems.
- 7/23/96: Unit 1 - Manual trip due to turbine maintenance.
Maintenance Backlog:
- Non-outage corrective maintenance backlog: 1101 items, no significant changes since beginning of year.
- Overdue Preventive Maintenance Backlog: 30 Maintenance PMs were late Maintenance Rule A(1) systems: 6 systems
- EDG governors. EDGs. 4.16 KV AC safety related breakers, PORVs, j
C Future Inspections:
- Maintenance Rule follow-up: 62703 (RI) - I week 1
- ISI inspection: 73753 (core) - I week
- Integrated S/G Replacement Inspection: 73753 (RI) - 3 weeks IV.
Functional Area Assessment - Enoineerina i
A.
Assessment St Lucie received a SALP 1 rating during the SALP period that ended January o, '1996. The licensee has declined in performance l
during this PPR period (March-September 1996) due to problems with configuration management / design control and a failure to identify an USO.
i
6 4
B.
Ibun PIM TRENDS / ISSUES:
The trend indicated was for configuration management as described in design control issues below and an issue for failure to identify an US0 for a 50.59 evaluation (September 19. 1996),
i ENFORCEMENT: Letter of violation issued September 19. 1996. One level III and two level IVs in the area of US0 and configuration management.
l DESIGN CONTROL ISSUES:
In enforcement identified two problems, one which failed to coordinate design changes to operating procedures with three exam]les: 1) Set point change to low level alarm in the Hydrazine tanc 2) removal or ICW lube water piping and did not change abnormal procedure which affects operator actions. and 3) disabled a steam dump valve annunciator without changing the annunicator response procedure. The second problem j
identified the failure to change ICW drawings after a modification (All three examples September 19. 1996).
OPERATING FOCUS:
The licensee took steps to prevent tube failure of its steam generators on Unit 1 by plugging approximately 2300 tubes. These steam generators will be replaced in fall 1997 outage.
MAJOR INITIATIVES:
Unit 2 outage 4/15/97 97 Unit 1 S/G replacement outage fall '97 j
rSAR IWITIATIVES: A review has been conducted of approximately one-third of the FSAR (July 1996 inspection). This review was performed mostly on Unit 1 and was performed on text material and not for curves and tables.
No USQ or operability problems were i
found. Approval pending for reviewing remaining part of FSAR.
DBD/R: A Design Basis Documentation was performed for 20 design basis documents. Tne program was completed near the end of 1995.
C.
Future Inspections Engineering-9 weeks. basis:
Evaluate new engineering organization. FSAR project, configuration management and followup on design control issues.
V.
Functional Area Assessments - Plant Suocort A.
Assessment The last SALP cycle ended 1/6/96.
Plant Support was Category 1.
The licensee continues to maintain a satisfactory level of performance in the area of Plant Support.
Some decline in Radiation Protection has been noted due to the loss of control of contaminated tools and exceeding dose goals.
Emergency Preparedness ongoing inspection indicates a decline in L
performance.
Hurricane preparations for hurricane Bertha were conservative.
Overall. site security has been adequate.
Training and qualification noted as a strength and management observed to be aggressive in pursuing issues. but not aggressive in doing indepth review of events.
Implementation of the fire protection program continued to be satisfactory.
B.
Basis Radiation Protection NCV for failure to control contaminated tools used in RCA (96-04 p 45)
Violation (repeat of above NCV) for numerous examples of failure to control contaminated tools. (96-09. p 25)
Internal and external exposures below 10 CFR Part 20 limits. (96-04, p 45 and 96-04, p 23) (1996 dose levels?).
1995 dose was 412 person-rem. Unplanned maintenance and rework caused 1995 dose goal of 283 person-rem to be exceeded by 129 person-rem. (96-04, p 50)
Rad Techs decreased from 32 to 30 and 2 supervisors lost (96-04, p 48)
Decon staff reduced from 22 to 12 persons.
Levels of contaminated equipment and materials increasing. (96-04, p 46)
Good radiological housekeeping and controls. (96-09, p 28) 2 The total area contaminated was at 250 ft.
(96-04, p 47)
Licensee accreditation of the FP&L DADS a good example of Radiation Protection staff's technical capabilities.
(96-04. p 44) l Emeraency Preoaredness Conservative actions taken to prepare for Hurricane Bertha.(96-11, p 3)
Security Failure to report a confirmed tampering event within one hour, which resulted in a violation.
Two. events in prior to the above tampering event were documented as tampered or unauthorized work, but management failed to notify security of these events.
Numerous problems discovered by a 0A audit determined the FFD r
a program to be weak.
\\
~
L Fire Protection A backup fire pump was installed to replace an out of service fire pump.
C.
Future Inspections l
Insoections Rationale Health Physics (SALP 1 decline - maintain: watch)
Operational HP(83750) 2-Inspections with focus on procedure compliance: rework doses Effl/RadWast(84/86750) 3-inspections with focus on accident / process monitor installation & maintenance TI 133 Rad Waste Combine with 86750 Emergency Preparedness 1-Inspection with focus on Self-Prog. (82701)
Assessment results Regional Initiative inspection on allegation followup (3 weeks. 2 inspectors)
Security Prog (81700)
Core Insp. to review security l
audits, corrective actions.
1 management support and effectiveness, and review protected area detection equipment-Sec. Prg/FFD (81700/81502)
One regional initiative to followup on tampering and FFD issues Fire Protection None VI.
Attachments 1
l 1.
Power Profile j
2.
Plant Issues Matrix 3.
Current NRC Performance Indicators 4.
Licensee Organization Charts 5.
Allegation Status 6.
Enforcement History 7.
Major Assessments 8.
Recent Generic Issues Status List i
i i
4 4
.l
ST. LUCIE - INSPECTION PLAN INSPECTION NUMBER OF PLANNED PROCEDURE /
TITLE / PROGRAM AREA INSPECTORS INSPECTION TYPE OF INSPECTION -
TEMPORARY DATES COMMENTS INSTRUCTION 37550 NUCLEAR INSTRUMENTATION 2
10/7-18/96 REGIONAL INITIATIVE INSPECTION 82701 OPcRATIONAL STATUS OF T11E EP 2
10/7-18/96 REGIONAL INITIATIVE PROGRAM 10/28-11/1/96 81502 FITNESS FOR DUTY 1
10/21-25/96 FOLLOWUP FFD/ TAMPERING 40500 EFFECTIVENESS OF LICENSEE 1
10/21-25/96 INSPECT STATUS OF
[
CONTROLS IN IDENTIFYING PERFORMANCE IMPROVEMEf/T i
RESOLVING. AND PREVENTING 2
1/97 PROGRAM PROBLEMS: CORRECTIVE ACTION REVIEW I
84750 RADI0 ACTIVE WASTE TREATMENT AND 1
11/4-8/96 REGIONAL INITIATIVE EFFLUENT AND ENVIRONMENTAL TI 133/86750 MONITORING: SOLID RADI0 ACTIVE 11/18-22/96 WASTE MANAGEMENT AND TRANSPORTATION OF RADIOACTIVE MATERIAL 83750 OCCUPATIONAL RADIATION EXPOSURE 1
12/2-6/96 REGIONAL INITIATIVE 1
71001 LICENSED OPERATOR REQUALIFICATION 1
12/2/96 REQUALIFICAT10N PROGRAM PROGRAM EVALUATION INSPECTION 62703 FOLLOWUP MAINTENANCE RULE TEAM 1
1/27 -31/97 REGIONAL INITIATIVE INSPECTION
2 i
INSPECTION NUPEER OF PLANNED PROCEDURE /
TITLE / PROGRAM AREA INSPECTORS INSPECTION TYPE OF INSPECTION -
f TEMPORARY DATES C0lWENTS INSTRUCTION 73753 STEAM GENERATOR INTEGRATED 1
1/27-31/97 REGIONAL INITIATIVE INSPECTION 2/10-14/97 5/5-9/97 37550 ENGINEERING 1
2/3-7/97 CORE 50.59 FOCUS 92703 FOLLOWUP A/E EXPANDED SSFI TEAM 3
3/3-14/97 REGIONAL INITIATIVE INSPECTION OPEN ISSUES 73753 INSERVICE INSPECTION 1
4/28-5/2/97 CORE -MAINTENANCE 81700 PHYSICAL SECURITY PROGRAM FOR 1
TBD CORE - SAFEGU/RDS POWER REACTORS 6
i l
I
ST. LUCIE UNIT 1
Operational P eri o d Fe b ru a ry 1996 through October 18, 1996 1
2 3
100
=
3On August 23,1996, 1
On February 24,199S, a manual trip was 80 -
x a manua trip was initiated initiated to perform y
while going to a TS required turbine maintenance.
2 60-shutdown 4
E-Z 4Q-2 April 29, 1996, 4
The unit operated at Daox shutdowlfor 60% power du e to main refueling trans former roblems i
0 o n o i: :o uin n o io n n o"viivi m m m t m t m rt m "iu o u u""n o ni o u o io n o.
F M
A M
J J
A S
O PERIOD OF OPERATION Graph does not include power reductions for. routine repairs, waterbox cleaning, or required repairs.
l
ST. LUCIE UNIT 2
Operational Period February 1995 through October 18, 1996 1
2 100
=
1 On April 20,1996 80 -
the unit was removed rza from service during
>"o turbine testing 60 -
a P
Z rza 40_
U 2 On June 6,1996, the g
ria unit was manually tripped w
20 -
due to high generator hydrogen gas temperature.
O o n o n o nii n n oi n n: :nno iningm oiinoniunonnioniununioninin F
M A
M J
J A
S O
PERIOD OF OPERATION Graph does not include power reductions for routine
- repairs, wa te rbo x
- cleaning, or required repairs.
PLANT ISSUES MATRIX BY SALP AREA St. Lucie SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS ENGINEERING 4/18/96 NCV IR 96-06 M
L Missing orifice plate identified in Unit 1 Either failure to install orifice during ICW system during licensee field plant modification, or failure to reinstall walkdowns.
orifice following maintenance.
4/29/96 NCV IR 96-06 N
Failure to promptly document a Engineering failed to initiate CR upon nonconformance.
discovery that approx. 35 S-R instruments on each unit might have been calibrated at temperatures lower than those assumed in setpoint cales.
L initial temperature (and other) conditions Programmatic weakness in Plant 96-236 specified in Unit 1 spent fuel pool heat Change / Modification process.
load calculation (to support total core offload) was not factored into procedures.
4/9/96 NEG S
CIRC water piping through-wall leaks Galvanic corrosion due to inadequate observed in two water boxes' outlets.
cathodic protection fo!!owing installation of stainless steel Tapparogge components.
6/3/96 OTHER IR 96-08 O
L Unit 1 outage extended due to expansion New plugging criteria resulting from of SG MRPC tube inspections. Tube discussions with NRR on defect plugging approached 25% limit. PLAs characterization methodologies.
submitted to NRR to allow plugging up to 30%.
6/8/96 OTHER IR 96-08 L
Ongoing review by licensee of UFSAR Failure to update FSAR over time and accuracy identified approximately 150 failure to review FSAR properly when items, ranging from typographical errors to preparing procedures more substantive issues.
FROM: 10/18/95 TO: 10/18/
Page 1 of 26 21-Oct-96
._~_
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE1 COMMENTS 7/18/96 OTHER 1R 96-11 M
L Unit 1 AFAS setpoints found Failure to employ as-built elevations of nonconservative during review of condensate pots in the development of recalibration activities.
calibration criteria.
7/30/96 OTHER 1R 96-11 O
L 3 of 4 Unit 1 linear Ni channels found Drawing errors - discrepancy between miswired, wim the detectors
- upper vendor technical manuals and control chambers feeding the lower NI drawer wiring diagrams generated for the inputs and v'ce-versa. Result was 3 installation of the new Unit 1 NI drawers.
channels for which axial shape index was in error.
4/13/96 POS IR 96-06 N
Engineerir c response to failure of HVS-4A Procurement engineering effective in motor considered good.
locating and dedicating replacement motor and in identifying and resolving incorrect bearing rating calc for new motor. Minor problem existed in that new starting current profile was not adequately treated.
6/1/96 POS IR 96-08 N
CNRB activities surrounding PLA reviews in support of SG tube plugging issues were probing and competent.
6/8/96 POS IR 96-08 M
N Unit 1 RWT liner inspection.
Licensee satisfied committments to inspect fiberglass liner ir' RWi~. Results sat.
8/26/96 POS IR 96-14 N
Engineering activities associated with leak in class 3 line to containment fan cooler in accordance with GL 91-18 and GL 90-05 for non-code repair.
6/8/96 STREN IR 96-08 M
N ISI activities for SG and reactor vessel Examinations well-planned, performed eddy current examinations reviewed.
and managed by very talented and knowledgable personnel.
FROM: 10/18/95 TO: 10/18/
Page 2 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 6/6/96 VIO IR 96-12, EA-N USQ, involving taking a normally open Licensee determined that sma!! increase 96-249 EDG fuel oil line isolation valve to the in the probability of failure could be closed position and the use of operator overcome by admin processes.
action to open the valve on EDG start, cited at SL 111.
Two SL IV violations cited for Lack of appropriate pre and post-96-236 configuration management control installation review.
problems involving inaccuracies in procedures and drawings due to design changes.
8/3/96 VIO IR 96-11 M
N Prefubrication of valves prior to Procedure which required prelube had surveillance testing in 1995 resolved as not been considered for potential effects
~
being a violation of 10CFR50 Appendix B on stroke time.
criterion XI.
