05000346/LER-2004-001

LER-2004-001, Violation of Steam and Feedwater Rupture Control System Technical Specification

Davis-Besse Unit Number 1
Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
3462004001R00 - NRC Website

DESCRIPTION OF OCCURRENCE:

At approximately 1850 hours0.0214 days <br />0.514 hours <br />0.00306 weeks <br />7.03925e-4 months <br /> on January 6, 2004, with the plant in Mode 3, FirstEnergy Nuclear Operating Company's (FENOC) Davis-Besse Nuclear Power Station (DBNPS) Operators realized that a Technical Specification (TS) Action was missed. Approximately two-and-a-half hours earlier (1621 hours0.0188 days <br />0.45 hours <br />0.00268 weeks <br />6.167905e-4 months <br />, from unit log entry), during performance of surveillance test procedure DB-MI-03204, "Channel Functional Test and Calibration of Steam and Feedwater Rupture Control System (SFRCS) Actuation Channel 2, Steam Generator Differential Pressure Inputs PDS-2685A, PDS-2685B, PDS-2686C, and PDS-2686D," Feedwater/Steam Generator 2 Differential Pressure High Instrument Actuation Channel 2 (PDS-2685B) was removed from service and TS 3.3.2.2 Action 16 was entered. TS 3.3.2.2, SFRCS Instrumentation, limiting condition for operation states in part for modes 1 through 3 that the SFRCS Instrumentation channels shown in Table 3.3-11 shall be OPERABLE with their trip setpoints set consistent with the values shown in the Trip Setpoint column of Table 3.3- 12..." With a SFRCS instrumentation channel inoperable, actions are to be taken as shown in Table 3.3-11 (Action 16) of the Technical Specifications.

With PDS-2685B Inoperable Action 16 was applicable on January 6, 2004:

With the number of OPERABLE Channels one less than the Total Number of Channels, STARTUP and/or POWER OPERATION may proceed until performance of the next required CHANNEL FUNCTIONAL TEST provided the inoperable section of the channel is placed in the tripped condition within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />.

Note: NRC approved License Amendment Number 259 on September 29, 2003, which was implemented on January 14, 2004. This amendment allows an 8-hour delay in entering an action statement when an SFRCS instrumentation channel is undergoing channel functional testing.

At approximately 1630 hours0.0189 days <br />0.453 hours <br />0.0027 weeks <br />6.20215e-4 months <br /> the Master Nuclear Instrument & Controls (I&C) Technician informed the Unit Supervisor and the I&C Supervisor about the inability to isolate the process flow from the 5-valve manifold on PDS-2685B.

The Unit Supervisor did not inform the Control Room Operators of the problem, and no one was assigned to monitor the TS Action time. Approximately 15 minutes later (approximately 1645 hours0.019 days <br />0.457 hours <br />0.00272 weeks <br />6.259225e-4 months <br />) the Master Nuclear I&C Technician and the I&C Supervisor arrived at the Operations Support Center (OSC) to discuss the problem. The Shift Engineer, Shift Manager, OSC Senior Reactor Operator (SRO), and Work Week Manager were present for the discussion. The Operations Shift Manager directed the I&C Supervisor to restore PDS 2685B to service.

The briefing ended without further discussion between Operations and I&C of the time remaining in the action statement or the time required to restore the channel to an operable condition. I&C proceeded with the following order and priority: 1) process and approve a procedure deficiency form then return PDS- 2685B to service, 2) initiate a discrepancy notification to document the deficiency with the 5-valve manifold, and 3) initiate a Condition Report (2004-00163).

The I&C Supervisor then proceeded to the Control Room to inform the Unit Supervisor of the course of action. The Unit Supervisor assumed that I&C was going out into the field and directly restoring the instrument. Following this update, the Unit Supervisor and the Shift Manager became focused on other immediate activities occurring in the plant.

DESCRIPTION OF OCCURRENCE (continued):

From approximately 1715 until 1830 shift turnover activities took place. The Unit Log entry for removing PDS2685D from service was reviewed by the on- coming shift. Restoration status was not challenged by the crew during turnover. The Reactor Operator turnover sheet identified the testing as being complete. However, the SRO turnover sheet did not identify the testing as complete and did not describe TS Action requirements.

At 1804 the Unit Log was updated by the Shift Engineer to document the isolation concerns identified with PDS-2685B as was discussed during the 1645 OSC meeting. Another Log Entry occurred at 1846, where the dayshift Shift Manager documented that appropriate management notifications per the procedure were made in regard to emergent issues that were encountered during the previous hour.

