ML20029D841

Responds to Severity Level III Problem During Insp of Activities Re Failure to Recognize That ANO Unit 1,exceeded TS Required Limiting Condition for Operation

ML20029D841
Person / Time
Site:	Arkansas Nuclear
Issue date:	05/02/1994
From:	Yelverton J ENTERGY OPERATIONS, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
0CAN059402, CAN59402, NUDOCS 9405100180
Download: ML20029D841 (8)

Text

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Entergy Operations, Inc.

E ENTERGY " * * "'o Ra x W .AR 72601 Tel501 % 48838 Jerry W, Yelverton

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May 2,1994 OCAN059402 U. S. Nuclear Regulatory Commission Document Control Desk Mail Station Pl-137 Washington, DC 20555 Gentlemen:

Pursuant to the provisions of 10CFR2.201, attached is our response to the Severity Level

!!I problem identified dur'..ig the inspection of activities concerning the failure to recognize that Arkansas Nuclear One (ANO) Unit I, exceeded a Technical Specification required Limiting Condition for Operation for approximately 59 hours6.828704e-4 days <br />0.0164 hours <br />9.755291e-5 weeks <br />2.24495e-5 months <br />. Additionalinformation concerning the violation is contained in Licensee Event Repon 50-313/94-001 transmitted via letter ICAN029403 dated February 25,1994.

Should you have comments or questions please call Mr. Dwight Mims at 501-964-8601.

Very truly yours,

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r Attachments To the best of my knowledge and belief, the statements contained in this submittal are true, SUllSCRillED AND SWORN TO before me, a Notary Public in and for b 0%

I County and the State of Arkansas, this 2nd day of May 1994.

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NotaryJ4tilie My Commission Expires 494 2(1.4- - - - - -

PA .imG DAVIDSON Notary Publ!C POPE COUNTY, ARXANSAS Comminion Expues 4 24-2002

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cc: Mr. Leonard J. Callan Regional Administrator U. S: Nuclear Regulatory Commission Region IV .:

611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011-8064 NRC Senior Resident Inspector Arkansas Nuclear One - ANO-1 & 2 Number 1, Nuclear Plant Road Russellville, AR'7280l Mr. George Kalman NRR Project Manager Region IV/ANO-l U. S. Nuclear Regulatory Commission NRR Mail Stop 13-11-3 One White Flint North 11555 Rockville Pike Rockville, MD 20852 Mr. Thomas W. Alexion NRR Project Manager, Region IV/ANO-2 U. S. Nuclear Regulatory Commission NRR Mail Stop 13-11-3 One White Flint North 11555 Rockville Pike Rockville, MD 20852

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s s Attachment to OCAN059402 NOTICE OF VIOLATION During an NRC inspection conducted February 2-9,1994, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for

.NRC Enforcement Actions, "10CFR Part 2, Appendix C, the violations are listed below:

A. Technical Specification 3.4.1 states, il part, that the reactor shall not be heated above 280 degrees F unless both EFW pumps and their flow paths are operable.

Technical Specification 3.4.5.1 states, in part, that with one EFW flow path inoperable, the unit shall be brought to hot shutdown within 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />.

Contrary to the above, at approximately 12 a.m. on January 28,1994, one EFW flow path became inoperable due to a malfunctioning steam generator level transmitter (which would have affected automatic flow control in one flow path) and the unit was not brought to hot shutdown within 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />. The unit was brought to hot shutdown at approximately 1:55 p.m. on February 1,1994, approximately 74 hours8.564815e-4 days <br />0.0206 hours <br />1.223545e-4 weeks <br />2.8157e-5 months <br /> afler one EFW flow path became inoperable. (01013)

B. Technical Specification 6.8.1.a requires, in part, that written procedures be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, November 1972.

Regulatory Guide 1.33, Appendix A, Revision 2, November 1972, lists typical safety-related activities that should be covered by written procedures, including:

(1) administrative procedures governing the authorities and responsibilities for safe operation and shutdown, and (2) administrative procedures governing log entries and record retention.

ANO Procedure 1015.003 A, Revision 31, " Unit One Operation Logs," Section 6.5.4 requires, in pan, that operators perform the following actions when an Operability Difference ("Op. DifT.") value is exceeded: declare the alrected instrument channel or indicator inoperable; initiate a condition report; and implement any actions required by Technical Specification Limiting Conditions for Operation.

