ML17261A969

Responds to Violations Noted in Insp Rept 50-244/89-16. Corrective Actions:Operations & Maint Personnel Received a Procedure Training That Highlights A-1408, Independent Verification, Requirements

ML17261A969
Person / Time
Site:	Ginna
Issue date:	02/23/1990
From:	MECREDY R C ROCHESTER GAS & ELECTRIC CORP.
To:	RUSSELL W T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
References
NUDOCS 9003020138
Download: ML17261A969 (18)

See also: IR 05000244/1989016

Text

AO;ELERATED

DISHUBUTION

DEMONSHWTION

SYSTEM REGULATORY

INFORMATION

DISTRIBUTION

SYSTEM (RIDS)ESSION NBR:9003020138

DOC.DATE: 90/02/23 NOTARIZED:

NO DOCKET ACIL:50-244

Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH.NAME.AUTHOR AFFILIATION

MECREDY,R.C.

Rochester Gas&Electric Corp.RECIP.NAME

RECIPIENT AFFILIATION

RUSSELL,W.T.

Region 1, Ofc of the Director SUBJECT: Responds to violations

noted in Insp Rept 50-244/89-16.

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ROCHESTER GAS AND ELECTRIC CORPORATION

~89 EAST AVENUE, P 5cwp.~0\1~*K I ,%0%l5 55A55 ROCHESTER, N.Y.14649-0001

February 23, 1990 T C 5.E P H O N C A@CA CODE VI55 546-2700 Mr.William T.Russell Regional Administrator

U.S.Nuclear Regulatory

Commission

Region I 475 Allendale Road King of Prussia, PA 19406 Subject: Response to Inspection

Report 50-244/89-16

Notice of Violation R.E.Ginna Nuclear Power Plant Docket No.50-244 Dear Mr.Russell: The enclosed response to the Notice of Violation contains our response to Violation 89-16-01 from the inspection

at the R.E.Ginna Nuclear Power Plant from November 7 through December 11, 1989.The attached response includes Human Performance

Evaluation

System (HPES)investigation

information

and our corrective

actions.Our long-term corrective

actions have been determined

to address the repetitive

nature of these concerns, and the need for increased management

attention.

Very truly yours, Robert C.Mecredy Division Manager Nuclear Production

xc: U.S.Nuclear Regulatory

Commission

Document Control Desk Washington, DC 20555 Ginna NRC Senior Resident Inspector 5'003020'q

PDR A'i'OC.I;0.000:44 C~PDC (original)

~zpv(I'I

I

RESPONSE TO NRC INSPECTION

REPORT 50-244/89-16

Routine Inspection

Report 50-244/89-16, Appendix A, stated in part: " During an inspection

at the R.E.Ginna Nuclear Power Plant from November 7 through December 11, 1989, the following violation was identified

in accordance

with the NRC Enforcement

Policy (10 CFR 2, Appendix C).Technical Specification 6.8.1 requires in part that written procedures

shall be'established, implemented, and-maintained

.covering activities

referenced

in Appendix A of Regulatory

Guide 1.33, November 1972.Activities

referenced'n

Appendix A include maintenance

and equipment control.Calibration

Procedure (CP)-410A, Calibration

and/or Main-'tenance of Saturation

Temperature

Monitor System"B" Loop, requires restoration

of the test switch to the original position.In addition, Administrative

Procedure (A)-1408,.

Independent

Verification, and Procedure A-52.4, Control of Limiting Conditions

For Operating Equipment, require in-dependent verification, by observation

of proper indication

or response, following alignment and restoration

of equipment required by technical specifications.

Contrary to the above, on November 17, 1989, following maintenance

on the'B'oop saturation

temperature

monitor required by TS 3.5.3 using CP-410A, the test switch was not restored.to the original position and did not receive independent

verification

of instrument

response or switch position." Rochester Gas and Electric concurs with the above violation as described.

J

1.Reason for Violation A Human Performance

Evaluation

System (HPES)investigation

was conducted on this event.A Causal Factors Chart has been prepared and is attached.The concept of barriers and defense in'depth to ensure safe operation and maintenance

of the plant was challenged

by this event.The HPES investigation

identified

numerous Specific Barriers that were meant to ensure correct performance

of CP-410A, but in varying degrees were ineffective

in preventing

this event..Our analysis of this and other similar events points to three Primary Root Causes.iI Inadequate

procedural

direction Ineffective

statement of station policies, mmunication, and follow-up of these policies Lapse.in the"good work practices" of individuals

co-some 2 0 Corrective

Actions Taken and Results Achieved A.While performing

Main Control Room channel checks, the operators discovered

the 1B subcooling

monitor indicator pegged high.Instrument

and Control Technicians

were called in for troubleshooting

and found the test switch not in the recpxired position.The test switch was repositioned, the monitor's restoration

