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Special Insp Rept 50-333/97-03 on 970304-13.Apparent Violations Being Considered for Escalated Ea.Major Areas: Insp Scope & Event Overview
	ML20137W745
Person / Time
Site:	FitzPatrick
Issue date:	04/14/1997
From:	; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	;
Shared Package
ML20137W736	List: ML20137W732; ML20137W745;
References
	50-333-97-03, 50-333-97-3, NUDOCS 9704180203
	Download: ML20137W745 (7)
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U.S. NUCLEAR REGULATORY COMMISSION

Region I

License No.: DPR-59

Report No.: 97-03

Docket No.: 50-333

Licensee: New York Power Authority

Post Office Box 41

Scriba, New York 13093

Facility Name: James A. FitzPatrick Nuclear Power Plant

Dates: March 4,1997 through March 13,1997 !

Inspectors: G. Hunegs, Senior Resident inspector

R. Fernandes, Resident inspector

L. Briggs, Senior Reactor Engineer

Approved by: Curtis J. Cowgill, Chief

Projects Branch 2

Division of Reactor Projects * !

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9704100203 970414

PDR ADOCK 05000333 )

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DETAILS

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1. Incorrect Control Rod Ooeration ;

a. inspection Scope

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On March 3, a licensed reactor operator mistakenly withdrew one control rod from

position 22 to 26. The resident staff and a Region Iinspector with licensed

examiner experience reviewed the circumstances surrounding the control rod I

j withdrawal. The inspectors interviewed selected personnel including the reactor l

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operator, control room supervisor and licensee management. Procedures and l

i training related to conduct of operations and control rod operation were reviewed. j

! The purpose of the specialinspection was to provide a timely and systematic l

inspection of an event which involved concerns pertaining to licensed operator and j

management performance with regards to reactivity management.

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l b. Observations and Findinas l

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j Event Overview: f

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i On March 3, a licensed reactor operator (RO) mistakenly withdrew control ?

l rod 26-11 from position 22 to position 26. Rod out movement was stopped by an

l automatic rod withdrawal block due to high neutron flux. The rod out movement

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resulted in recctor power increasing to 101.2 percent for approximately 1 minute.

l A rod block monitor (RBM) upscale alarm annunciated and alerted the RO to the

t error. The RO informed the senior reactor operator (SRO) and requested permission

j to insert the rod. The SRO directed that the rod be inserted and informed the shift

! manager (SM). Reactor coolant chemistry and off-gas samples were normal and the

3 3D Monicore showed that no core thermallimits were exceeded. The 3D Monicore

! is a system of computer programs designed to monitor and predict important core

, parameters. An analysis was performed to determine the consequences of

j withdrawing the control rod. The analysis showed that thermal limits were not

exceeded, however, pre-conditioning limits may have been exceeded. Sub-

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sequent analysis determined that the preconditioning envelope had been exceeded

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at 4 nodes. Fuel pre-conditioning is the process involved in limiting the rate and

magnitude of fuel power increases to limit cladding stresses to prevent pellet clad

interaction (PCI) failures. The licensee also consulted with the fuel vendor, and,

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although the preconditioning envelope had been exceeded, the fuel vendor

determined that fuel damage was unlikely.

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j Ucensee Corrective Actions:

A post event critique was held after the crew was relieved. The operators involved

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were removed from watchstanding duties pending remediation training and licensee

evaluation. Fitness for duty tests were performed for selected individuals. The

i Operations Manager conducted briefs on reactivity manipulations for all crews prior

to standing watch. The emphasis was that control rods are only to be manipulated

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when directed by a scheduled surveillance test, rod pattein adjustment, or when

j required to respond to a plant transient and that any control rod manipulation must

be treated as a reactivity manipulation. Additionally, manipulations in the plant

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specifically for training and not part of a scheduled plant evolution are not

authorized.