Procedure 1015.003A, Section 4.4, defines operability difference values as variations between Technical Specification or other NRC required instrumentation channels monitoring the same parameter which, if exceeded, will constitute -

' instrument component inoperability.

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OCAN059402 Procedure 1015.003 A, Form 1: i5.003 A-7, "CBO Reactor Logsheet," specifies an operability difTerence of 8 inches for instmmentation channels monitoring Steam Generator Low Range Level and, in Footnote 2, requires that if the operability difTerence limits are exceeded, the SS/CRS (shift superintendent / control room supervisor) be immediately notified, a condition report be written, and the afTected instrument'be declared inoperable.

Section 6.5.2 of ANO Procedure 1015.001, Revision 46, " Conduct of Operation,"

requires, in part, that the Control Board Operator (Reactor) monitor parameters associated with plant operations, recording those which are specified on log sheets,

- and notify the SS or CRS of unusual indications or abnormal trends.

Contrary to the above, from January 2< , .,94, until Januarv 31,1994, the indication from Steam Generator Low Range Level Trar.,mitter LT-2622 varied from the other NRC required instrument channel indications monitoring the same part. meter by more than 8 inches, a value in excess of the specified operability difference, and licensed operators did not: (1) immediately notify the SS/CRS that the operability limit was exceeded; (2) decir.re Low Level Transmitter LT-2622 inoperable; (3) initiate a condition report; and (4) implement actions required by the Technical Specifications Limiting Conditions for Operation for an inoperable EFW fVw path (0_1023)

These violations represent a Severity Level III problem (Supplement I) i 6

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Attachment to O' OCAN059402 Respnnselp violation 313/9412-01;j68/9412-01 (1) Ikason fpr the violation; .>

On January 22,1994, Once Through Steam Generator (OTSG) Level Indicator LI-2622, the indicator for level transmitter LT-2622_, was noted to be greater than the allowable maximum normal difference between channels during the channel check performed every eight hours as part of the reactor operater (RO) log. To ,

perform the channel check in question, three OTSG level indicators are compared by the RO, the maximum difference between channels is mentally calculated, and'a comparison is made to the values for maximum normal difference and operability difference. These readings are reviewed once per shin by the Control Room Supervisor (CRS), and daily by the Operations Shin Superintendent (SS). The RO '

is procedurally required to initiate a job request if the difference exceeds the maximum normal difference of five inches. If the difference between the channels exceeds the operabilim difference of eight inches, the RO is required to notify the SS/CRS immediately and write a Condition Report.

In this instance the RO logged the reading as being greater than five inches on January 22,1994, circled the reading on the log sheet, and initiated a job request to repair the indicator as required by procedure. Thejob request number was annotated on the back of the log sheet as corrective action for the out of specification reading and subsequent readings were circled referencing the same note. During the midnight shin (2300-0700) on January 28,1994, Ll.-2622 exceeded the operability difference of eight inches; however, this was not recognized by the Control Room Operators.

LI-2622 was identified as being outside ofits operability limits at 2150 on January 31,1994, by the evening shin (1500-2300) RO while walking down the control panel. The RO notified the Shift Superintendent as required and a Condition Report was initiated. The unit entered the Technical Specification action which requires placing the plant in hot shptdown within 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> based on the inoperability of one EFW flow path associated with the level control feature of LT-2622 A Notification of Unusual Event (NUE) was declared when shutdown commenced at 0905 on February 1,1994, based on the initiation of a shutdown required by Technical Specifications. Transmitter LT-2622 was replaced while the plant was in hot shutdown and was declared operable along with its associated EFW flow path at 2204 on February 1,1994. The NUE was terminated at this time. The  !

Unit was returned to power on February 2,1994.

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' Attachment to j OCAN059402 The root cause of the failure to identify LT-2622 being inoperable was determined ' q

. to be inattention to detail on the part of ANO Unit I licensed operators while l taking logs. The operators did not exhibit a questioning attitude as the difTerence l continued to grow and exceed the operating limit. Several factors were identified  !

- which contributed to this event. The RO log which contains the channel check I requires a mental calculation to determine the channel difference that is then compared to a specified value. This difference was not procedurally required to be written on the log. This task is performed many times for a single set oflogs and requires attention to detail to avoid error. Additionally, procedural requirements were vague as to the requirements for CRS/SS review of these logs, and Operations management did not provide sufTicient feedback to operators on the seriousness oflog taking errors. Further, a false sense of problem resolution was created as a result of the continued reference on the log sheet to the job request that had been initiated to correct the levelindication discrepancy. This condition obscured the need to take further action when the difference increased beyond the ,

operability limit.