10/18/96 VIO IR 96-17 L
Failure to satisfy QA plan requirements in Failure to perform independent the development of design modifications verifications of design outputs to the Unit 1 Nuclear instrumentation (drawings). Multiple examples. Also, system.
failure to perform adequate validation and verification of software for incore monitoring.
6/3/96 VEAK IR 96-12. EA M
S High temperature condition in Unit 2 rod Failure of an air conditioner. Further 96-236 control cabinet room due to failure of an review by licensee /NRC showed air air conditioner led to indications of rod conditioner was temporary equipment control problems." Indications later shown installed without design controls during to be false. Also, high temp condition led pre-op test phase.
to failure of a diverse turbine trip relay.
7/12/96 WEAK IR 96-12 L
Licensee veritcal slice inspection of EDG, Lack of proper configuration control over HPSI, and CCW systems revealed time.
numerous deficiencies in procedure, design document and FSAR accuracy.
FROM: 10/18/95 TO: 10/18/
Page 3 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS 10/12/96 WEAK IR 96-15 PS N
No evidence could be found that lack of design basis documentation.
containment leakage de*ection systems satisfied leak-before-break assumptions for detectability or seismicity.
MAINTENANCE 11/1/95 NCV IR 95 S ICI wiring error during RX head installation Personnel Errer NCV 95-18-05 last RFO.
2/17/96 NCV IR 96-01, IR PS N
Work on 1 A ECCS suction header through-Personnel work practices (workers 96-04 wallleak revealed strong FME, but poor ignored RWP requirements)
HP work practices observed regarding contamination control resulted in NCV.
5/8/96 NCV IR 96-06 N
Lack of verified (controlled) copy of Failure of Maintenance workers to procedure identified at CCW heat property verify procedures prior to exchanger jobsite.
beginning work.
5/17/96 NCV IR 96-08 N
Failure to verify the currency of procedure Cognitive personnel error in use at jobsite 5/17/96 NCV IR 96-08 N
Failure to satisfy requirements for Cognitive error.
" independence' on the part of independent verifier.
8/3/96 NCV IR 96-11 N
Review of outage freeze seats indicated Stop work order by management for that one freeze seal had been left cleanup of the Unit 1 pipe tunnel unattended for approximately one hour.
resulted in directing freeze seal watch to another area to make room for trash being hauled out of area.
FROM: 10/18/95 TO: 10/18/
Page 4 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS 10/12/96 NCV IR 96-15 N
QA identified 3 areas of noncompliance M&TE storage area had been relegated with M&TE controls; one lack of a cal to a self-service facility, counter to OA sticker, lack of segregation of sat and plan requirements. Indications are that unsat M&TE, lack of an individual a lack of personnel contributed.
controlling M&TE.
2/17/96 NEG IR96-01 N
Freeze seal procedure lacked objective ProceduralWeakness criteria defining when a freeze seal existed.
2/17/96 NEG IR 96-01 L
Weakness identified in I&C calibration ProceduralInadequacy procedure - lack of detail provided for safety related calibrations.
3/30/96 NEG IR 96-04 N
Control of maintenance procedures was Programmatic vunerability.
such that an outdated procedures could, programmatically, wind up in the field due to their inclusion in previously prepared packages. Licensee corrective action adequate.
6/8/96 NEG IR 96-08 N
Application of ladder and scaffolding programs appears to be minimally compliant with licensee's self-imposed requirements. Many scaffolds and ladders required caution tags or had not been removed promptly after use.
11/6/95 OTHER 1R 95-21 S
Failure of EDG 2A relay sockets.
Equipment Failure Potential common mode failure.
12/9/95 OTHER IR 95-22 L
2A2 RCP seal pkg lower seal destaged Filling RCS Before Coupling RCP due to reverse pressure across seat.
FROM: 10/18/95 TO: 10/18/
Page 5 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 12/20/95 OTHER 1R 95-22 S
RX vessel flange inner O-ring groove Pitting - Localized Corrosion pitting resulted in cooldown and head removal for repair.
3/30/96 OTHER IR 96-04 S
Maintenance underwent major departmentalreorganization. Selected supervisors' qualifications found satisfactory per TS requirements.
5/22/96 OTHER L
V 3483 (SDC Suction Relief) setpoint Root cause not established. Either found out-of-spec high, rendering valve tampering or poor maintenance incapable of performing its intended practices (most likely).
function.
6/3/96 OTHER 1R 96-08 N
EDG reliability calculations indicate that EDG reliability is in keeping with SBO assumptions 6/8/96 OTHER IR 96-08 N
Review of maintenance backlog indicated thatlicensee had a plan for backlog reduction in place but has yet to meet goals.
8/3/96 OTHER IR 96-11 E
N Licensee's activities regarding maintenance of rod control system were adequate.
9/7/96 OTHER IR 96-14 N
Apparentimproper use of M&TE for Failure to follow procedure.
meggering NI cabling identified. Lack of tracability from M&TE to work order due to borrnwing the equipment from one job for use on another job. URI.
9/9/96 OTHER 1R 96-15 S
Set screw / locknut in Trip Circuit Breaker 5 Root cause pending. Initialindications sheared off during surveillance testing and were of apparent hydrogen was later found in breaker cubicle.
embrittlement.
FROM: 10/18/95 TO: 10/18/
Page 6 of 26 21-Oct-96 i
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS 2/17/96 POS IR 96-01 N
Noted improvements in housekeeping and material conditions.
3/30/96 POS IR 96-04 N
10 maintenance activitss observed during inspection period. No significant deficiencies noted.
5/11/96 POS IR 96-06 N
Observations of Pressurizer Code Safety No deficiencies noted Valve testing and repair 5/11/96 POS IR 96-06 N
Preparations for Unit 1 reactor vessel ISI.
In accordance with requirements and showed good outage planning.
5/11/96 POS IR 96-06 N
Observations of maintenance activities in No deficencies noted.
containment (Unit 1 outage) involving valve packing replacement and modification.
5/11/96 POS IR 96-06 N
MSSV testing - Unit 1 Outage Review of test data and methodology sat.
5/11/96 POS IR 96-06 E
N Polar crane load rating calc and Unit 1 No deficiencies identified.
head lift.
6/8/96 POS IR 96-08 N
Repair work for Unit 1 fuel transfer tube Conducted satisfactorily isolation valve.
6/13/96 POS IR 96-09 N
Maintenance activities associated with Work conducted satisfactorily.
Unit i reactor head lift and Unit 2 feed reg valve work.
FROM: 10/18/95 TO: 10/18/
Page 7 of 26 21-Oct-96
JA SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE / COMMENTS 6/20/96 POS IR 96-09 O
L Loss of 3 Wide Range Nuclear Instrument Operators prompt and accurate in Channels on Unit 1 resulted in entering TS verifying shutdown margin requirements.
AS for Nls.
7/20/96 POS IR 96-11 O
N Post-outage walkdown of Unit 1 containment indicated excellent cleanliness.
9/7/96 POS IR 96-14 N
ESF response time testing procedure identified as weak in detail. CR resolution to change procedure appropriate. Review of last 4 performances of procedure for each unit indicated that TS satisfied for complet on of all channels.
9/7/96 POS IR 96-14 N
Review of 20 work orders indicated appropriate control of work scope.
2/24/96 VIO IR 96-04 N
Acceptance criteria specified for CEDM Failure of l&C System Supervisor to coil resistances in PC/M package found adhere to test criteria compounded by varied and unclear. Criteria were not failure of I&C management to identify properly applied and values outside of obvious errors during post-work review.
specifications were not documented and resolved.
6/13/96 VIO IR 96-09 N
A review of overtime for a one month Failure of management to track the use period indicated that overtime guidelines of overtime as specified in site were routinely exceeded without prior (or procedure. Procedure poorly defined subsequent) approval. 56 examples cited requirements.
for 5 individuals.
7/6/96 VIO IR 96-09 E
N Review of testing activities for continment Failure to properly implement App. B blast dampers indicated that violations of and QA plan as they related to 10 CFR 50 App. B and site procedures documenting as-found and as-left data.
existed. Two violations cited.
FROM: 10/18/95 TO: 10/18/
Page 8 of 26 21-Oct-96
.=
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 10/12/96 VIO IR 96-15 N
M&TE used in testing control channel NI M&TE was borrowed from anotherjob, during instailation was not logged out in violation of procedural controls.
against the work order for the job.
Tracability was thus lost.
10/18/96 VIO IR 96-17 N
Failure to initiate a condition report for a Resulted in miswiring the detector.
deficiency when cable labeling for Unit 1 B channel NI detector did not agree with drawing.
2/24/96 WEAK IR 96-04 N
Maintenance practices for Steam Bypass Poor preventive maintenance on SCBC and Control System and Feedwater valve airlines and FRVs.
Regulating valves found weak in inspection following 2/22/96 Unit 1 trip.
OPERATIONS 1/7/96 N
SALP CYCLE 12 BEGINS 3/31/96 EMERG IR 96-06 PS N
Operator response to RCS leakage Operators effective at through CVCS system.
identifying / isolating leak; however, Unusual Event call was non-conservative in that the call was delayed to allow a 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> RCS inventory balance to be calc *d when other information indicated that excessive leakage existed.
7/13/96 EMERG IR 96-11 M
L NOUE declared when 2C ~ charging pump Check valve stuck open due to possibly check valve stuck open, creating bypass generic effects of pulsating low flow in a flowpath from charging pumps to VCT.
continuous service valve.
Operators timely in declaring event.
8/9/96 EMERG IR 96-14 M
L NOUE declared due to RCS leakage in Charging pump packing leakage excess of 1 gpm unidentified.
identified as source of leak. Operators correctly applied EAL.
FROM: 10/18/95 TO: 10/18/
Page 9 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 2/22/96 LER LER 335/96-M S
Dropped CEA led to declaration of NOUE 002 and plant shutdown. During shutdown, failure of air line to a FRV led to manual trip.
5/29/96 LER M
L Suspected loss of approximately 1200 condenser tube cleaning balls reported to state /NRC. Balls were found unaccounted for during an inventory balance.
Suspected that balls were released to Atlantic Ocean.
6/2/96 LER M
L Non-safety related breaker alignments to Operators not aware that containment support Unit 1 outage resulted in loss of amplifier was going to be affected by audible count rate amplifier for lineup. Control room amplifier not containment. Audible counts lostin affected.
containment for approximately 5 minutes during fuel movements.
10/18/95 NCV IR 95 L Missed RCS Boron samp!e surveillance.
Personnel Error NCV 95-18-07 10/19/95 NCV IR 95 S Missed shift CEA position indication Personnel Error NCV 95-18-06 surveillance.
11/21/95 NCV IR 95 L Failure to maintain Penetration Log.
FTF Procedure NCV 95-21-04 1/5/96 NCV IR 95 PS N
Several deficiencies in prodecure change Failure to Properly implement NCV 95-22-01 process implementation identified.
Procedures Expired or cancelled TCs found in control rooms and hot shutdown panel.
FROM: 10/18/95 TO: 10/18/
Page 10 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 4/22/96 NCV IR 96-06 E
L Unauthorized breech in RAB fire barrier Operators showed good attention to during installation of CCW piping detail in identifying two holes bored in modification.
wall. Engineering failed to account for the effects of modification installation in fire rated assembly, as required by procedure for engineering packages.
5/14/96 NCV IR 96-08 L
Fuel movement begun with only one of Poor communication between control two required wide range NI channels room operators performing surveillance operable. Condition identified and fuel testing (which inop'd NI) on the subject movement secured after approximataf 1 channel and the refueling center.
f ft of travel.
8/3/96 NCV IR 96-11 L
QA audit discovered that corrective action Rush to close out STARS (old corrective documents had been closed without being action document) when CRs (new forwarded to originator for approval (as corrective action document)were required by procedure). NRC identified instituted.
that personnel without signature authority were closing documents.
9/6/96 NCV IR 96-14 N
Operator observed not walking down control boards prior to assuming shift, as required by procedure. Operator terminated.
9/9/96 NCV IR 96-15 PS L
Licensee had not complied with Failure to follow procedures.
requirements for ensuring that operators read training bulletins required to maintain requalification current. Licensee identified issue, with independent NRC findings.
9/18/96 NCV IR 96-15 L
Licensee bypassed the wrong ESFAS Poor labeling of bypass key slots.
steam generator low level channelin response to channelinoperability.
Resulted in a failure to satisfy TS action statement requirements.
FROM: 10/18/95 TO: 10/18/
Page 11 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE / COMMENTS 12/1/95 NEG IR 95-21 N
Recurrent non-valid alarms when starting FTF Procedure fire pumps were not documented as operator workarounds. Voltage dips associated with such starts were contributors to a trip previously.
12/1/95 NEG IR 95-21 N
Operators unable to effectively obtain l&C Inadequate Operator Training setpoints from cornputer after hard copies were removed from control room.
12/1/95 NEG IR 95-21 N
Unit 2 procedures and valve deviation log Valve Position Administrative Controls used to cycle Unit 1 cross connect valves.
12/1/95 NEG IR 95-21 N
SDC Procedure required natural circ-ProceduralInadequacy related surveillance prior to establishing RCS pressure boundary. Natural circ not possible without pressurization.
12/27/95 NEG IR 95-22 E
S FRG meeting suffered / items deferred due Lack of Attendance at FRG to lack of OPS /Eng'g attendance at meeting. Major issues at meeting affected OPS /Eng'g.
1/5/96 NEG IR 95-22 N
Several procedural deficiencies and inadequate Procedure Review and calculational errors identified in reload Execution physics test procedure.
