ML20135E606

Responds to NRC Re Violations Noted in Insp Rept 50-293/96-06.Corrective Actions:Procedure 2.2.87 Was Revised to Require Verification & Monitoring When Tasks Being Performed

ML20135E606
Person / Time
Site:	Pilgrim
Issue date:	02/28/1997
From:	Boulette E BOSTON EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BECO-2.97-026, BECO-2.97-26, NUDOCS 9703070170
Download: ML20135E606 (10)

Text

l g 10CFR2.201 Boston Edison Pigrim l Nuclear Power staton Rocky Hill Road Plymouth. Massachusetts 02360 i

E. T. Boulette, PhD February 28, 1997 Senior Vice President - d.uclear BECo Ltr. 2.97-026 U.S. Nuclear Regulatory Commission

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Attention: Document Control Desk Washington, DC 20555 '

Docket No. 50-293 License No. DPR-35

Subject:

Supplemental Reply to Notice of Violation 96-06-02 Our first response to Violation 96-06-02 (BECo Ltr. #2.97-009 dated January 31,1997) described the causes of overall procedural usage and adequacy problems at Pilgrim Station, their causes and our corrective actions to address them. As a supplement, we have provided in this letter, for each of the individual examples stated in the notice of violation, the reasons for the violation, corrective i action taken and results achieved, actions planned to avoid further violations, and the date when '

full compliance will be achieved. This information is contained in the enclosure to this letter.

This letter also contains the following commitments: 4

. Recertify the calibration of certain hardness tester calibration blocks and retire the blocks prior 4 to startup from RFO#11.

. Conduct a review of Pilgrim Station conduct of operations using licensed industry peers in 1997.

. Complete installation of the cellular communications system by June 30,1997.

Please contact Mr. J.W. Keene at (508) 830-7876 if you have any questions concerning this letter.

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Enclosure:

Reply to Notice of Violation 9703070170 970220 PDR ADOCK 05000293-G PDR 070096 ymppsppi,B,Eppu

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• U.S. Nuciser Rsgulttory Commission Page 2 l

1 cc: l l Mr. Alan B. Wang, Project Manager '

Project Directorate 1-1 Office Of Nuclear Reactor Regulation Mail Stop: 1482 1 White Flint North r

11555 Rockville Pike l

Rockville, MD 20852 I J

U.S. Nuclear Regulatory Commission i Region 1  :

l 475 Allendale Road  !

King of Prussia, PA 19406 J

l Senior Resident inspector Pilgrim Nuclear Power Station  :

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ENCLOSURE '

REPLY TO NOTICE OF VIOLATION ,

i BACKGROUND l

In October 1996, the NRC issued IR 96-06 containing the following violation:

"As a result of an inspection conducted January 22,' 1996 through February 9,1996,  !

information received on June 17,1996, and additional inspection conducted during this l- inspection period (July 29 - September 23,1996), the following violation of NRC requirements  ;

was identified. In accordance with the NRC Enforcement Policy (60 FR 34381; June 30.  !

1995), the violation is described below: 1

! Criterion XVI, " Corrective Action," of 10 CFR Part 50, Appendix B, states, in part, that

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i measures shall be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.

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Contrary to the above, corrective actions for problems identified since at least April 1995, were

, not effective in identifying and correcting overall procedural adherence and adequacy

! problems at Pilgrim. The following specific procedural adherence and adequacy problems were identified:

1. Procedure 2.2.87, Control Rod Drive System, Revision 53, was inadequate by not

! providing direction to operators moving reactor fuel to verify the correct orientation of the blade guide before control rod insertion. As a result, on April 30,1995, control rod 18-35 was inserted into the reactor core and physically jammed into a mispositioned blade guide causing blade guide and control rod damage.

2. Procedure 9.13, Control Rod Sequence and Movement Control, Revision 12, Attachment 3

!isted control rods to be moved. During the power reduction required on October 6,1995, operators did not follow the reverse order of the pull sheet as evidenced when control rod

34-23 became mispositioned.

3. Nuclear Operating Procedure NOP 92A1, " Problem Report Program," Step 6.5.3 directs that Severity Level I problem report evaluations be forwarded to NSRAC for their review.

However, as of January 1996, the NRC identified that NSRAC had not been forwarded l approximately one-third (60) of the Level I evaluations.  ;

4. On July 31,1996 valve MO-1001-16A ("A" RHR loop heat exchanger bypass) became l mispositioned when a reactor operator failed to follow the established RHR procedure when securing torus cooling. The valve was mispositioned for approximately 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br />.

! 5. In February 1995, a calibration problem on the "B" scale of the Rockwell Hardness Tester machine was adverse to quality and was not promptly identified or corrected. Quality 1

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control inspectors relied on verbal advice from an outside vendor rather than contacting the i- BECo measurement and test equipment personnel, as specified in the M&TE program, or initiating a problem report in accordance with NOP 92A1, " Problem Report Program". Also,

{ the degradation of a related BECo calibration block has not adequately been addressed to  ;

t date.

l l This is a Severity Level IV violation (Supplement IV)."

f in this response, we will address the individual problems of procedural usage and adequacy stated l above. The details of the requested information follows.

I REQUESTED INFORMATION i l A. Misoriented Blade Guide

! Procedure 2.2.87, ' Control Rod Drive System', Revision 53, did not provide direction to  !