and indication

was verified and the monitor was returned to service.B.Operations

and Maintenance

personnel have received"A" procedure training that highlights

A-1408,"Independent

Verification" requirements

and A-503,"Procedure

Ad-herence".C.Meetings were held with each operating shift, selected discipline

and Administrative

groups.The HPES in-vestigation

was discussed with each group in detail, using the Causal Factor Chart as a presentation

aid.These discussions

focused on:*Barriers and defense in depth*Work group interfaces

• Management

communication

of policies, and follow-up for effective implementation

• Importance

of the independent

verification

Process in daily plant operation*Corrective-Action Plan and specific roles for each work group

Management

conducted a group meeting with the three Operators and the three I&C Technicians

that were involved in this event.This meeting addressed What, Why, and Under What Conditions

events occurred from the perspective

of each participant.

The focus was on understanding

the event and establishing'

basis for Corrective

Action to prevent recurrence.

A memo to all Maintenenance

personnel, dated February 06,1990, provides instructions

to ensure that the latest revision of the implementing

procedure is in the work package and that.the procedure has been marked up for independent

verification

of restoration

steps as applic-able.A read and acknowledgement

sheet was included with the memo, to en'sure the.memo was understood.

Good work practices have been re-emphasized

in Section, Foreman, planning, and Shift Supervisor

meetings.Also, as noted in the RGGE response to Inspection

Report 89-15, directions

have been provided to Operations

personnel concerning

improved on-shift attention to detail, improved in-depth communications

and acknowledg-

ement of responsibilities

for return of equipment to service.CP-410A and CP-409A have been deleted to prevent use of these deficient procedures.

The new Procedure Upgrade Program (PUP)procedures

for calibration

of the Saturation

Temperature

Monitor System are in draft form, ready for review, and will be available prior to next scheduled use.This upgrade corrects multiple action steps, lack of independent

verification, inadequate

technical content, lack of proper warnings, cautions, and notes and improves on overall procedure format and performance.

Label requests were initiated and completed for test switches TS-410A-1 and TS-409A-l.,Also, a Drawing Change Request was initiated to revise Foxboro's drawings CD-11 and CD-21 to clearly identify the test switches.Other protective

system rack drawings were reviewed for test switch installations

similar to TS-409A-1 and TS-410A-1 and none were found.

Corrective

Ste s Which Will Be Taken To Avoid Future Violations

A.The Procedure Upgrade Program (PUP), for calibration

procedures

is ,in progress and on schedule for a 1990 completion.

The remaining maintenance

procedures

to be upgraded are scheduled to be completed in 1992.This upgrade program address industry recognized

procedure good practices in terms of'content, format, and process.C.-A Task Force will be formed to focus on problems as-sociated with procedure adherence,=

system alignments, independent

verificaton, and their repetitive

nature.The Task Force goal will be to eliminate these conditions.

This task force will report to the Plant Manager.A request for a Training Effectiveness

Evaluation

on"A" Procedure training was generated by the Plant Superinten-

dents.This evaluation

iscurrently

being performed by the Training Evaluation

Group, and will be completed by March 02, 1990.The Request focused on the following areas: 2 How effective were the Station personnel in communicating

plant needs to the training groups?How effective is the training process as it was applied to training on"A" procedures?

This evaluation

will assist the Task Force'in assessing the effectiveness

of Plant and.Training Organization

interfaces.

This will provide information

for potential changes in the training process and the training programs that address procedure adherence and independent

verific-ation.D.A Training Change Request (TCR)was submitted requesting

training for I&C personnel concerning

the Saturation

Temperature

Monitor System interrelationships.

E.As noted in the RG&E Response to Inspection

Report 89-15"Administative

Procedure A-52.4"Control of Limiting Conditions

for Operation" has been changed to further delineate expected actions of personnel for return to service of previously

inoperable

equipment.

Specific examples are utilized within the body of the procedure to reinforce these requirements." This procedure change is currently awaiting PORC approval following comment resolution.

This approval will be completed by March 09, 1990.

'i'

F.Utilize the Quality Performance

Organization

to aid management

by providing a special assessment

as feedback on the effectiveness

of procedure adherence and indepen-dent verification

procedures

and activities.

4.The Date When Full Com liance Will Be Achieved Full compliance

was achieved November 17, 1989, when the test switch was repositioned, the monitor's restoration

and indication

was verified, and the monitor was returned to service.RGEE recognizes

the need for increased management

attention, due to the repetitive

nature of problems associated

with procedure adherence, system alignments

and independent

verification.