Following the initiation of the PDS-2685B discrepancy notification and the approval of the procedure deficiency form for DB-MI-03204, I&C restored the instrument to service at approximately 1845 and notified the nightshift Unit Supervisor that PDS-2685B had been returned to service. The failure to comply with the action statement of TS 3.3.2.2 was then recognized by the Shift Manager, and appropriate management notifications for this event were made.

Because the missed action to place the inoperable section of the channel in the tripped condition did not occur within one hour (nor was the channel returned to operable status within one hour) this event represents an operation or condition prohibited by the Technical Specifications and is reportable in accordance with 10 CFR 50.73(a)(2)(i)(B).

APPARENT CAUSE OF OCCURRENCE:

An immediate investigation response team was assembled to provide analysis on this and other issues that had recently occurred at Davis-Besse. Previously written Condition Report corrective actions that were either implemented or proposed were reviewed as part of the extent of condition. Based on the team's evaluation, the Root Causes identified were: less than adequate (implementation) work practices, and less than adequate (implementation) managerial methods.

Operations shift personnel did not consistently exhibit accountability and ownership in performing the requirements of the Work Control process, Conduct of Operations, and the Surveillance Test Program. The licensed operators assigned shift responsibilities did not have a clear owner of the 1-hour action statement associated with the inoperability of PDS-2685B.

Less than adequate managerial methods were exhibited by the Shift Manager, Shift Engineer, and Unit Supervisor. They did not consistently reinforce roles and responsibilities of shift personnel and did not hold personnel accountable to meet standards and requirements of the conduct of Operations procedure and directives on conduct of pre-job and post-job briefs.

Operations management failed to address known performance deficiencies and APPARENT CAUSE OF OCCURRENCE (continued):

did not effectively implement adequate corrective actions in a timely manner.

Also, Operations management failed to enforce the consequences of these actions in accordance with FENOC standards.

Contributing causes include less than adequate verbal communication and less than adequate supervisory methods.

No one in Operations supervision communicated to the I&C Supervisor/ Technician the necessity of restoring the instrument to service within one hour. The pre-job brief was found to be inadequate in that the I&C brief did not include any discussion of Technical Specification Impact times as required by the briefing checklist and the Maintenance Handbook. Also, the pre-job brief conducted in the control room by Operations did not use the briefing checklist, did not actively involve the Reactor Operators, did not include I&C personnel, had no discussion of Action time requirements, had no discussion of who was responsible for ensuring the Action time requirements were met, and had no contingency plan in place if something went wrong.

In addition, the Shift Management became distracted by other emergent TS- related activities which deterred them from ensuring that the instrument was being returned to service in a timely manner.

ANALYSIS OF OCCURRENCE:

There were no adverse consequences to any system, structure, or component important to safety; however, this occurrence did result in a violation of the DBNPS Technical Specifications.

Prior to this occurrence FENOC had initiated License Amendment Request (LAR) 99-0004 by letter date April 1, 2001 (later revised on April 30, 2003, supplemental information provided on May 6, 2003, and approved by the NRC on September 29, 2003), to revise TS Table 3.3-11, Action 16. The amendment eliminated the requirement to immediately enter Action 16 (added an 8-hour allowance) of TS Table 3.3-11 for SFRCS channels during channel functional testing and subsequently entering TS 3.0.6 even if the test exceeds 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, provided at least both logic-channels of the redundant actuation channel (which is not being tested) are operable for the SFRCS. During the process of obtaining approval of the LAR, the NRC staff requested a quantitative assessment of risk assuming the entire 8-hour allowance was used for each SFRCS channel functional test. FENOC Serial Letter Number 2838, dated May 6, 2003, provided the results of the quantitative risk using the assumption that each time an SFRCS channel undergoes a channel functional test, the channel is unavailable for nine hours (8-hour allowance plus one hour Action completion time). The testing frequency assumed was monthly plus an annual channel calibration. The results of this evaluation show an increase in the baseline average maintenance Core Damage Frequency (CDF) of less than 1E-7/year. Based on the guidance of Regulatory Guide 1.174, "An Approach for Using Probabilistic Risk Assessment in Risk-Informed Decisions on Plant- Specific Changes to the Licensing Basis," this increase in risk is considered very small.

ANALYSIS OF OCCURRENCE (continued):

While the Surveillance Test DB-MI-03204 is written for the Channel Functional Test and Calibration, the total time the channel was out of service was approximately 2.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />, which is less that the 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> (each channel monthly plus an annual channel calibration) used to determine the risk for LAR 99- 0004.