2/15/96 NEG IR 96-01 M
N Tours of ECCS rooms revealed several Material Condition active leaks. Licensee could not explain how (if) FSAR assumptions on ECCS leakage were satisfied. Later review of FSAR indicated leakage within assumptions.
3/7/96 NEG IR 96-04 N
Licensee failed to place a CEA which had Operator oversight.
been declared administrative!y inoperable in the equipment out-of-service log. CEA was operable per TS.
FROM: 10/18/95 TO: 10/18/
Page 12 of 26 21-Oct-96
m SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE / COMMENTS 3/7/96 NEG IR 96-04 N
During MTC testing, inspector noted that Poor attention to detail.
boron concentration had been verified at 30 minute intervals, vice 15 minute intervals as called for in procedure.
6/3/96 NEG IR 96-08 N
Poor practice observed in spent fuel pool "On deck" status was an effort to operations. Fuel assemblies were left expedite reload. Operator leaving hanging in an "on deck" status while machine was due to inadequate awaiting upender availability. Also, manpower-operator had to operate operator left machine unattended with fuel ~ upender controls, which were mounted hanging at least once per movement.
on wall.
7/16/96 NEG IR 96-11 L
2C auxilliary feedwater pump tripped on Operator errorin not property overspeed during post-maintenance implementing cautions in a procedure.
testing.
7/20/96 NEG IR 96-11 M
L 2 operating charging pumps tripped when l&C failed to recognize that reactor maintenance induced an erroneous level regulating system would be affected by signalinto reactor regulating system.
their activities. Operators had charging Letdown isolated by operators. Upon pump backup switch in wrong position, reinitiating letdown, minor waterhammer leading to cessation of charging flow.
event occurred.
10/1/96 NEG IR 96-15 O
N 2B HPSI pump discharge pressure noted Poor attention to detail.
to be 860#. Operators could not explain it, had not noticed it. Was'due to a pump run a week before.
11/16/95 OTHER 1R 95-21 M
S Unit 1 manually tripped when 18 MFRV Long-Standing Equipment Problem locked in 50% position. Root cause -
degraded power supply, compounded by voltage dip on starting both station fire pumps.
11/21/95 OTHER 1R 95-21 S
Light socket failure during lamp Equipment Failure replacement results in loss et oling to 1 A Main Transformer. Unit downpower to
-60%.
FROM: 10/18/95 TO: 10/18/
Page 13 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE ICOMMENTS 1/26/96 OTHER 1R 96-01 N
Inspection of corrective action program Corrective Actions revealed timely action on the part of management, but weaknesses in plans for tracking progress on personnel performance and procedure quality improvement.
3/1/96 OTHER-L Management Changes - T. Plunkett succeeds G. Goldberg, C. Wood replaces L. Rogers as manager of SCE, C. Marple replaces C. Wood as Ops Supervisor.
3/10/96 OTHER IR 96-04 L
Unit 1 downpowered to 97.5% due to hot Hot leg stratification.
leg stratification and flow swirl which resulted in higher than actual indicated reactor power.
4/4/96 OTHER 1R 96-06 L
Interim Operations Manager (H. Johnson) named.
4/10/96 OTHER IR 96-300 N
4 of 4 SRO candidates passed SRO examination. In 3 of the cases, performance was marginally satisfactory.
No generic candidate weaknesses identified.
4/20/96 OTHER IR 96-06 S
Unit 2 downpowered and taken off-line Blockage in auto-stop oil line orifice due to low pressure condition in auto-stop which prevented buildup of auto-stop oil oil. Operators observed to control pressure. Only negative aspect was evolution well.
crowding of control panels by control room SROs during portions of evolution.
5/31/96 OTHER IR 96-08 M
S Blown fuse resulted in closure of all Unit 2 Moisture found in a junction box MSR temperature control valves, resulting following heavy rain.
in a 5% load rejection.
FROM: 10/18/95 TO: 10/18/
Page 14 of 26 21-Oct-96
r l
l l
=
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS 6/27/96 OTHER IR 96-09 E
L Site reorganization announced which would place almost all engineering functions (system engineering, STAS, test engineers) under Engineering. Also, Outage Management folded into a global work planning group under the Plant General Manager.
3/12/96 POS IR 96-04 S
Licensee disposition for deficiency noted in 1 boroflex panel (top 15" missing) found satisfactory. FRG treatment of issue found appropriate.
3/29/96 POS IR 96-04 N
Operator requalification program found to be supporting mi.. jment expectations for operations and covering timely and important topics.
3/30/96 POS IR 96-04 N
Review of 5 clearances indicates better attention to detail than had been observed in past.
4/10/96 POS IR 96-300 N
Simulator performed well throughout SRO qualification testing.
4/28/96 POS
. IR 96-06 N
Operators performed well during Unit 1 Communications formal, excellent use RFO siwtdown.
of annunciator response procedure.
Performance of rod drop time testing a noteworthy initiative.
5/2/96 POS.
IR 96-06 N
Good performance by operators and test personnel during integrated safeguards testing on Unit 1.1B EDG output breaker failed to close during first test. Operators handled situation well.
5/5/96 POS IR 96-06 N
Reduced inventory operations conducted well by operators.
FROM: 10/18/95 TO: 10/18/
Page 15 of 26 21-Oct-96
4 SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 5/11/96 POS IR 96-06 N
2 clearances audited, both correct.
5/14/96 POS IR 96-08 N
Fuel movements during Unit 1 core offload and reload performed well.
5/24/96 POS IR 96-08 M
S Rod control system failure resulted in Operators conservative in interpreting inability to move (electrically) 4 CEAs.
TS, plant organizations provided timely Operators conservatively interpreted TS to support with lists of equipment which require shutdown in this instance.
would be inoperable when the main Situation complicated by an out of service generator was tripped.
Startup Transformer.
6/6/96 POS IR 96-08 S
Unit 2 manually tripped due to high main Operators acted promptly and correctly generator gas temperature due to failed in tripping the unit. Post trip response of temperature control valve.
both plant and operators was good.
6/8/96 POS IR 96-08 N
3 QA audits reviewed Broad in scope, appropriately focused, indicated an aggressive application of quality standards.
6/8/96 POS IR 96-08 N
3 QA Audits reviewed Broad in scope, focused on weak areas. Agressive application of standards evident in the number of findings cited.
6/19/96 POS IR 96-09 N
Unit 1 reduced inventory preparations and Controls were appropriate.
execution.
7/5/96 POS IR 96-09 N
Unit 1 reduced inventory preparations and Mid-Loop controls effective. Licensee execution.
attention and management oversight excellent.
FROM: 10/18/95 TO: 10/18/
Page 16 of 26 21-Oct-96
SECONDARY DATE.
TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 7/8/96 POS IR 96-11 M
N Licensee preparations for Hurricane Hurricane forcasts showed storm Bertha proactive and responsible.
missing area, but licensee prepared as though it would change course.
8/31/96 POS IR 96-14 M
L Operators manually tripped Unit 1 due to Operators acted quickly, conservatively, indications of gas accumulating in the 18 and in accordance with plant transformer. Operating crew self-procedures.
assessment following event viewed as excellent.
9/2/96 POS IR 96-14 N
Unit 1 startup conducted well. Operator action to terminated first approach to criticality when Xe decay drove estimated critical conditions near allowed band limits was appropriate.
9/9/96 POS IR 96-15 PS N
Control room watchstanding practices satisfactory. Watchstanders maintained a professional environment and were attentive to plant paramenters.
10/9/96 POS IR 96-15 N
Surveillance testing of 2A EDG performed well. Good use of Realtime Training Coordinators 7/9/96 STREN IR 96-11 N
Two entries into reduced inventory made during inspection period. Strong management involvement in scheduling around Hurricane Bertha. Reduced inventory operations continues to be a strength.
11/11/95 VIO IR 95 N Tech. Spec. equipment not specified for IV FTF Procedure VIO 95-21-02 on Equipment Clearance Order.
11/20/95 VIO IR 95 N Valve discovered Closed vice Locked FTF Procedure VIO 95-21-01 Closed as specified on Equipment Clearance Order.
FROM: 10/18/95 TO: 10/18/
Page 17 of 26 21-Oct-96
o SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE / COMMENTS 11/27/95 VIO IR 95 L Missed RCS Boron sample surveillance -
Personnel Error VIO 95-21-03 Repeat from IR 95-18.
1/5/96 VIO IR 96-04 L
NLO failed to employ procedure when Fai!ure to use procedure, failure to notify placing EDG fuel oil tank on recirculation control room of evolution.
for chemistry. As a result, he improperly performed the evolution by isolating the discharge of the EDGFO transfer pump, which resulted in an inoperable EDG.
L Boron dilution event due to operator Operator error, poor short term 96-040 leaving control panel while dilution was in tumover, poor command and control progress. Weak command and control, procedural adherence, and short-term tumover. Additionally, OP for boration/di!ution not consistent with FSAR and no 50.59 performed.
1/26/96 VIO IR 96 N Violation identified regarding temporary Procedure Control VIO 96-01-01 changes to procedure which changed intent and which were approved for use hout prior FRG review.
v 2/22/96 VIO IR 96-04 O
N s perators found adding boric acid to VCT Procedures were put away to tidy up without procedure in hand, as required by control room prior to NRC senior conduct of operations procedure.
managers' tour prior to SALP meeting Additional example of EEA 96-040.
3/27/96 VIO IR 96-04 N
Operators failed to property log boron Management direction to operators dilution evolutions. Globallog entry was allowing globallog entries for reactivity made at the beginning of the shift stating manipulations during transient dilutions would be made; however, conditions (e g. uppower) which was procedure required each dilution to be not in accordance with Conduct of logged.
Operations procedure.
8/19/96 VIO IR 96-16 N
Operations key controls found inadequate Keys found uncontrolled at for keys associated with control room normal / isolate switch boxes for unit 2 evacuation / remote shutdown PORVs.
FROM: 10/18/95 TO.10/18/
Page 18 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEi COMMENTS 12/1/95 WEAK 1R 95-21 N
SDC procedure contained conflicting ProceduralWeakness/ inadequate values for RX cavity level requirements.
Review Procedure had be.n approved since emphasis on accuracy stressed.
12/1/95 VEAK IR 95-21 N
CCW sample valve showed dual FTF Procedure indication without corrective action documentation initiated.
12/1/95 WEAK IR 95-21 N
Clearance in place to isolate N2 from CST Poor Corrective Actions to facilitate pressure switch replacement for nine days without work order being written.
12/1/95 WEAK IR 95-21 N
Followup to previous inspection findings Corrective Actions indicated a weakness in followthrough in addressing deficiencies.
12/5/95 WEAK IR 95-22 M
N ESFAS cabinet doors found unlocked Poor Logkeeping/ Attn to Detail following maintenance work -I&C error.
Log entries associated with work were not complete.
1/5/96 WEAK IR 95-22 M
L U2 manual RX trip on high generator H2 Temp Control Valve Failure.
temp due to failure of temp control valve.
Additionally, failure to identify Operator awareness of RPS status post-unexpected reactor trip signals which trip poor. Inspection of post-trip review (for came in during trip.
current trip as well as past trips) indicated weaknesses in the rigor of post-trip reviews 2/17/96 WEAK IR 96-01 E
N Numerous deficiencies identified in Proceduralinadequacy instrument air system walkdowns, including drawings accuracy, ONOP adequacy, and annunciator response procedure accuracy.
FROM: 10/18/95 TO: 10/18/
Page 19 of 26 21-Oct-96
s EN SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 2/24/96 WEAK IR 96-04 S
Procedural weakness results in attempting Procedure review weakness -lack of to synchronize main generator with grid verification that disconnect links were with generator disconnect links open.
closed.
4/14/96 WEAK IR 96-06 E
N Configuration Controlissues resulted from Walksdowns of both units' CS, ICW and ESF system walkdowns.
IA systems indicate programmatic failures in incorporating design changes into drawings, the FSAR and operating procedures. Unresolved item tracking expansion of inspection scope to include instrumentation setpoints.
4/14/96 WEAK 1R 96-06 E
N ICW system walkdown.
Results in'dicate weaknesses in procedure-to-procedure agreement, labeling, and surveiffance requirements, in addition to configuration control issues disussed separately.
8/6/96 WEAK IR 96-14 N
Operator aids found in various areas of Type of aids identified did not meet the plant which were not in agreement criteria for inclusion in operator aid with system operating procedures.
program and were not controlled.
PLANT SUPPORT 8/14/96 EMERG IR 96-16 O
L NOUE declared due to security alert Event was similar to discoveries made resulting from discovery of tampering. A in July of a glue-like substance in glue-like substance had been injected into padlocks.
Unit 1 and 2 hot shutdown panel key lock switches.
3/1/96 NCV IR 96-04 N
Inspection of Hot Tool Room identified Attention to detail in tool storage and several tools which were either not surveying.
painted purple (as required) or which slightly exceeded limits for contamination.
8/12/96 NCV IR 96-15 O
L Failure to follow procedure resulted in the Poorly written procedure, compounded inoperability of the Unit 1 containment by weak execution by chemistry radiation monitor following PASS panel personnel. Good attention to detail be operability check.
NLO in identifying condition FROM: 10/18/95 TO: 10/18/
Page 20 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS 12/1/95 NEG IR 95-21 N
Rad survey results unavailable for B hot Failure to Document RAD Survey leg work. Surveys performed but not documented.
2/7/96 NEG IR 96-02 N
Two areas for improvement identified in inconsistencies m the use of Florida graded EP exercise - Need for Notification Message Form. Confusion management to become more involved in existed between NLOs dispatched frorn assuring correctness ofinfo being OSC and Control room fc r similar repair provided in offsite notification forms and missions.
need to refine C&C for damage control teams.