A root cause analysis is being conducted by a team to review expectations,

personnel responsibilities, understanding of managements expectations and the

station's safety culture.

NRC Assessment:

The RO was conducting impromptu training with an RO license candidate. The RO l

had been discussing the control rod drive hydraulic system, and, to demonstrate a

point, requested permission from the control room supervisor (CRS) to perform a I

control rod coupling check. The CRS granted permission, however the evolution )

was not authorized by the SM nor was it part of a scheduled surveillance test. Had

a procedure been used, the applicable procedure was ST-20C, Control Rod

Operability Check. This procedure requires that the SM grant permission to conduct

the evolution. The RO and CRS both stated that a coupling check was a routine

evolution. Their stated reason for making this determination w a that control rod

coupling checks are conducted weekly and no rod motion w . , expected. The

inspectors concluded, based on this information that the licensed operators were

insensitive to possible control rod movement. For example, they f ailed to consider l

what actions they would have taken had the control rod been actually uncoupled l

from the control rod drive mechanism. An independent verifier was not stationed as i

required by ST-20C and AP 12.03 nor was procedure ST-20C used as required by

station administrative procedures. l

The RO selected control rod 26-11 because he thought the rou was full out. He

had not made a determination to select a particular rod, he stated that his intent i

was to select a rod that was full out. Control rods are selected for movement by l

depressing an associated rod select pushbutton on the rod select matrix. When a I

control rod is selected for movement, the position of the selected rod and up to

three adjacent control rods are displayed on the four rod display. The rod selected

is identified by a lighted window on the full core display and a lighted select

pushbutton on the rod select matrix. The RO selected control rod 26-11 and did

not recognize that its position was 22 vice the desired position of 48. The rod ;

selected and its position were not verified as required by ST 20C. l

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The inspectors noted that licensee management expectations concerning the j

conduct of evolutions for the purpose of training were not effectively I

communicated. At the time of the event, licensed operator candidates had been on

shift for approximately 5 weeks. Operations management had not discussed with

or briefed crews on expectations concerning conduct of training. Based on

interviews, the site executive officer would not expect this control rod manipulation

to be performed unscheduled. However, some subordinate managers including shift

managers were not aware of this expectation.

The inspector noted that licensed operator training and procedures emphasized

sound operating practices. Periodically, through the use of crew briefs and required

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reading, operations management has attempted to reinforce standards. In spite of i

the procedures and training which emphasize sound operating practices, and

licensee management's emphasis on safe operating practices, a licensed reactor

operator and senior reactor operator were involved with an inadvertent control rod

manipulation. ;

The NRC noted that previous personnel errors have resulted in or contributed to

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several plant transients or adverse conditions. A summary of these concerns l

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follows:

In January 1997, a large influx of fish blocked the traveling screens, causing a i

reduction in intake water level and leading to a manual reactor scram. The !

automatic start function was disabled for maintenance at the time of the event.

The licensee's work planning and control process did not identify the risk

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significance of this evolution and thus allowed this to occur. Failure to recognize

the importance of the travelling screens automatic start function resulted in a poor ;

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decision to remove two of the three travelling screens from service at the same

time. ,

During the 1996 refueling outage, several personnel errors indicated that a poor

questioning attitude existed at the station. For example, a personnel error during

surveillance on the reactor water level instrumentation resulted in a reactor

protection system actuation, assumptions made during high pressure coolant ;

injection system maintenance resulted in the improper installation of hydraulic '

control system lines and incorrect control rod drives were removed. The last event {

was compounded because, when faced with unexpected conditions, there were '

several opportunities for plant and contractor personnel to stop work and '

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investigate anomalies, but this was not initially done.