CORRECTIVE ACTIONS:

The team concluded that the causes and contributing factors for inconsistent crew performance could not be addressed through one-time corrective actions, but need to be addressed through continual involvement of Station management's monitoring, coaching, feedback and correction. The corrective actions listed below are activities that are a part of a series of initiatives developed by Operations management.

Actions taken or pending that address the root causes include (but are not limited to):

Develop, issue, and complete required reading to the Operations Department to enforce the current standards and expectations. Standing Order 004-02 was issued by Operations on January 13, 2004, which documented that the pre-job brief for the missed TS Action Statement did not meet expectations.

Specifically, during the Control Room pre-job brief, the Pre-Job Brief Checklist found in the Operations Directive, Conduct of Pre-Job Briefs and Post Job Reviews, was not utilized and the I&C technicians were not present.

The Standing Order contained compensatory actions to re-enforce the current standards and expectations for job briefings.

The Director of Plant Operations has assessed the effectiveness of the Operations Leadership in place during the event. In accordance with the FENOC personnel policies, a new Operations Manager and Operations Superintendent, both with prior operations experience, have been appointed to strengthen Plant Operations.

A lesson plan designed for Just-in-Time. Training for licensed operators was developed to ensure a consistent understanding of the root cause findings and corrective actions. The Operations Manager presented the lessons learned to the target population of licensed shift personnel in an interactive training session. The Operations Manager stressed the adverse consequences that accompanied the less than adequate performances.

Communication was provided to Davis-Besse Personnel which documented Operations role as station leadership due to their licensed responsibilities, and the senior management expectation of station personnel providing timely support to Operations for effective fulfillment of that critical role. Also included in this communication was a depiction of the operations shift organization, an explanation of the roles and responsibilities for each shift member, and a memorandum describing the Shift Manager's command responsibilities. This information was provided to station personnel to CORRECTIVE ACTIONS (continued):

ensure there is a clear understanding of the roles, responsibilities, and authority of licensed personnel.

Other actions taken or to be taken to address the contributing causes documented above include (but are not limited to):

Procedure DB-OP-00100, "Shift Turnover," Attachment 1 - General Turnover Guidelines, was revised to provide guidance for review of any license requirements currently in effect to include TS, Fire Hazard Analysis Report, Off-Site Dose Calculation Manual, and Technical Requirements Manual. Also, shift turnover sheets were revised for the Shift Manager, Shift Engineer, Unit/Field Supervisor, and Reactor Operator to include review of license requirements in effect and sign-offs for the Shift Manager, Unit/Field Supervisor, and Reactor Operator indicating that responsibility for license requirements has been transferred. These actions were taken to improve consistency of tracking technical specification activities.

Operations Directive, "Conduct of Pre-Job Briefs and Post-Job Reviews," has been revised to include provisions to allow the use of other checklists developed for specialized activities in addition to the existing Pre-Job Checklist form.

A "crew update" concept towards normal plant operations will be applied as a means to keep the crew informed of changes in plant status. The current standard only applies crew updates to transient conditions. A consistent format will be applied to improve the formality of this communication tool.

DB-OP-00000, "Conduct of Operations," will be revised to align with FENOC wide Operations.

FAILURE DATA:

There have been no Licensee Event Reports in the past three years submitted from DBNPS which reported an event due to missed TS Action Statements. In addition to LERs, a reasonable search was conducted of previous DBNPS condition reports written in the past two years for items directly related to this event. Three relevant items were found directly related to this event:

• In early 2002 a Condition Report was written that documented a control room surveillance which was completed 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 14 minutes late while the staff was waiting for the plant computer to return to full service.

• In late 2003, a SFAS isolation valve was deenergized in the open position which resulted in a missed TS entry.

• During the NRC Restart Readiness Assessment Team Inspection conducted in mid-December 2003, a condition report was initiated to document shortfalls noted during the inspection. That Condition Report identified causal factors and recommended corrective actions that closely mirror the ones identified in the evaluation performed on the event identified in this License Event Report.

FAILURE DATA (continued):

From each of these events, human performance tools were not used or were used improperly. Additionally, reinforcement of desired behaviors and correction of behaviors that deviate from station standards and procedure requirements were not always corrected. Corrective Actions listed above include actions taken to ensure a consistent understanding of the root cause findings and corrective action for licensed operators. This was presented in an interactive training session where the adverse consequences that accompanied the failures was stressed.

Energy Industry Identification System (EIIS) codes are identified in the text as [XX].

NP-33-04-001-00 � CR 2004-00181