Our goals are to eliminate incorrect system alignments, and assure independent

verification

whenever specified.

We have made progress toward achieving this goal, and are continuing

to reinforce our corrective

actions on an urgent basis.Any future inadequacies

in procedure adherence, system alignments, or independent

verifications

will be dealt with on a case-by-case

basis and will be thoroughly

investigated.

Any necessary follow up actions including procedure corrections, policy clarifications, or individual

counseling

will be taken.

Training on A-lant Procedure Adhcreacc Requirements" snd work group discussion

of 6/29/89 memo referring to ncw requirement

on double signoff was not effective.

Training on A-1408"Indcpcndent

Vcrilication" was not cffectivc.(Note: 12/15/80letter

to NRCcommincd

RG&E to perform vnilication

of correct performance.

Maasttancnt

communication

and follow-up on A-303 and A-1408 did not occur.Maintcnancc

memo of 6/29/89 follow.up mcaiags with shops aot held.Double signroff steps should have been identilied

in planning, but werc not.HPES 90-01"CP-410A Test Smite Returned" CAR 1990 NRC Inspection

Report 60-244/89-16

Violation 01 Proccdurc dcsignt Test switch is not called out.Ia step 5.6.7, thrcc actions arc uircdi~isconncct equipment~Rcstorc module to operation~Restore test switch 5.6.7 is on the bottom of a page.Turn thc page for 5.6.8, which may bc out of sequence-or

not rcquircd?The same function pnformcd in second"and" of$.6.7.g.Tech 1 cominues step 5.6.7 2.ThC 2 add Tech 2 had a 4.Calibratioa

steps corn letcd I i.JOB START 5.Tech I begins step 5.6.7 which contains three'steps

nncctcd by two"ands": fT, I2, Tech IandTech2tookout

-52.4,"Control of Limiti~~dIustments

not required P L'~.Cs ibration ok..ccdhdioaadat

t problem understanding

step 5.6.Unclear directions

for tep 5.6.3'f ihc procedure.

topped and discussed.

ng't>i.m~dCT'~~ro

Condrtrons

for Opcraung I2t~drcstore module to normal': operation aad rcstorc." Rcconnccts

leads thea indcpendenily

verify tightness of!.all tcrminah.-

Disconnca all calibration

uipmcnt and rcstorc." cvicwcd logic snd agreed to tdq g rocecd ast5.6.3.'2"w"~rr'~~~

'cch I dtseoaneas

test ul meat.i tep 5.6$is rcdundart of middle J rtion of ste 5.6.7 (above).i(Friday, November 17, 1989 air~0"f>CP, adtddWTT drdxl$w i Q9 pp hours>ah~a.'.=g.

IQ 17 hour1.967593e-4 days <br />0.00472 hours <br />2.810847e-5 weeks <br />6.4685e-6 months <br />s-atp~~@IIcqhtac

fha ihi After Iulleh":-*': "",~id~%$'k<R~e55'iN~hrv~M!Nw~:s

fa I'<<Pare"+I 0@v r I O"'P 409A and CP 410A arc done only once a year.CP 410A was originally

schcdulcd for Tcehs A&B, but they werc called away on another job.Tech I and Tech 2 took over thc cart at approx.09:00 hrs.For steps 5.6.0-5.6 6, Tech I was in Relay Room and Tech 2 in the Control Room?During thc course of thc day'work, Tech 2split his time bctwcen tbc Relay Room and thc Control Room.Tech I spent thc entire day in thc Relay Room.To"restore module" r cans to rcconnca leads.Takes 3-I min.Checks tightncss of taminals.Moves on to step 5.6.8-top of a new page.5.6.8 stata"Connea leads to pair terminals from which they werc remcved.Check tightncss of all terminals." Ncithcr Tech I nor Tech 2 had done CPr4IOA before.g'ceh 2had done CPr409A ss part of 1989 Outage.)Tcchs and plannns wnc trained on Foxboro Spec 200 rnodulcs by thc vendor.The l&C Planner was not in that dsy.A backup planner handled thc p!arming.t t No"tsilgstcscssion" (discussion

bctwcen pbnncr snd crew)wss held.a'.6.3"Hold thc voltage constant across pair terminal rrl (approx.4.5 VDC)snd incrcssc the voltage across pair terminal//3 until thc alarm actuates.Thc abrm is d low differential

temp.alarm snd actuates when thc difference

betwccn thc 2 voltages is Td 1.0 volt=.I volt." Brokea barrier Intact barrier Wonders: Is 5.6.8 pate of"rcsiorc module to normal opemtion.It is possible to rcconrc.".

and test tiahtness of leads, sad skip ihe third"and" of 5.6.7.