5/15/96 NEG IR 96-08 N
Observations of radiation worker practices revealed inconsistencies in the application of site practices (e.g. wearing of dosimetry, donning / doffing PCs).
7/26/96 NEG IR 96-10 L
QA audit of Fitness for Duty program Failure to follow procedures and lack of identified problems including personnel both attention to detail and self-checking with negative tests being recorded as cited as root causes.
positive (and vice versa) and personnel randomly selected for testing not being tested (even though they were available).
8/9/96 NEG IR 96-14 N
Examples of poor radiolaogical housekeeping observed. Barrels for anti-C collection located outside of contaminated areas, use of multiple, undefined, stepoff pads, contaminated trash overflowing contaminated area boundaries.
8/23/96 NEG IR 96-16 N
Licensee extended control room access to a large number of personnel, potentia!!y in excess of those needing access.
FROM: 10/18/95 TO: 10/18/
Page 21 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS 9/19/96 NEG IR 96-16 N
Licenme response to identification of glue Events believed to have occurred at in padlocks in July not thorough, as glue same time, and licensee's intitial audits was later found in key lock switches.
included only padlocks, door locks and valve locks.
2/7/96 OTHER 1R 96-02 N
EP exercise demonstrated that onsite emergency plans were adequate and that licensee was capable of implementing them.
3/1/96 OTHER 1R 96-04 N
Licensee found to be utilizing ALARA techniques and making progress at reducing collective doses for staff.
3/1/96 OTHER IR 96-04 N
Licensee found to be implementing adequate RP controls and monitoring individual exposures per code requirements.
3/1/96 OTHER IR 96-04 N
Housekeeping in RABs generally good; however, equipment storage areas found cluttered and untidy.
3/14/96 OTHER L
Management change. A. Desoiza (human resources manager) replaced by Lynn Morgan (from TP) 8/12/96 OTHER IR 96-14 O
L Operator identified low flow in Unit 1 Failure to follow procedure.
containment air monitor. Condition the result of Chemistry personnel failing to properly secure from a PASS system surveillance. URI 2/7/96 POS IR 96-02 N
Observations of licensee performance in CR, TSC, OSC, and EOF indicated good command and control, staff utilization and staff demeanor during graded exercise.
FROM: 10/18/95 TO: 10/18/
Page 22 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 2/7/96 POS IR 96-02 N
Licensee's onsite emergency organization was found to be we!!-defined and generally effective at dealing with simulated emergency during graded exercise.
2/7/96 POS IR 96-02 N
Communication among the licensee's emergency response facilities and emer 1ency organization and emergency response organization and offsite authorities were good during graded exercise.
2/7/96 POS IR 96-02 N
Licensee made significant observation of Licensee objectively questioning overal!
E-Plan execution - 2 practice drills were state of readiness.
required prior to graded exercise for management to be satisfied with performance. Managementdetermined that more frequent drills were required to ensure readiness.
3/1/96 POS IR 96-04 N
Ongoing HP efforts to obtain accreditation of FPL electronic dosimetry program identified as a good example of department's technical capabilities.
5/3/96 POS IR 96-05 N
Inspection of FPL Speakout program.
Program effective in handling and resolving employee safety concerns.
6/8/96 POS IR 96-08 N
Fire barrier inspections performed by the licensee were found to employ conservative criteria and be detailed.
7/6/96 POS IR 9S-09 N
Review of RCP oil collection system.
System met description in FSAR and was in accordance with App R, except as allowed by approved exemption.
FROM: 10/18/95 TO: 10/18/
Page 23 of 26 21-Oct-96
_______________,_______________________s
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSE I COMMENTS 9/19/96 POS IR 96-16 N
Licensee response to August discovery of glued key lock switches satisfactory.
2/24/96 VIO IR 96-04 O
L Unit 1 containment radiation monitor found Failure to follow procedure on the part of out-of-service due to isolation valve which HP personnel, compounded by failure to was closed to support a grab sample prior identify condition by operators during to a containment entry and not retumed to rounds.
the open position. Condition existed for 2 days, unknown to licensee.
5/7/96-VIO IR 96-06 N
Programmatic weaknesses identified in 11/62 members had expired medicals.
Fire Protection Program for medical 9/65 with expired medicals worked 60 qualification of fire brigade members.
shifts in April. 2 Fire Team leaders not listed on roster worked 31 shifts in April.1 Fire Team member with expired medical and not on roster worked 1 shift.
8/23/96 VIO IR 96-16 N
Failure to report tampering which occurred Licensee made decision at the time that in July to NRC in accordance with 10 CFR tampering'd.d not affect operation of the 73 requirements, unit.
9/14/96 VIO IR 96-15 O
N Unit 1 containment radiation monitor HP tech failed to employ a procedure for rendered inoperable amer obtaining grab restoring the monitor to service.
sample due to mispositioned valve.
Independent verifications were not Repeat of previous violation.
performed.
10/18/96 VIO IR 96-18 N
Failure to implement requirements of E Autodiater was inoperable and backup Plan with respect to arrangements to staff (manual) caffout capability hindered by and activate emergency response lack of distribution of controlled and facilities from 7/22 to 10/3.
current phone number lists.
10/18/96 VIO IR 96-18 N
Failure to take corrective actions for Corrective actions were stillin dratft critique items identified after Hurricane format and had not been acted upon Erin in August,1995.
FROM: 10/18/95 TO: 10/18/
Page 24 of 26 21-Oct-96
SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEI COMMENTS 10/18/96 VIO IR 96-18 N
Failure to implement training program for Filures to provide training for multiple EP as specified in E Plan.
positions for 3 years, failure to provide initial and requal training to multiple personnel, and other examples.
10/18/96 VIO IR 96-18 N
Failure to provide adequate EPIP for EPIP provided no more detail than plan, transferring OSC functions to an attemate which said that EC would determine if location in event an evacuation of the relocation was required. No specifics OSC is required.
on possible attematives.
5/3/96 WEAK 1R 96-05 N
Response letters prepared by Speakout to concemed employees did not contain adequate feedback to concemed employees.
5/3/96 WEAK IR 96-05 N
Investigative techniques of Speakout No requirement to develop plans to program have the potential to reveal, ensure identity is protected.
inadvertently, of concemed employees.
5/3/96 WEAK IR 96-05 N
Speakout program corrective actions were Lack of procedural specificity.
not tracked through implementation as required.
8/16/96 WEAK IR 96-16 N
Interviews with maintenance personnel Ineffective communication of assigned to observe access to critical expectations during rapid development areas of the plant as a result of tampering of an augmented security posture.
event revealed that they had not been told what to look for, how to react, who to contact in the event of a problem, etc.
10/18/96 WEAK IR 96-18 N
Unreliable ability to notify state within 15 Too many colateral duties assigned to minutes of a declared emergency.
Emergency Coordinator.
10/18/96 WEAK IR 96-18 N
Inadequate program of drills to ensure No drills conducted since graded availability of sufficient personnel and exercise in February and no timliness of ERF staffing.
programmatic requirement to perform drills.-
FROM: 10/18/95 TO: 10/18/
Page 25 of 26 21-Oct-96
.___m SECONDARY DATE TYPE SOURCE SALP AREA ID ITEM APPARENT CAUSEICOMMENTS SALP Functional Areas:
ID Code:
lM E
' ENGINEERING
[L fLIC5N5EN MAINTENANCE
!N NRC O
RATIONS S
SELF-REVEALED PS SUPPORT k
SA FETY ASSESSMENT & QV t
FROM: 10/18/95 TO: 10/18/
Page 26 of 26 21-Oct-96
i PREDECISIONAL l
ST. LUCIE 1 5"""**" "aa"" 72 "" 'g
$==a '
Refuehng R
opemtson m l
~
I 95 3 to 96 2 Quartsely Data Not Shown Using Op. Cycle....
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Year. Quarter Year. Quarter Signiecant Events Safety System Failures i
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O 93 3 94 1-94.3 95-1' 95 3 96 1 93 3 94 1-94 3 95 1' 95 3 96 1' Year. Quarter i
Year - Quarter Equepment Formed Outagost Forced Outae Rate (%)
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PREDECISIONAL ST. LUCIE 1
! 'ee aa: s====i Sien*==
wien sius==
'"* E Peer Group:Combuscon Engineenng w/o CPC Low r 93-3 to 96-2 Tronas and Denstions Deviatens From Plant Peer Group Self-Trend Medran Short Term Long Term Deskr o improv.a worse sener OPERATIONS F
Automatic Scrams While Critical -
o
.-0.18 Ia Safety System Actuations -
0 o
Significant Events -
0 o
Safety System Failurus -
-0.24 1 I
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[
I Cause Codes (All LERs)
M 4.68 O
a.^--
_ Canow Pioneens -
- s. Laeenese osereur arrere ~
1.05 0.10 I I
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severe -
i 0.90 0.16 l
0.30 e.t'aemeneseserseaeme -
_ 0.26
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0,90 1.24 l
Significant Events -
o o
Safety System Failures -
o l
l0,32 Cause Codes (All LERs) e.
_. cenew pressens -
0 0.05 y
- n. * - opweier errore -
0 O
- s. oour oweenase Ervers -
0 0.09 ~.
- m. steenenence preessee -
0
] 0.02
- e. n 1-eressene -
0 E 0.17 0
0 r-FORCED OUTAGES i
Forced Outage Rate * -
1.43
-0.27 l
Equipment Forced Outages /
- I efswas 3.05 1.f iff[fj -0.80 1000 Commercial Critical Hours
+1.0
-05 0.0 0.5 1.0 1.0
-05 0.0 0.5 1.0 performance snoex Performance incex
.,ses c--- ear coeremonal Cyese l
PREDECIDICMEL i
ST. LUCIE.1 j
1 PI EVENTS FOR 95-3 4
SCSJnN 07/08/95 Leks 33595003 50.728: 29039 PWR HIST: POWER OPERATIONS AT 1001 DESC THE REACTOR TRIPPED ON NIGN PRESSURIZER PRESSURE WNEN THE MAIN TURBINE GOVERNOR Am INTERCEPT VALVES WENT CLOS 2 DURING TESTING. THIS EVENT WAS CAUSED BY AN OPERATOR OMITTING A TEST PROCEDURE STEP.
SSF Os/09/95 LERs 33595005 50.72s: 2917s PWR HIST: COWIT!cu EXISTD IN ALL MODES UP TO 1005 POWER SINE 1994 GROUP SAFETY AND RELIEF VALVES GROUP SYSTEM : REACTM rrn mi SYSTEM DESC
,a TIE POWR OPERATED RELIEF VALVES WERE FOUND INOPERABLE DURING TESTING. THE MAIN DISC GUIDES WERE l
INSTALLED INCORRECTLY DURING THE 1994 REFUELING QUTAGE.
SSF 08/10/95 LERs 33595006 50.728:
PWR NIST: EVENT OCCURRED IN COLD SNUTDOWN GROUP : RESIDUAL NEAT REMOVAL SYSTEMS GROUP I
SYSTEM : RESIDUAL MEAT REMOVAL SYSTEM DESC
- BOTN TRAINS OF RESIDUAL NEAT REMOVAL WERE RENDERED INOPERABLE AS A RESULT OF A FAILED OPEN SUCTION RELIEF VALVE. THE ROOT CAUSE WAS INADEQUATE DESIGN MARGlk BETWEEN THE RELIEF AND BLo@0WN SETPOINTS Am NORMAL SYSTEM OPERATING PRES $URE.
PI EVENTS FOR 95-4 NONE i
i PI EVENTS FOR 95-1 i
SSF 02/19/96 LERs 33596001 50.72s: 29994 PWR HIST: EVENT OCCURR E DURING OPERATION AT 1001 POWER GROUP : CONTROL ROOM EMERGENCY VENTILATION SYSTEM GROUP SYSTEM : GONTROL BUILDING / CONTROL CtmPLEX ENv!RONMENTAL CONTROL SYSTEM DESC
- THE CONTROL ROOM VENTILATION SYSTEM WAS RENDERED INCAPABLE OF PERFORMING ITS DESIGN FUNCTION WNEN j
TWO CONTROL ROOM ACUSS NATCHES WERE LEFT OPEN FOLLOWING MAINTENANCE. THE CAUSE WAS INADEQUATE d
GUIDANCE AND WORK CONTROLS FOR MAINTAINING THE BOUNDARY.
I PI EVENTS FOR 95-2 I
SSA 06/07/96 lea # 33596007 50.728: 30603 PWR HIST: ;;EFUELING 4
DESC
- AN DG STARTD AND LOADED WNEN A BUS LOAD SNED OCCURRED DURING A CONTAINMENT ISOLAfl0N ACTUATION SIGNAL TEST. AN INADEcuATE PROCEDURE CONTAINED NO INSTRUCTIONS 70 REINSTALL FUSES WNICH WERE i
REMOVED AS PART OF A PREV!OUS TEST.
4 i
SSA 06/0s/96 Leks 3359600s 50.72s 30604 PWR HIST: REFUELING j
DESC
- A 4.16KV ELECTRICAL SUS LOST POWER DURING MAINTENANCE ON TME ESF SYSTEM POWER SUPPLIES. THE DG DID NOT START BECAUSE IT WAS OUT OF SERVICE. THE POWElt SUPPLY FAILED DURING INSTALLATION OF A CIRCUIT l
CARD.
j SSA 06/08/96 Leks 33596008 50.728: 30604 PWR HIST: REFUELING DESC
- A SAFETY INJECTION ACTUATION $!GNAL WAS GENERATED DURING MAINTENANCE ON THE ESF SYSTEM POWER 4
$UPPLIES. THE POWER SUPPLY FAILED DURING INSTALLATION OF A CIRCUIT CARD.