(2) Corrective steps taken and results achieved:

. Transmitter LT-2622 was replaced while the plant was in hot shutdown and was declared operable along with its associated EFW flow path at 2204 on February 1, 1994.

• A dedicated operator was immediately stationed in the Unit 1 Control Room to manually control level in the "A" OTSG if required during the out-of specification and plant shutdown period.

e A review of the January 1994 Control Room logs was completed on February 5,  ;

1994, to identify any other errors associated with channel check comparisons. No significant deficiencies were noted.

• The Operations Manager for Unit I conducted a CRS/SS meeting on February 5,  ;

1994, to review this event emphasizing Technical Specification requirements, Licensed Operator responsibilities, and management expectations. The ANO Vice President of Operations also attended the Unit 1 CRS/SS meeting to reinforce management expectations.

. Unit 1 Shift Superintendents conducted crew meetings attended by either the Operations Manager or Assistant Operations Manager between February 4-8, 1994, to review this event with their respective operating crews emphasizing  ;

Technical Specification requirements, licensed operator responsibilities and management expectations.

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Attachment to OCAN059402

- . Unit 1 Shin St perintendents completed additional crew meetings between February 19 and March 3,1994 During these meetings emphasis was placed on management expectations on log taking, how this event could have been prevented by use of self checking techniques, review oflog taking errors from previous log reviews and lessons learned from this event.

• A Iluman Performance Enhancement System (IIPES) evaluation was perfonned regarding this event on February 10,1994, and several human factor enhancements were identified for implementation.

. involved operators responded to a questionnaire which provided their perspective of the event, acceptance of responsibility and accountability for their actions and provided recommendations for enhancing operator log taking practices.

• Unit 2 operations management reviewed this event with their Shin Superintendents on February 10,1994, to address the generic human performance implications.

. Iluman factor enhancements were added on February 16,1994, to the Unit I operator logs, which had previously required mental calculations / comparisons, so that difference values could be visually compared to a standard. Additionally, Technical Specification log readings were segregated on a separate log form. Until human factors enhancements could be incorporated a Senior Reactor Operator performed an additional daily review oflogs containing Technical Specification requirements

• Procedure 1015.003A, Unit / Operations Logs, was revised on February 16, 1994, to clarify the requirements for CRS/SS end of shifl log reviews.

. The lessons learned from this event regarding performance of routine, repetitive tasks were discussed with Units I and 2 Maintenance, Chemistry, Radiation Protection, and System Engineering personinel between February 14, and March 17,1994.

. An Improving Iluman Performance Operations task force has been formed with the support of Entergy executive management. This task force is comprised of Operations Department personnel from each Entergy nuclear site. The mission of the task force is to defme the characteristics of a culture that achieves and maintains high standards of human performance and to recommend efTective implementation methods for the Entergy Operations plants. The first meeting of the task force was held on April 5-6,1994. The agenda which consisted of presentations and discussions of human performance issues included a presentation on improving Iluman Performance by Dr. Chong Chiu, President of FPI International. The task force will continue to meet periodically to resolve human performance issues.

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Attr4chment to -

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• The following operations related job request priority system enhancements for Unit I were completed on May 1,1994:

Log deficiencies are tracked in the same manner as control room deficiencies.

The Planning and Scheduling Operations Liaist>n Desk Guide was revised to require periodic audits of operations log notes, operations control room status boards and disabled control room annunciators to help ensure items requiring maintenance action are properly prioritized.

(3) Corrt .1;ve steps that will be taken to prevent titrther violations:

• Computerized log taking is being evaluated for anaptation to both Unit I and Unit 2 Control Room logs. This evaluation is scheduled for completion by June 1, 1994.

• As a step toward future enhancements in human performance, Unit i Operations ,

will evaluate feedback mechanisms used in addressing log taking errors by June 1, 1994.

. Unit 1 Log taking errors are currently being addressed with a log discrepancy form that is generated, if needed, by the SS as a result of the final review of the daily logs. An evaluation is currently being performed, and will be completed by June 1, 1994, to determine if enhancements to the method of annotating out-of-specification conditions on operator logs are required.

• An evaluation is currently being performed, and will be completed by June 1,1994, to determine if enhancements to the methods of addressing Unit 2 log taking errors and annotating out-of-specification conditions on operator logs are required.

(4) Datc3Aen full compliance will be achieved:

Full compliance was achieved when the out-of specification condition was corrected i

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