I 0

Switch func t called oui in training.I&C training stops at thc Spec 200 Icvcl.dNo training to address thc unique RG&E fcaturcs, such as the tnt switch,'or how thcsc modilications

affect thc'plani operation.

Switch was installed in I9S5 as patt of a modification

for thc R&T for monthly reactor uip breaker testing.Switch is called diffcrcnt names by different plant groups..Test switch is not fail-safe.

d>>4J a HPES 90-01: "CP-410A Test Switch Not Retu'-conducted herc NRC Inspection

Report 50>>244/89-16

Violation Ol System training for I&C covering T SAT (temperature

differential

system)to include function of the test switch was not done.Test switch is not direaly labeled.Switch is a unique Ginna Station fcaturc.Test switch is located near thc bottom of the rack-aot near thc equipment being scrviccd Test switch is noi considcrcd

part of thc Spec 200 module for I&C purposes.Of up to 20 modules in this rack, this is thc only loop with a test switch.Thcrc are only 3 switches of this type in thc entire plant.There are approximately

200 similar modules in the plant.THIS IS AN EXCEPTION.

I lf~Test switch Two tcchs arc rcquircd to sign off thc A-52.4.Procedure A-52;4 as written and as practiced may bc unclear and open to imcrprmauon

.Issues:~Who is rcsponsiblc?

~What is evcryonc rcsponsiblc

for?.,7, last part of step 5.6.7:;>','" andrestoretestswitchto

,-g:.original position." j ga'OT PERFORhIED!

~9.Tech 1:>.'-.Oeans

up job site.~@~.'Returns

to shop..>>",>cGocs

to Control Room to j~clear thc A-52.4"Contro 8, Continued proccdurc through S~tcp 5.95, a logical stopping 9:wg:po>>t.

~dr~>>Tech 2 leaves for doctor'aji iatmcnt.1 0, Tech I calls I&C ShoP.)>I I.A 52.4 also signed off by:~3~eg i>.I,-jTceh 3 takes call.Hc goes-,"v>" Head Control Operator i.-'.~a.'tothcControl

Room and"-.'+Control Room Foreman ,";'+signs off thc A-52.4.'==~4 Shift Supervisor

,'.Tech I signs off thc A-52.4.i'~NZIeclarcd

opcrablc at 15:00~~I';rCdd>>Ccc ccctccdcc.

Ncw shift docs proccdurc 0.6.13.Loop IB subcooling

Žindication

pegged high.A.~>.I"Ginna Station Event Report" lilcd.lof Yi+?~~;-~y"~-+";LimiYing

Conditions

for" c KV>>>>~t~m~f'iM~::::-c:::->";:.".:;:.-.:."-c"(d>>cd'~L>>;:>>>>'::c':

'Ad.dc>>cd.<-14:45 hours~q=;-g~,'.:;

yu~d~.--.-.$~:..-Nr',.,>";...;~~",-'*.v.-"c

--.=.,-,~AY,.

p 15:00hours

t;'..i g,.-.:p;Mgg, Possible intcrruptioa

-Tech 2 returns to Relay Room?Procedure CPA IOA, step 5.6.7"~nd rcstorc test switch to original position" was not pcrformcd.

Double vcriTication"with adouble check to bc performed by Ihc person(s)performing

the proccdurc" was not done.Step 5.6.7 was not slashed in'he planning process per m<<mo to indicate that double sigaeff is ncccssary.

Tcchs werc not aware of this speciTic (double veri Iicatioa)suuation for step 5.6.7.Tech 2 had been in and out of thc Control Room during thc day.'ech I was ia thc Relay Room.Eatirc proccdme was not complctcd.

Tech 2 was in thc Control Room durino 5.7.4?Not sure.Howcvcr, hc de not check instrumentation

relating to steps in 5.6.Tech 2did not do a walk@own inspection

or check thc Coauol Room instrumentation

prior to leaving for his doctor's appointment.

Good practices, (instrumentation

check, walkdown, noting'as found'ad'as is'onditions)

were not followed.Tech 2 gone to doctor and unavailablc

to sign off the A-52.4.A-52.4, step 3.9 for verification

of operabihty, was not pcrformcd correctly.

f (Procedure

statesi"if operabihty

of cquipmeat is not dcmonstratcd

by performing

a PT, an operator will veriEy thc valve l>>c up, switch and brcakcr position.)Good work practice not Eol!owed.I&C did not check instrumen-

tation in thc Control Room.Good work practice not followed.Operations

did not'check instru-mentation in thc Control Room.Friday afternoon 3:00 p m.Going into a wcckead.Coming up on a shift change.Broken barrier I Intact d barrier I&C Planner was contamcd at home.Hc knew about ihc test switch and surmised that it was the problem.

'