1 i
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!6-j PREDECWONAL w
ST. LUCIE 2
'""*"'""""7'""',
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ST. LUCIE 2
- 3 *"=' 5 *"""
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e -
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1A 03 0.0 03 1.0 1.0 03 0.0 03 1.0 Performance incex Pefformance Index
- seat Cesamme ser oseromanes cyane
PREDECISICIDLL ST. LUCIE 2 PI EVENTS FOR 95-3 NONE PI EVENTS FOR 95-4 SSF 11/20/95 LER# 38995005 50.72#: 29626 PWR HIST: ComITION EXISTED FOR AN INETERMINATE PER!ao QF TIME i
GROUP : EfERGENCY AC/DC POWER SYSTEMS group SYSTEM EfERGENCY ON51TE POWER SUPPLY SYETEM DESC DEGRADED RELAY SOCET CONNECTIONS CAUSED THE FAILURE OF ONE EDG, AND THE POTENTIAL FAILURE OF THE OTNER. V!BRATION IWUCED FATIGUE CAUSED THE SOCKET CONNECTION DEGRADATION.
j PI EVENTS FOR 96-1 l
NOn PI EVENTS FOR 96-2 i
SEF 06/25/96 LER#
50.72#: 30676 PWR HIST: CONDIT!DN EX!sTED FOR AN INDETERMINATE PER!co 0F TIME 1
GROUP : EMERGENCY CORE COOLING SYSTEMS GROUP SYSTEM : LOW PRESSURE SAFETY INJECTION SYSTEM DESC
- THE PLANT PRACTICE OF DEENERG! ZING THE SAFETY INJECT!DN TANK !$0LATION VALVES AFTER CLOSURE IN MODE FOUR DEFEATS THE AUTOMATIC OPEN FEATut! AT 515 PSIA AND ON A S!AS. THIS CONDIT!DN WAS CAUSED BY INADEQUATE PLANT PROCEDURES.
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ST. LUCIE 2 PREDEQSINL.
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i PLANT IPE CORE DAMAGE FREQUENCY INFORMATION
.)
t Ino.coe co.e on ge -
,e, age ci.co
,s.ee. e. es.e on go noo.s e,
, asei.e. =
i Plant IPE a7ws l 1 -
toca l som l moca l== n-.
90 ams l1.-*
l toca l== lmoca l== n-_._
j
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General Electric BWR 1 i
5.4E-05l 5.10E-07 1.10E-Opl 1%
7%l Og Rock Pomt 3.00E-06 S.50E 6 4.32E 05 noghgesta 12%
RI%
0%
0%
General Electric BWRs 2 and 3 (Isolation Condensers)
Pene Mdo Poet t 5 SE46 3.50E 06 5.40E-07 7.90E-07 7.00E-07 2.00E-00 noghgesse 84 %
10%
14 %
13%
0%
0%
Oyster Creek tsee Note till 3.9E 06 2.30E 06 2.40E-07 0.20E-07 2.50E-07 1.03E-07 2.10E-07 59%
8%
21 %
5%
3%
5%
Oresden 2/319wR 31 1.9E-05 9 30E 07 5.30E-07 1.40E45 1.00E-06 4.34E-10 neghetto 5%
3%
83%
9%
0%
0%
f l
umstone t town si s.iE 05 7.00E Os s 00E-07 i.s0E46 s s4E-07 i.30E-07 2.50E-07 e5%
7%
te%
a%
i%
2%
j regn= i town 3:
5.sE 05 noe,we 4.iOE46 5.OsE45 3.20E46 i.00E 07 7.s7E 07 0%
7%
se%
e%
0%
1%
n General Electric BWRs 3 and 4 l
f Monteoso IBwn 31 2.0E 05 1.20E-05 2.50E-06 3.47E-06 " L20E-06 3.20E-10 0.50E-Oe 46 %
10%
13%
5%
0%
20 %
r f
Oued C*es 1/2 tewn 31 1.2E 06 5.72E-07 7.8tf 08 2.95E-07 2.00E-07 neghgese neghgible 50%
7%
29 %
15%
0%
0%
Browns Ferry 2 4.OE-05 1.30E-05 1.30E-06 2.79E-05 4.00E-07 4.00E-00 4.70E OS 27%
3%
58 %
1%
0%
10%
Grunswick 112 2.7E-05 1.90E-05 7.00E-07 8.72E-06 1.00E-07 5.10E-OO 1.90E-06 67%
3%
25 %
1%
0%
7%
j Cooper 0.0E-05 2.50E-05 3.90E-06 3.97E-05 8.33E46 neghette neghgible 35 %
5%
50%
10 %
0%
0%
[
Ovene Arnold 7.OE-06 f.90E-08 1.90E-06 3.90E-08 1.00E 07 neghette neghgede 24 %
24 %
50 %
2%
0%
0%
j b
Fereni 2 5.7E-06 1.30E-07 1.90E-06 3.50E-00 nocheads 2.00E-07 9.77E-00 2%
32 %
6'1 %
0%
4%
2%
Fitapetrich 1.9E 06 t.75E-06 1.20E-00 1.5 tE-07 7.40E-09 noghgibes negugede St%
1%
OT 0%
0%
0%
I l
Hetch 1 2.2E-05 3.30E-06 5.10E-07 2.07E45 2.22E-07 1.7tE-07 1.20E-07 15%
2%
30%
1%
1%
1%
Hetch 2 2.4E 05 3 23E-06 6.37E-07 1.90E-05 2.22E-07 1.77E-07 1.00E-07 14%
3%
80 %
1%
1%
1%
Hope Creek 4.0E 05 3.39E-05 7.45E-07 8.42E-06 3.03E-OS neghgilde 5.50E-07 78 %
1%
14 %
7%
0%
1%
{
Lienerick 1/2 4.3E-00 1.00E-07 9.30E-07 2.93E-Os 1.20E47 neghande 1.90E-07 2%
22 %
88%
, 3%
0%
4%
i Pooch Bottom 2/3 5.9E-08 4 31E47 1.44E46 2.87E-Os 5.92E-07 noghgeste 1.47E-07 9%
25 %
52%
11%
0%
3%
[
I veevnont ventee 4.4E-Os 8.24E-07 7.99E-07 2.70E-08 8.42E-08 2.33E-OO noghgitile 14 %
IS%
$2%
1%
1%
gg l
I f
FILE:IPE CDF.T9L l
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PLANT IPE CORE DAMAGE FREQUENCY INFORMATION cor. os o.o e e e, ciese e.es= ee es ees.o.o r.o sos a.e== chose Plant IPE 1 =ca l = = = l a= l 7-l taa I== lmoca l = =
l l a= l 7-ltoca rism c0r
0 90
General Electric BWR S l
I~eSese 112 4.7E 05 3.9N-05 1.07E-07 7.30E45 2.83E-OS noghette 3.39E48 81 %
0%
10%
0%
7%
i emne We Pome 2 3.1E 05 5.50E OS 1.10E 06 2.31E-05 7.40E-07 2.50E M 1.50E-05 10%
4%
75 %
2%
0%
5%
t I
wwP 2 1.eE45 1.10E 05 s.25E 07 2.83E46 5.10E-07 noghgese 2.5N48 63%
4%
15%
3%
0%
14 %
General Electric BWR 6 Canton 2.7E M 1.00E M 1.40E-07 1.40E-05 1.10E-00 negughes 1.00E-06 30 %
1%
53%
4%
0%
8%
Grand Gulf 1 1.7E 05 7.49E-08 5.5eE.00 9.35E-OS 5.10E-07 nogagels 1.90E-07
'43%
0%
54 %
3%
0%
1%
{
Perry 1 1.3E-05 2.25E OS 4.70E 06 4.30E-OS 4.50E-07 negaghte 1.50E-06 17%
30 %
33%
3%
0%
12%
\\
ftwe Send n SE-05 1.35E 05 negegelo 2.05E.08 noghette noghgele 1.90E-00 87%
0%
13%
0%
0%
0%
1 t
Babcock and WHcox PWR 2-loop l
aNo 1 4.7E 45 i.5eE45 9.93E47 i.4eE45 1.57E45 9.20E4e e 90E Os 9 34E 47 34 %
2%
32%
34 %
0%
0%
2%
Crystal M6ver 3 1.5E-05 3.28E-06 negsgete 9.45E47 9.00E-08 6.70E-07 negughte 1.25E-08 21 %
0%
0%
59%
4%
0%
0%
Oevio een.
s.oE45 3 54E 07 5.7tE45 5.24E Os 4.e0E.07 e e0E-07 2.00E4e 1%
se%
e%
i%
i%
3%
Oconee 1.2.3 2.3E-05 2.57E-00 100E-07 5.33E-06 9.70E45 2.10E-07 4.50E-10 5.50E48 11%
0%
23%
42%
1%
0%
24 %
FMI 1 4.5E-05 1.57E-06 negsgets 2.30E-05 1.57E-05 S.94E-07 1.00E47 3.00E-OS 3%
0%
52%
35 %
2%
0%
7%
Combustion Engineermy PWR 2-loop t
ANO 2 3.4E-05 1.23E-08 1.ON-Os 2.87E-05 4.00E-00 9.53E-08 3.30E-07 nogmente 4%
3%
79 %
14 %
0%
t%
0%
j i
Calvert Chffs 1/2 2.4E 04 2.40E-05 1.30E-04 S.SSE-05 4.49E '08 1.90E48 1.55E-05 10%
54 %
28%
2%
1%
0%
I I
Fort Colhoun 1 1.4E-05 2.89E47 8.93E48 1.07E 06 7.97E-07 5.74E-07 1.87E-00 2%
88 %
8%
0%
5%
14 %
l i
St Lucie 1 2.3E-05 2.85E-OS 4.13E47 5.30E-OS 1.2N45 S.15E-07 f.74E48 5.00E-07 12%
2%
23%
53%
4%
0%
2%
St Lucio 2 2.0E-05 2.84E-08 1.7EE45 5.31E-08 1.29E-05 8.99E47 2.72E40 5.00E-07 10%
7%
20%
49%
3%
10%
2%
i Mulatene 2 3.4E-05 4.3E-07 1.9E48 2.OE-OS 9.01E-05 5.22E47 S.90E-00 2.00E47 15 4%
74 %
18%
2%
0%
1%
Pense 4es 5.1E-06 9.ON40 4.00E48 2.00E-05 157E-05 2.54E-OS 3E47 3E47 10%
8%
39 %
31 %
5%
0%
0%
i I
FILE: 1PE-COF.TOL Man Seri 30.199613 2temi F
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PLANT IPE CORE DAMAGE FREQUENCY INFORMATION IPieniCDr Core Demage Feespooney Per accident Onee Percent et Core Desunge Feegsency Per Accident Ones Plant IPE soo ar*s irone toCa sein moCa w ased soo arws rear, sis te toCa v.