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In September 1996, an automatic reactor scram was caused because of a personnel

error when a technician improperly performed a calibration on a generator relay. In

this case, a fundamental principle of good work practices was not adhered to in that

a technician proceeded to continue a task when faced with a condition that was

acknowledged to be risk significant. In addition, during this event, operator errors

and performance weaknesses ware evident as reflected in operators transferring the

Reactor Protection System (RPS) buses to alternate power supplies that were de-

energized, in spite of clear indications that the RPS was energized and the alternate

power supply was not powered. 4

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In each of these examples, workers failed to exercise sound decision making and a i

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questioning attitude. The inadvertent control rod withdrawal event is similar to past

events in that personnel involved failed to think before acting and consider the

consequences of their actions. These types of errors indicate an operating j

environrnent where a questioning attitude is not always a part of station practices.

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c. Conclusions

The safety consequence of the error was minimalin this event. The nuclear

instrumentation and rod control system responded properly and prevented local fuel

damage. However, the potential existed for a more significant problem if the rod

position or power level had been different. Additionally, fuel preconditioning values

were exceeded. Also, the RO and SRO actions are of concern because of their

improper watchstanding practices.

The inspectors concluded that the licensed operators were insensitive to a possible

control rod manipulation. This mindset led to a non-conservative decision to l

conduct an unscheduled plant es aiution. Both the SRO and RO, because they I

thought that no rod movement vould occur, did not implement the requirements of !

AP 12.03 paragraph 8.17.9 for ir iependent verification and paragraph 7.2 for self

checking. Paragraph 8.17.9 requires that a second individual with no concurrent

duties to be stationed to verify correct control rod selection and paragraph 7.2 ,

states that personnel who operate plant equipment shall practice self-checking while

performing a task. The RO was not paying attention and did not consider the ,

consequences of his action. The operators' failure to follow procedures resulted in j

a reactor power excursion which was not monitored and is an apparent violation ;

(eel 50-333/9703-01).

Summarv of Findinas:

A licensed RO moved a control rod without the use of a procedure, without

verifying that the proper rod was selected and without monitoring appropricte

reactor parameters. ,

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A licensed SRO inappropriately granted permisdon to conduct an unscheduled j

evolution and failed to provide proper supervision. Additionally, he failed to get '

permission from the SM to conduct the evolution. .

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Management expectations with respect to the conduct of evolutions for the purpose

of training were not effectively communicated.

Operators failure to follow procedures resulted in a reactor power excursion which

was not monitored and is an apparent violation.

The communication between the SRO and SM was weak. The SM was not

informed until after the rod was mispositioned. The SRO demonstrated inadequate

oversight in that he failed to provide supervisory oversight and failed to

communicate the evolution to the shift manager.

Licensee management expectations were insufficiently established and reinforced.

Licensee management had not clearly communicated their expectations to the

operating crews concerning training evolutions as a clear understanding of when a

training evolution can be conducted was not established.

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in several recent plant events, workers failed to exercise sound decision making and

a questioning attitude. The inadvertent control rod withdrawal event is similar to

past e'/ents in that personnel involved failed to think and consider the consequences

of their actions. These types of errors indicate an operating environment where a

questioning attitude is not consistently a part of station practices.

Exit Meetina Summary

The inspectors presented the inspection results to members of the licensee

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management at the conclusion of the inspection on March 14,1997. The licensee '

acknowledged the findings presented.

The inspectors asked the licensee whether any materials examined during the

inspection should be considered proprietary. No proprietary information was

identified.

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PARTIAL LIST OF PERSONS CONTACTED

j Licensee

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M. Colomb, Site Executive Officer

J. Maurer, General Manager - Support Services

D. Vandermark, Quality Assurance Manager

D. Topley, General Manager - Maintenance

D. Lindsey, General Manager - Operations

NRC

L. Briggs, Senior Reactor Engineer ;

R. Fernandes, Resident inspector - FitzPatrick

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ITEMS OPENED, CLOSED, AND DISCUSSED

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Ooened ;

50-333/9703-01 eel Operators' failure to follow procedures resulted in a reactor

power excursion which was not monitored. ;

Closed

None

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ML20137W745

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