moCa
= nood fessee en CDF entwee;
- For Davis Besse. Calvert Celts. & Fort Calhoun. seperate S90 CDF was uneveilable, so Tronsiw
'For Turkey Point. the CDF Ested in the snee surnmery of the outmattet, which CDF ond % CDF includes S90 contribution corresponds to *e8 levees of recovery." was used The detsbase values for Oyster Creek do not oppear to include the CDF for intemel floods; the For Solem I & 2. the revised flood and plent CDFs lated in the submittelletter for the IPi velues hsted here include the CDF for intemet flood were used
'IThe Surry intemel flood CDF is from page 9 of 4/21f92 NMR letter which hsts a revised value from 11128/91 Surry reenelysis subtrettet For Wotts Bar, the CDFs from the sevised submittel were used Deferred means that hcensee included Intemet flood enelysis in their IPEEE Fit.E: IPE-CDF.T BL Hm % in tnom (191ame
PL ANT IPE C000f AINMENT FAILURE FREQUENCY INFORMATION Core Damage Frequency.y Containment Femure stede Percent of Core Damage Feogeeney Por FeAureInsee Pien, ire CO, e
l w
u NC, e
l l
l u
C, General Electric - Eerge Dry l
7.56E-07l 2.32E-06l neghgWel 5.09E-05l 1%l 4%l, 0%l 81G ROCK POtNT 5 4E-05 94 %
General Electric - Mort t OROWNS FERRY 2 4.8E-05 4.46E-07 2.18E-05 1.25E-05 1.33E-05 1%
45 %
26 %
29 %
ORUNSWICK 162 2.7E-05 6.2 t E-06 2.38E-06 f.83E-05 8.33E-06 1%
9%
90 %
31 %
COOPER 8 0E-05 neghg&e, 1.29E 05 5.77E-05 9.13E 06 0%
16 %
72%
11%
DftESDEN 2&3 1.9E-05 poghgeo 5 55E-07 1.59E 05 2.04E-06 0%
3%
86 %
11 %
00ANE ARNOLD 7.8E-06 neghgme 3.67E-06 2.49E-06 1.88E-06 0%
47%
32%
21 %
FERMI 2
- 5. 7E -06 2.00E 07 1.71E-06 2.22E-06 1.57E-06 4%
30 %
39 %
28 %
FliZPATRICK 1.9E 06 neghgMe 1.20E-06 4.18E-07 3.03E-07 0%
63%
22%
16%
HATCHI 2.2E -05 1.85E-07 5.47E-06 5.70E 08 1.10E-05 1%
25 %
26 %
49%
HATCH 2 2.4E-05 1.94E-07 5.00E 06 5.91E-06 1.25E-05 1%
2t%
25 %
53%
HOPE CREEK 4.8E-05 noghg&s 2.87E-05 1.20E-05 5.56E-06 0%
62%
26 %
12%
MILLSTONE I 1.1E-05 1.25E-07 3.74E-06 3.27E 06 3.07E-06 1%
34 %
30 %
35 %
MONTICELLO 2.6E-05 5 20E-09 4.15E-08 6.24E-06 1.56E-05 1%
18 %
24 %
90%
NINE MILE POINT 1 5.5E-06 7.48E-08 1.31E-06 3.40E 06 7.12E-07 1%
24 %
82%
13%
OYSTER CREEK 3.7E 06 2.70E-07 5.87E47 9.69E-07 1.86E-06 7%
16 %
26 %
51 %
PEACH OOTTOM 2&3 5.5E-06 6 84E-09 1.55E-08 f.40E-06 2.57E-06 1%
28 %
25 %
46%
PtLGRfM 1 5OE05 2.32E-07 1.25E-05 3.54E-05 9.86E-06 1%
22 %
61%
17%
QUAD CITIES 1&2 1.2E-06 6.00E-10 2 84E-07 6.62E-07 2.53E-07 1%
24 %
55%
23%
VERMONT YANetEE 4.3E 06 4.30E-08 2.11E-06 9.89E-07 1.16E 06 1%
49%
23%
27%
IPE-CFF.T8L September 30.1996 P+ae 1 af 7
~
Pt ANT IPE CONTAINMENT FAILURE FREOUENCY INFORMATION Care Damage Frealmancy By Concebement FeSere Imede Percent of Core Damage FengesFey Per - Famore mode l
leCF NCF Dypees EF LF EF LE General Electric - dNorb #
LA SALLE 162-5305 4.7E-05 noghgee 1.86E-05 2.42E-05 6.64E-06 0%
'35%
51 %
14%
LIMERICK 1&2 4.3E 06 noghg ee 3.96E 07 1.16E-06 2.75E-06 0%
9%
27%
64 %
8RNE MtLE FOINT 2 3.1 E-05 2.79E-08 2.32E 06 2.04E 05 8.30E-06 1%
7%
66 %
27%
WNP 2
- 1. 8E -05 2.98E-08 5.34E 06 5.30E 06 6 83E 06 1%
31%
30 %
39 %
General Electric - Mech m CLINTON 2.6E-05 neghges 3.27E-07 4.84E47 2.4 7E-05 0%
3%
2%
95 %
GRAND GULF l 1.7E 05 neghgee 8 05E-06 5.66E-06 3.51E-06 0%
47%
33%
20 %
PERRY I t.3E 05 noghgee 3.14E-06 4.76E-06 5.30E-06 0%
24%
36 %
40 %
RIVER SEND I 6E-05 neghgee 4.38E-06 2.14E-06 8 98E-06 0%
28 %
14 %
58%
PWR - Ice Condenser CAT AW8A 1&2 4.3E-05 7.71E-08 2.31E-07 2.02E-05 2.27E-05 1%
1%
47%
53%
D.C. COOK l&2 6.3E-05 7.11E-06 9.26E-07 1.53E 06 5.40E-05 11%
.1%
2%
86 %
MCGUME 1&2 4.0E-05 9.60E-07 9.50E-07 1.64E-05 2.20E-05 2%
2%
40%
54 %
SE000VAH t&2 1.7E-04 7.99E-06 2 81E-06 8.32E-05 7.80E-05 5%
2%
49%
45%
WA175 BAR 1&2 8 OE-05 5 95E-06 4.03E-06 1.72E-05 5.27E 05 7%
5%
22%
86%
PWR - Subetmospheric SEAVER VALLEY 1 2.1 E-04 1.02E-05 4.73E-05 9.15E-05 6.17E-05 5%
23%
44 %
29%
SEAVER VALLEY 2 1.9E-04 9 94E 06 4.74E-05 8.54E 05 4.69E-05 5%
25%
45%
25%
NOR1H ANNA 162 6 SE 05 8 98E-06 1.05E-06 7.68E-06 5.03E-05 13%
2%
11 %
74 %
SURRY 1&2 MILLSTONE 3 5.8E 05 3.98E-07 2.24E-08 1.10E-05 4.4 7E-05 1%
1%
20 %
80 %
IPE-CFF.18L September 30,1996 m
~
t Pt ANT IPE CONTAINMENT FAS URE FRE00ENCY INFORMATION f
pg,,,
Cees Dernese Fregeeney Dy Casseshonent FeSere Mode Percent of Core Desumes Feegonney Per h Femuse h Plent IPE COF Oyreos l
EF LF NCF Syymes EF LF IOCF r
PWR - Lor 8e Dry
+
ARKANSAS NUCLEAR ONE 1 4.9E-05 2.00E-07 3.03E-08 5.95E-08 3 98EM 1%
8%
12%
81 %
i ARKANSAS NUCLEAR ONE 2
- 3. 7E-05 4.07E-07 4.51EM 5.14E-08 2.89E-05 1%
12%
14 %
73%
ORAIDWOOO 1&2 2.7E-05 1.10E M 5.48E-00 2.54E-06 2.40E-05 1%
1%
9%
90%
r 8YRON 152 3.1E-05 1.24E-00 2.13E-07 2.50E-08 2.82E M 1%
1%
0%
91 %
I i
CALLAWAY 5.8E-05 1.17E-08 1.17E-07 3.09EM 2.83EM 2%
1%
53%
45%
CALVERT CLIFFS 162 2.4E-04 7.44E 08 2.11E-05 9.53E-05 1.18E-04 3%
9%
40%
48%
COMANCHE PEAK 182 5.7E-05 4.87E M 8.75E 07 2.93E-06 2.28EM 8%
1%
51 %
39 %
CRYSTAL RfVER 3 1.5E M 7.39E-07 5 53E-07 9.58E-08 4.42E 08 5%
4%
83%
29%
I OAVIS 8 ESSE 8.8E-05
.1.72E-08 4.18E-08 4 95E-08 5.52E 05 3%
0%
H....
b 84 %
i OIA8tO CANYON 1&2 8.8E 05 1.83E-08 1.01E-05 3.98E-05 3 85EM 2%
11 %
41%
L r
FARLEY 1&2 1.2E-04 4 47E-07 7.19Em 3.90E M 1.20E-04 1%
1%
3%
98 %
FORT CALHOUN 1 1.4E-05 1.44E-00 2.23E-07 3.80E-08 8.13E-08 11%
2%
28 %
80 %
}
GINNA 8.7E M 3.71E-05 2.87E-08 1.27E-05 3.50EM 42%
3%
15%
40 %
H.8. RO8tN3ON 2 3.2E 04 8.37EM 4.19EM 3.20E-05 2.40E-04 2%
13%
13%
75 %
HA00AM NECE 1.8E-04 1.18EM 1.21E M 9.70E M 7.01EM 8%
1%
54%
39 %
INotAN POINT 2 3.1E-05 1.94E-08 5.81E m 2.82E M 2.85E M 8%
1%
9%
85 %
{
INDIAN POINT 3 4.4E M 2.44E-08 3.12E-07 1.07EM 3.0$E-05 8%
1%
24 %
89%
KEWAUNEE 8.8E-05 5.28EM 1.48E M 3.22EM 2.88E-05
<1%
1%
49%
43%
L MANE YANKEE 7.4E-05 1.21E-08 5.79E-08 3.54E-05 3.18E-05 2%
8%
48%
42%
I MILLSTONE 2 3.4E-05 7.88E-07 3.22E.A 1.11EM 1.91E-05 2%
9%
32%
58 %
L OCONEE 1.2.&3 2.3E-05 4.80E-10 2.81E-07 1.71E M 5.81E M 0%
1%
74 %
24%
[
PAllSADES 5.1E-05 2.89E-08 1.87E-05 7.88E-00 2.35E-05 8%
33%
15 %
48 %
l I
PALO VEROE 1,2,63 9.0E-05 3.28E-08 9.41E 08 1.21E M 8.53E-05 4%
10%
13%
73%
f k
POINT SEACH 142 1.0E-04 8.32E-08 3.24E-08 1.81E-08 7.97E-05 8%
1%
17%
77%
PRAIRIE RSLAN0162 4.9E-05 2.19E-05 4.15E-07 1.11E-05 1.58EM 44%
1%
22%
3gg
[
[
[
IPE-CFF.TOL I
September 30.1996 h
I m
f
-.m
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m
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_mm..
m.,__m_
a PL ANT IPE CONTAINMENT FAltuflE FRE00ENCY NfFORMAfl0N i
pg,,,
Core Demote Feequency Dr Contoimeent FeBure Mode Percent of Care Demo 8e Fregonney Per Centehunent FeAure Mode Plant IPE CDF
. Sypoes EF LF NCF Sypees EF LF BICF SALEM 1 5.9E 05 9.39E-07 3 48E-06 2.101-05 3.29E-05 2%
8%
37%
56 %
SALEM 2 6 3E 05 8 08E-07 4.89E-06 2.76E 05 2.94E-05 1%
8%
44 %
47%
SAN ONOFRE 2&3 3.OE 05 2.02E 06 2.00E-08 2 84E-06 2.52E-05 7%
1%
9%
84 %
SEA 8 ROOK 6.7E 05 1.54E-07 9.52E-Os 4.38E-05 1.35E45 1%
14 %
65%
20 %
SHEARON HARRfS 1 7.0E-05 7.18E-06 4.38E-07 3.15E-06 5.9?E-05 10 %
t%
5%
85 %
SOUTH TEMAS PROJECT 1&2 4.3E 05 1.66E-06 5.88E-06 1.08E-05 2.44E-05 4%
14 %
25%
57%
ST. LUCsE 1 2.3E-05 2.76E-06 2.30E-07 3.45E-06 1.66E-05 12%
1%
15%
72 %
St. LUCIE 2 2.6E-05 3.90E-06 2.60E-07 3.30E-06 1.85E-05 15 %
1%
13%
71 %
SUMMER 2.0E -04 8.40E-07 5.80E 07 4.10E-05 1.53E 04 1%
1%
21%
77%
TML 1 4.5E-05 1.57E-06 1.40E-06 2.83E-05 1.36E-05 4%
3%
63%
30 %
TURKEY POINT 364 4.6E-C4 1.30E-05 6.10E 06 2.99E-04 1.44E -04 3%
1%
65 %
31 %
VOGILE 152 4.7E 05 t.61E 06 1.68E-07 neglgtdo 4.50E-05 3%
1%
0%
96 %
WATERFORO 3 1.7E-05 1.36E-06 4.42E 06 3.40E-06 7.82E-06 8%
26 %
20 %
46%
WOLF CREEK 3 6E-05 8.51E 08 4.95E 08 1.41E-06 3.40E-05 1%
1%
4%
94 %
ZlON 1&2 4.0E-06 1.15E-06 8.24E-08 2.13E-07 2.55E-06 29%
2%
5%
64 %
NOTESe:
Dypese - Centeenment bypees EF - Eedy feeure. Including teoletion femure LF - Late feaure 90CF No containment failure
'Dete for Surry are not entered uroMng for updated resulte IPE-CFF.TOL Septerr+er30,1996 Psee 4 of P i
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1.
e ENFORCEMENT HISTORY EA 95-026 - Weaknesses in the control of maintenance and testing that resulted in inoperability of both of the U1 PORVs during periods that the PORVs were relied u on to provide low temperature overpressure protection (CP' issued on i
11/13/95 SL III: $50,000)
I EA 96-003 - Overdilution event occurred when. a licensed operator left the controls without informing his relief that a dilution was in progress (CP issued e
on 3/18/96: SL III: $50,000)
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ST LUCIE MAJOR ASSESSMENTS DATE' TYPE OF ASSESSENT JULY.1995 INPO ASSESSENT - CATEGORY 1 AUGUST 1995 DR. CHOU ANALYSIS BY REGION II TO IDENTIFY ROOT CAUSES OF TE RECENT DECLINE IN PERFORMANCE AND MULTIPLE EVENTS The team concluded that the predominant root cause for the events observed at St Lucie l
was insufficient detail and scope in site oroaraus and procedures. This causal factor was found to result in recent events which demonstrated deficiencies in the following areas:
e job skills, work practices, and decision making:
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interface among organizations as evidenced by a lack of interface formality; e
e organizational authority for program implementation as evidenced by instances of unclear responsibility and accountability.
AUGUST 1995 LICENSEE SELF-ASSESSENT: A SPECIAL TEAM PERFORMED AN ASSESSENT OF OPERATIONAL PROBLEMS AND IDENTIFIED ROOT CAUSES: MANAGEENT AND STAFF COMPLACENCY - POOR PERFORMANCE.
ACCEPTING LONGSTANDING EQUIPENT PROBLEMS. AND NOT KEEPING UP WITH INDUSTRY IMPROVEENTS.
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GENERIC ISSUES ST. LUCIE ISSUE STATUS NRC Bulletin 92 Failure of Thermo-Lag 330 The licensee has identified those areas with installed thermo-lag and implemented compensatory measures IAM NRC Bulletin 92-01 and Supplement 1.
Compensatory measures will remain in effect until an acceptable solution is implemented.
NRCB 92-01, response dated July 27, 1992 e
NRCB 92-01 Supp 1, response dated September 29, 1992 GL 92 Thermo-Lag 330-1 The licensee has outstanding cosmiitments to Gk,92-08 in the following areas:
o Update response on status of ampacity, exemptions and schedule for modifications (8/30/96)
Unit 1 e
Evaluate Thermo-Lag barriers to NEI App. guide or select alternate option (due 1/30/97)
Determine acceptability of Thermo-Lag wall configurations and radiant heat shields combustibility issues'(due 1/31/97) e Complete evaluations and submit Thermo-Lag exemptions (due 4/30/97) e Complete design changes to support implementation of modification during spring 1998 outage (Spring 1998) e Submit summary report to NRC within 1C0 days of end of Spring 1998 outage (due 180 days after breaker closed Spring 1998)
Unit 2 e
Evaluate Thorno-Lag barriers to NEI App. guide or select alternate option (due 5/31/96)
Submit Thermo-Lag exemptions (due 9/30/96) e Complete design changes to support implementation of modification during spring 1997 outage (Spring 1997)
Unit 2 - Submit sumatory report to NRC within 180 days of end of Spring 1997 outage (due 180 days after breaker closed Spring 1997)
NRC Bulletin 96 Control Rod Insertion N/A Action requested frem Westinghouse-designed plants only.
Problems GL 89-10 Safety Related MOVs Testing &
The licensee has completed the design bases verification of safety-related motor operated Surveillance valves (Move) and is available to meet with the FRC to discuss alternatives for closing the NRC GL 89-10 program.
GL response,-dated February 2, 1994 (Unit 1) e GL response, dated March 14, 1996 (Unit 2)
Unit 1 Completed during the Fall 1994 refueling outage (SL1-13)
Unit 2 Completed during the Fall 1995 refueling outage (SL2-9) generic.iss pwn
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ST. LUCIE ISSUE STATUS GL 95 Pressure Locking and Thermal The licensee has completed the assessment and evaluation of both Unit 1 and tFnit 2 power Binding 8** *** - f SR Power Operated Gate operated valves (POVs) susceptible to PL/TB.
Valves e
GL response, dated February 13, 1996 The licensee has outstanding cossaitments to GL 92-07 in the following areas:
1Rait 2 e
Schedule submitted including justification for modification to shutdown cooling valves V-3480, V-3552 and V-3551 during spring 1997 refueling outage (SL2-10)
Boraflex Boraflex installed on Unit 1 in 1988. Two successful blackness testing campaigns completed (5 year surveillance). Upper 15 inches of one panel discovered missing. Engineering Evaluation (JPN-PSL-SEFJ-55-023, Rev. 3) completed March 5, 1996. Licensee reviewed manufacturer's fabrication records and concluded that the missing boraflex in PSL1 spent fuel pool was an isolated incident and did not affect SPF criticality.
Boraflex not installed on Unit 2.
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ST. LUCIE ISSUE STATUS i
spent Fuel Full Offload Permitted From the UFSARs I
Wait 1 Two thermal analyses were performeds the Normal Batch Discharge and the Full Core Discharge.
In the case of the Normal 9atch Discharge, the analysis assumes 80 assemblies each have been discharged from the core in 18 month intervals. A refueling batch of 80 assemblies i
is added 150 hours0.00174 days <br />0.0417 hours <br />2.480159e-4 weeks <br />5.7075e-5 months <br /> after reactor shutdown. This analysis shows a maximum pool bulk temperature of 133.3 degrees F with the fuel pool cooling system in service.
For the Full Core Stocharge, assuming that 73 of the assemblies have 90 days of irradiation. 72 hsoe 21 months of irradiation and the remaining 72 assemblies have 39 months of irradiation (217 assemblies total), the analysis shows a maximum pool bulk temperature of 150.8 degrees F with the fuel pool cooling system in service.
Mt2 Two thermal enslyses have been performeds the Normal and the Accident Case Assumptions.
The Normal Case assumess a.
11 batches teach 1/3 core) discharged b.
Most recent batch cooling for five days after shutdown c.
Adiabatic heat up of the pool The analysis shows a maximum pool bulk temperature of 131 degrees F with the fuel pool cooling system in service.
The Accident Case assumess a.
11 batches plus one full core discharged b.
One (1) core cools for 7 days c.
Most recent 1/3 core batch cools for 90 days This analysis shows a maximum pool bulk temperature of 140 degrees F with the fuel pool cooling system in service.
The licensee has furnished a tabulated SFP Storage Data on both Units for PM on site inspection the week of Narch 25, 1996.
i Improved Standardized Technical Specifications No Licensee couaitment 3
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m-e ST. LUCIE ISSUE STATUS Steam Generator Issues WRC Bulletin 89 Westinghouse Alloy 600 The licensee has addressed the predicted service life of thermally Treated (TT) Alloy 600 Steam Generator Mechanical Tube Plugs Mechanical Tube Pluge identified by Westinghouse.
Unit 1 Tube plug repair plan formulated for April 1996 refueling outage. All plugs will be visually inspected and repaired or replaced, if leaking.
e Both SCs scheduled for replacement 1st quarter 1998.
Unit 2 No installed Westinghouse mechanical plugs.
e GL 95 Circumferential cracking of Steam The licensee has addressed the detection and sizing of circumferential indications to determine Generator Tubes applicability including the requested RAI dated September 26, 1995. No tube leaks have occurred on either unit due to circumferential cracks.
The licensee has outstanding commitments to GL 95-03 in the following areas:
Unit 1 100% tube inspection of all active tubes using both full length bobbin coil and e
conventional motorized rotating pancal e coil (MRPC) technique for selected bobbin indleations, i.e. 100% Not Leg and 3% Cold Leg, during Spring 1996 outage.
Maintenance Rule Program defined and implemented. Resident Inspectors confirmed. A Maintenance Rule Team inspection completed on 9/20/96. Although the licensee's maintenance rule implementation program found to be satisfactory three apparent violations were identified in the areas of program design 1 sues, system scoping issues, and procedure implementation.
IPERE Submitted PSL-IPREE Rev. O, submitted December 1994 which met the objectives of GL 88-20, Supplement 4.
The licensee has one outstanding commitment to GL 88-20 supplement 4, in response to RAI dated January 9, 1996.
e Action 1 The Engineering evaluation has been completed to allow use of the station blackout crosstle between the units to mitigate an IPEEE fire and plant operating procedure changes are scheduled to be completed by August 1996.
TOTAL ELECTRICAL COMPONENT FAILURES 1994-1995 Number of Failures
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12
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1994-1995 Number of Failures
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TOTAL COMPONENT PERSONNEL ERRORS - ELECTRICAL SYSTEMS 1994-1995 Number of Failures 8
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SIGNIFICANT CIRCUIT CARD FAILURES 4
1994-1995 4
i Number of Failures t
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CIRCUIT CARD FAILURE BY SYSTEM 1994-1995 Number of Failures 5
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SIGNIFICANT CONTROLLER FAILURES 1994-1995 Number of Failures 2.5
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b CONTROLLER FAILURES BY SYSTEM 1994-1995 4
Number of Failures l
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2 1.5
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SIGNIFICANT RELAY FAILURES i
1994-1995 Number of Failures i
5 1
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RELAY FAILURES BY SYSTEM
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1994-1995 Number of Failures
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4 3
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I-SIGNIFICANT POWER SUPPLY FAILURES 1994-1995 i
Number of Failures
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3 2.5
-7
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SIGNIFICANT SENSOR / LOOP / MODULE FAILURES 1994-1995 Number of Failures 2.5
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PC'WER SUPPLY FAILURES BY SYSTEM 1994-1995 Number of Failures l
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2 1.5
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SENSOR / LOOP / MODULE FAILURES BY SYSTEM 1994-1995 Number of Failures 3.5
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2 1.5
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SIGNIFICANT SETPOINT AND INSTRUMENT INACCURACIES 1994-1993 Number of Failures
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2.5 Y
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2 1.5
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1 0.5 7
0 FAR HAT OCO STL SEQ Site Based on Site issues Matrix /LERs
SETPOINT DRIFT / INSTRUMENT INACCURICES BY SYSTEM 1994-1995 Number of Failures
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SIGNIFICANT PERSONNEL ERRORS - INSTRUMENT CALIBRATION 1994 -1995 k
Number of Errors
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3.5 l
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3 2.5
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2 1.5
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Site Based on Site issues Matrix /LERs
SIGNIFICANT PERSONNEL ERRORS - INSTRUMENT CALIBRATION - BY SYSTEM 1994-1995 Nunkber of Errors
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System Based on Site issues Matrix /LERs
SIGNIFICANT PERSONNEL ERRORS - ELECTRICAL SYSTEMS CAUSING TRIPS /RUNBACKS 1994-1995 Number of Errors 3.5
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3 2.5 l
2 1.5 l
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1 0.5 O
P Site Based on Site issues Matrix /LERs
SIGNIFICANT PERSONNEL ERRORS - ELECTRICAL SYSTEMS CAUSING TRIPS /RUNBACKS - BY SYSTEM 1994-1995 Number of Errors 2.5
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2 1.5
/
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1 0.5
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Type of Error Based on Site issues Matrix /LERs
SIGNIFICANT ERRORS IN CONTROL OF SETPOINTS AND LIMITS 1994-1995 Number of Errors 3.5
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3 2.5
/
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2 1.5 7
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1 0.5 O #
Site Based on Site issues Matrix /LERs
v SIGNIFICANT ERRORS IN CONTROL OF SETPOINTS AND LIMITS l
1994-1995 1
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6 Number of Errors 3.5
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3 t
2.5
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2 1.5
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1 0.5
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Type of Error Based on Site issues Matrix /LERs t
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4 p October 19, 1995 ST LUCIE Site Integration Matrix Date -
Salp Ref.
Cause Identified Description FA 9/28/95 MS IR 95-18 Equipment Failure Self Identifying Leaking PZR SVs extended forced outage - problems with tailoipe alignment.
9/20/95 MS IR 95-18 Equipment Failure Self identifying Grounds in EDG 1 A/1B governor control wiring resulted in load oscillations.
9/15/95 OPS /
IR 95-18 Failure to Follow Self identifying Maint/ Ops did not provide clearance for work on MS Procedures condenser waterbox cover. Vacuum severed worker's finger.
9/14/95 PS 1R 95-18 Failure to Follow Ucensee Secunty failed to take correct compensatory action on Procedure computer failure.
9/10/95 OPS IR 9518 Failure to Use Self identifying SG blowdown sent to incorrect system on RAB roof.
Correct Procedure Operator used wrong procedure. When identified did j
not back out of procedure correctly.
l 9/9/95 MS IR 9515 Weakness in Work Self identifying Leak on SV 1201 flange extended outage, identified Screening and one month earher but not worked.
i Planning 7/95 OPS IR 95-15 Personnel Error /
Ucensee Unit 2 Main Generator overpressurized while filling inoperable with H2. Inattention by operators.
Equipment /OWA 9/2/95 OPS iR 95-15 Personnel Error NRC Weaknesses identified in logs relating to abnormal VIO 95-15 equipment conditions and out of service equipment not logged (multiple examples).
8/31/95 MS IR 95-15 Personnel Error Self identifying Damaged cylinder and head on 1B EDG due to loose lash adjustment.
8/30/95 PS IR 95-15 Management and NRC Containment closure walkdowns by management were OC weaknesses inadequate and depended heavily on OC involvement i
to identify deficiencies.
! 8/30/95 MS 1R 9515 Supervisory NRC Maintenance personnel not using procedures for work oversight and in progress.
worker attitude 8/29/95 OPS IR 95-15 Personnel Error Ucensee Started 1B LPSI pump with suction valve closed. (No VIO 95-15 damage to pump) i 8/29/95 MS IR 95-15 Procedure Use NRC Maintenance journeyman not signing off procedure j
steps as work completed (previously identified as a
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weakness in May 1995L l
1 8/23/95 MS, IR 95-15 Equipment Self identifying 2A HDP trip due to relay failure. Eight HDP trips in Failure /
past year. Engineering solution available but not Inadeouate impiemented.
Corrective Action 9r22/95 PS lR 95-15 Personnel Error NRC CA failed to occument a ceficiency on containment l
spray valve surveillance noentified in an aucit.
I ci19/95 OPS IR 9515 Operator Error /
Self identifying Ovedill of PWT. Soilleo approx.10K gallons on j
Operator ground inside RCA. Operator work around on level i
Workaround control system and inattention to filling process by i
l operator caused error.
8/18/95 MS IR 95-15 Procedural NRC Procedural weakrt:ss involving sup;rvisory oversight Weakness and joumeyman qualification.
j G/17/95 OPS LER U195-Procedural Self identifying Spraydown of Unit 1 containment. STAR process did 007 Inadequacy and not assign accountability for corrective action. Valve VIO 95-15 Weakness /
surveillance prelube not documented on STAR.
Operator Work-Around 8/9/95 MS LER U195 Maintenance /
Ucensee Inoperable Unit 1 PORVs due to maintenance 005 Testing errors error / testing inadequacy. (Valves assembled incorrectly) (Used acoustic data only) 8/6/95 ENG LER U195-Corrective Self identifying Ufting of Unit 1 SDC thermal relief due to procedural 006 Action / Procedural revision from previous corrective action. Inoperable VIO 95-15 Weakness equipment not logged.
8/2/95 OPS LER U195-Procedural Ucensee 1 A2 RCP seal failure due to " restaging" at high 004 Weakness / Failure temperature.
VIO 95-15 to Follow Procedures 8/2/95 OPS LER U195-04 Operator Error Self-identifying Operator failed to block MSIS actuation during cooldown.
VIO 95-15 7/29/95 MS IR 95-14 Prodcodural Self dentifying I&C personnel attempt to test a level switch circuit Weakness which could not actuate given system conditions.
7/29/95 OPS IR 95-14 Operator Self identifying Turbine / Reactor Trip due to test error.
Error / Procedural Weakness 7/29/95 MS IR 9414 Root Cause Self identifying Catastrophic failure of Unit 2 B train CEDM cooling Pending fan.
3/05 PS IR 9514 Security Self identifying Automobile passed through normally closed secunty Weakness gate to plant intake / discharge canals at beach.
Subsequent accident resulted in vehicle lodged in discharge canal piping.
7/1/95 OPS IR 95-12 Weak Log NRC Weaknesses identified in logs relating to battery Keeping jumper installation and out-of-service equipment.
7/1/95 MS IR 9512 Maintenance Self Identifying Corrosion in transformer fire protection deluge system results in multiple failures.
7/1/95 PS IR 9512 Personnel Error NRC Three pieces of SNM found improperly tagged.
NCV 95-12-02 7/1/95 PS IR 9512 Program NRC Fire Protection program weaknesses identified in f;te-Weaknesses fighting techniques and respirator qualification program.
7/1/95 MS IR 95-12 Personnel Error NRC M&TE found installed across battery cell without J/LL NCV 951241 authorization.
6/3/95 MS IR 95-10 Procedural NRC Several examples of weak adherance to procedures.
Adequacy /
including step signoffs and independent verification.
Adherance identified.
6/3/95 MS IR 9510 Poor Communica-Licensee Poor communication / lack of detailed instruction leads tion to improper 1B EDG governor installation.
6/3/95 MS IR 9510 Poor NRC HVAC systems for both un'ts poorly P
Maintenance / roc maintained / Operating procedures contained edures numerous deficiencies.
i 3/95 MS IR 95-10 Poor Surveillance Licensee Missed several surveil lances (7 day) on EDG.
NCV 95-10-01 Tracking System 4/29/95 MS IR 95-09 Personnel Error Licensee Failure to perform personnel air lock testing on time.
NCV 95-09-01
4/28/95 OPS IR 9545 Corrective Action NRC STAR /NCR program did not addrzss evrluiting ptst Program opersoility d
Weaknees
'28/95 MS IR9%5 Maintenance Error Licensee incore Instruments at ICI Flange 8 miswired. ICI output signals directed to wrong computer points.
4/28/95 OPS IR9%5 Weakness in NRC Weakness in addressing how mods would affect Temp Mod control room drawings.
Procedure 4/28/95 ENG IR 9545 Failure to NRC Failure to document nonconformance regarding ICI NCV 954544 implement flange 8 conditions.
Corrective Action Program 4/28/95 MS IR 9545 Design NRC Installation of wrong overload heater models in VIO 95-05-01 Implementation switchgear.
Discrepancy 4/1/95 OPS IR 9547 Apparent Licensee Unit 1 expenenced an approximate 14 minute loss of NCV 9%7-02 Personnel Error shutdown cooling while shifting from one shutdown cooling loop to the other. The root cause was the closing of the wrong SDC suction isolation valve (the valve for the operating, vice idle. pump) on the part of the operator.
4/1.'95 MS IR 9547 Poor Adherence to Licensee Jumper left installed in ECCS ventilation damper after NCV 9547 02 J/LL and work complete.
Maintenance Procedures 4/1/95 OPS IR 95-07 Weak Annunciator NRC Weak annunciator response by Ros contributed to
Response
loss of shutdown cooling event.
726/95 MS IR 94-09 Procedural NRC LPSI mechanical seal housing outer cap misinstalled.
Weakness 3/26/95 OFS IR 94-09 Operator NRC Operator failure to recognize out-of-sight high Error /Proced-ural indication on EDG cooling water tank. Failure of Weaknsss procedure to include instrwetions on draining tank.
3/04/95 ENG IR 95-04 Design Ucensee SDC suction relief valve lift due to water hammer.
3/04/95 OPS IR 9544 House.
NRC Loose plastic debris found in Unit 2 fuel pool area.
keeping 2/27/95 MS IR 95-04 Equipment Failure Self identifying Unit 1 was shut down for the replacement of 3 pressurizer code safety valves. The valves were leaking by the seat.
2/21/95 OPS IR 9504 Equipment Failure Sett identifying Unit 2 trip due to failure of a SGWL controllevel transmitter. Transmitter failed high, resulting in closure of the FRV and a subsequent trip on low SGWL (95-04) 2/20/95 OPS IR 95-04 Ecu:oment Self laentifying 29 LPSI pumo found air-cound during surveillance Anomaly testing. The licensee has theorized that the migration of air in the system resulted in the condition as a result of previous surveillance testing. The pumps are not self venting.
2/17/95 MS,
IR 9502 Physical Condition NRC Numerous areas of corrosion identified in Unit 1/2 CCW areas.
2/17/95 PS IR 95-03 Personnel Error NRC in two observed exercises. ECs failed to notify states
/ Training within 15 minutes.
Weakness 16/95 MS IR 95-04 Maintenance Solf Identifying Load snea of the 1 A31E 4160 bus due to inadvertent Error /
jumper contact wnile rectacing a degraded voltage Procedural relay.
Weakness
3/4/95 OPS IR 95-01 Operator Ucensee Failure to sample SIT within TS required time frame VIO 9%101 Error /Com-following volume addition. Second occurrence in 2 munications years.
4/95 OPS IR 9%1 Poor NRC Failure to identity and analyze Unit 1 hot leg flow Communications stratification 3/4/95 MS 1R 95-01 Personnel Error /
Self identifying inadequate independent verificat on resulted in CVCS VIO 95-0142 Program letdown control valve failing to respond due to Weakness reversed leads. Resulted in a cessation of letdown flow.
12/31/94 ENG IR 94-25 Engineering Self identifying Ir. adequate design control of NaOH cross connection NCV 94-2541 Design Error between ECCS trains.
12/3/94 PS IR 94-24 Procedure Review Ucensee Failure to perform TS-required periodic procedure i
NCV 94-24-01 Inadequacy reviews.
12/3/94 MS IR 94-24 Mainteriance NRC Inadequate process for changes to vendor technical
)
VIO 94-2442 Procedures manuals.
Inadequacy 11/25/94 MS IR 94-22 Program Ucensee The licensee's QA organization identified numerous weakness weaknesses in the implementation of the site's j
welding program. As a result, the Maintenance Manager placed a stop work order on welding j
activities. The stoppage lasted one week.
11/24/94 MS IR 94-24 Procedure Self-identifying Unit 1 B side SIAS actuation due to a bistable module weakness which had not been adequately withdrawn from the j
ESFAS cabinet during maintenance.
a 11/23/94 MS IR 94 24 Equipment Failure Self Identifying Unit 1 SIAS with unit in mode 5 due to common mode failure of Rosemount transmitters used for pressurizer pressure channels.
/5/94 OPS IR 94-22 Operations, Licensee Waste gas release on Sept. 10,1993, with NCV 94-2243 Maintenance meteorologicalinstruments out of service.
Errors 10/26/94 MS IR 94-22 Weather-Related/
Self Identifying Unit 1 automatically tripped due to arc-over from a LER Maintenance potential tran-former due to salt buildup on switchyard insulators.
0/30/94 OPS IR 94-20 inconsistent NRC Local valve position indicators not maintained MS Expectations accurate. Procedures / training provided to operators on venfying valve position found weak.
9/30/94 OPS IR 94 20 Operatons.
NRC Plant personnel not trained on IPE and not using it for Maintenance work planning and scheduling.
Deficiency 9/30/94 OPS 1R 9419 Operations NRC During requal exam, a licensed operator exhibited an Weakness apparent disregard for EOPS-9/30/94 MS IR 94-20 Personnel Error Ucensee Maintenance personnel begin to work the wrong RWT isolation valve, threatening the operability of both trains of ECCS.
9/30/94 OPS IR 94-19 Operations Error L;eensee Failure to notify the NRC of changes in status of NCV 94-19-01 Ircensed operators' medical cond:tions.
8/29/94 OPS,
IR 94-20 Operations Errors NRC Operators placed 1 A EDG in an electrical lineup for VIO 94-2241 which TS-required surveillance tests had not been VIO 94-22 02 perform?d (with the safety-related swing bus powered from it). Also related control room log entries appeared to be inaccurate.
28/94 OPS iR 94-20 Equipment Failure Licensee Unit 1 was taken off line (Mode 2) to repair a DEH leak. The unit was returned'on line later the same gg day.
k 8/12/94 OPS IR 9410 Oper:tiorn/
NRC Th3 hcensee w s unlording n:w fuel for Unrt 1 with a Maintenance Error hoist grapple that was missing the safety latch sleeve 4
and Lack of locating pin. The safety sleeve functioned by friction Engineering only.
Drawings /in.
spection Cntena I
7/14/94 MS IR 94-15 Equipment Ucensee/NRC Dunng surveillance test. TCB 5 failed to open due to LER U-2 94-Failure / Poor mechanical binding (licensee). The licensee failed to 06 Management recognize the condition as requiring a shutdown per VIO 94-15-01 Decision TS (NRC).
7/9/94 OPS IR 94-15 Equipment Failure Ucensee Unit 2 turoine was shut down and reactor power reduced to Mode 2 because the 281 RCP lower oil level indication showed a leak. The indication was later shown to be erroneous.
l 7/8/94 OPS IR 94-15 Operator Error Ucensee TS 3.0.3 entry due to piacing 2A1 LPSI pump and 2B LER U2 94-05 charging pumo OOS at the same time.
1 1
1 6/28/94 MS IR 94-14 Personnel Error /
Ucensee Inoperable Unit 2 RAB ventilation exhaust WRGM due NCV 94-14-01 Procedural to failure to connect sample lines.
LER U-2 94 Weakness j
04 6/6/94 OPS IR 94-14 Weather Ucensee Unit 1 tno from 100% power dunng a severe thunoerstorm oue to cebns blown across two main transformer outout terminals.
5/28/94 PS IR 94-13 Poor Corrective NRC Emergency supplies in control room less that stated in DEV 94-13-01 Action FSAR.
5/6/94 ENG IR 94-11 Engineenng Error NRC Inadequate corrective action for MOVs which stalled V10 94-1101 during surveillances.
'23/94 OPS IR 94-12 Mfg. Error Self idntifying Unit 2 auto reactor trip from 30% power caused by LER U-2 94-RPS cabinet wiring error for trip bypass circuit, from 1
03 original unit construction.
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4/23/94 MS IR 9412 Equipment Failure Self identifying Following unit 2 tnp, steam bypass system operated unexpectedly and dropped RCS temp by seven degrees F, pressurizer heaters turned off.
4/21/94 OPS IR 94-12 Operator Ucensee Unit 2 reactor power increased from 26 to 31% due to inattentiveness positive MTC.
4/7/94 MS IR 94-10 Maintenance Error NRC Contractor personnel made and contractor OC V10 94-10-01 accepted pressunzer nozzie weld prop that did not meet procedural requirements for bevel angle.
Ucensee engineenng had specified overly tight I
tolerances.
4/3/94 OPS IR 9412 Operations
' Self-identifying Unit 1 auto reactor top due to unusual electrical lineup LER U19444 Procedure Error (isochronous EDG paralleled with offsite power (Lack of sufficient through TCBs).
depth in reviews I
!' 4/3/94 ENG IR 94-12 Surveillance Error Ucensee Ucensee discovered that the 4160 V [AB Bus) swing VIO 94-12-01 bus componer".s IC ICW Pump and C CCW Pumpj would not stnp from the bus upon undervoltage if the l
bus were angned to tne B bus oue to a missing wire.
3/28/94 l MS IR 94-09 Personnel Error Self identifying Unit 1 auto reactor tno. Maintenance foreman opened q
LER U194-03 generator exciter breaker on wrong unit.
I 3/15/94 iENG IR 94-08 l Engineennq NRC
, Regionalinsoector had two Unit 2 SL4 violations: U i Vt0 94-08-01 Corrective Action
- orrective act,on for an 11/24/92 water hammer event
! VIO 94-08-02 l was cone witnout cocumented instructions or proceoures. resulting in ocerating until 3/94 with five j
j snuobers on tne SRV ano PORV tailpipes inoperable.
j j
6
- 2) Failure to wnte a nonconformance report for a I
I camageo pipe support in Maren 1994.
e 3/16/94 ENG IR 94-10 Equipment Failura Ucensee A Unrt 2 pr:ssurizer instrument nozzle that had been LER U-29442 repaired a year ago was found leaking while the unit was in Mode 5. The unit remained shut down for repairs.
4/34 ENG IR 9446 Engineering Ucensee inadequate design controls on Unit 2 sequencer NCV-944642 Design Error charging pump loading block.
3/4/94 ENG 1R 94 06 Engineering Error Ucensee Failure to report an EDG failure.
NCV 944641 2/28/94 ENG IR 94-09 Refueling Ucensee/NRC inadequate grappling of a fuel assembly caused by NCV 944441 procedure &
error in Recommended Move Ust and operator error in operator error following procedure. (IR 9449) 2/17/94 OPS IR3446 Operator Error Ucensee Pressurizer aux. spray isolation valve had been looked NCV 94-0541 closed (vice open) since 3/27/93.
LER U2 94-01 2/11/94 PS IR 9442 Security Error Ucensee Failure to provide required compensatory measures in NCV 9442-01 response to a secunty computer system failure.
1/13/94 OPS IR 9441 Surveillance Self Identified UV relay test resulted in load shed of the 1 A3 4160 voit LER Ut 9442 Procedure bus and a 1 A EDG auto start Weakness /
Component Faliure 1/9/94 OPS IR 94-01 Equipment Failure Self Identified Manual reactor trip. feed pump control circuit failure.
LER U19441 1/2/94 SALP period 11 began
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