} operators moving reactor fuel to verify the correct orientation of the blade guide before control i l rod insertion. As a result, on April 30,1995, control rod 18-35 was inserted into the reactor core and physically jammed into a mispositicned blade guide causing blade guide and control rod damage. (Reference problem report (PR) 95.9255)

1. Reasons for Violation The direct cause of this event was poor communications between the control room panel C905 operator and the refueling bridge senior reactor operator (SRO) which led to a control rod being inserted with no concurrent monitoring of the cell from the refueling bridge personnel. Contributing causes included 1) a procedure (2.2.87) which did not specifically require monitoring by personnel on the refuel floor,2) the refueling bridge SRO allowed himself to be distracted by another refueling activity while the latching evolution was continuing,3) failure of the individuals who initially installed the blade guide to recognize it was not properly seated in the cell, and 4) the limited experience of the individuals who were performing the complex and infrequently performed tasks even though those individuals had received training prior to the outage.

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2. Corrective Actions Taken and Results Achieved The Chief Operating Engineer immediately halted refueling activities with concurrence of i the Plant Manager. Refueling activities were not resumed until the Operations Section Manager, Chief Operating Engineer, Plant Manager, and Vice President-Operations discussed with all operations personnel the significance of the event, its relationship to previous events, and reinforced management expectations that the pace of activities should ensure careful performance of the task. Also, procedure 2.2.87 was revised to require verification and monitoring when these tasks are being performed. The SRO involved is no longer performing licensed operator activities.

Inspections of affected components indicated they were all capable of continued service with the exception of control rod blade 18-35 which was replaced on May 1,1995. No other blade guides were mispositioned following these corrective actions.

Also, Licensed Operator Requalification Training (LORT) on this event was completed in January 1997 prier to RFO#11.

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3., Corrective Actions Planned No further corrective actions are planned.

4. Completion Date for Full Compliance Full compliance was achieved in January 1997 upon completion of LORT on this event.

l B. Mispositioned Rod Procedure 9.13, Control Rod Sequence and Movement Control, Revision 12, Attachment 3 listed control rods to be moved. During the power reduction required on October 6,1995,  ;

operators did not follow the reverse order of the pull sheet as evidenced when control rod 34-  ;

23 became mispositioned. (Reference PR 95.9528)'

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1. Reasons for Violation j The root cause of this event was related to less than adequate human factors and human error. Control room personnel were reacting to a rapidly degrading condition in  :

the screenhouse that necessitated a reduction in power to allow a seawater pump to be -

secured. The pull sheet was misread during a period in which numerous activities required monitoring creating an undue sense of haste. Additionally, the operators involved did not effectively use self-checking techniques.

A contributing cause was inadequate communications between the control room and ,

screenhouse. An inoperable page in the screenhouse necessitated the use of

, communications in altemate locations. This caused a delay in getting critical information I l to the control room adding to the sense of urgency felt by control room personnel. l Also, procedures were less than optimum. The control rod withdrawal sequence sheet ]

(procedure 9.13, Attachment 3) was cluttered, and the format was not conducive to l inserting control rods in reverse order under the conditions experienced during this event.  !

Also, procedure 2.4.154 contained unnecessary steps to be followed in a transient

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condition, resulting in delays in securing the seawater pump (i.e., required closing a valve '

in the discharge path prior to tripping the pump).

Training omissions occurred. Although both operators involved had approximately nine years experience, neither had previously been involved with a transient that required a rapid power reduction by inserting rods in reverse order of the pull sheet. Moreover, ,

simulator training did not provide scenarios that would have prepared them to perform j this activity under abnormal circumstances.

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2. Corrective Actions Taken and Results Achieved Upon discovery of the mispositioning, core thermal limits were verified, and the correct control rod pattern was established. The Operations Department Manager was notified, and an electronic mail message was sent to all operations personnel alerting them of the event.

Procedures 9.13 and 2.1.14 were revised to provide a method for rapidly lowering power with a selected set of control rods. This control rod set is the rapid power reduction (RPR) array and provides the required power reduction with only eight discrete rod l

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, , movements. The RPR is graphicalin nature thereby improving the ability to read the pull sheet.

All licensed operators have received training on the methods to rapidly reduce power using the RPR array. Operators commented favorably on this method.

Communications deficiencies between the control room and the screenhnuse were corrected under maintenance request (MR) 19502521, and a new cellular communications system is being implemented.

The Operations Department Manager discussed this event with alllicensed operators during Plant Status Update training (session O-RQ-04-01-04). The review included:

. A review / technical discussion of the event

. Changes made to procedures to establish the RPR array

. Management expectations for the use of the RPR array

. Management expectations for reactivity control turnover

. Management expectations for independent verification of control rod manipulation (when required, when not required).

. Management expectations for command and control / oversight by NWEs and NOSs

. Management expectations for promptly informing management of anomalies noted during steady state and transient operations Following the technical evaluation, procedure 2.4.154 was revised to allow tripping the seawater pump prior to closing the valve in the discharge path.

A practice requiring reactivity changes to be made one method at a time (i.e., reduce core flow, then insert control rods) was established through issuance of NOP 96A3, Reactivity Management Program in June of 1996.

No further control rod mispositioning events have since occurred at Pilgrim Station.

3. Corrective Actions Planned Complete installation of the new cellular communications system by June 30,1997.

4. Completion Date for Full Compliance Full compliance was achieved with the issuance of NOP 96A3, " Reactivity Management Program", in June of 1996 and completion of operator training on the NOP in January 1997.

C. NSRAC Distribution Nuclear Operating Procedure NOP 92A1, " Problem Report Program," Step 6.5.3 directs that Severity Level I problem report evaluations be forwarded to NSRAC for their review. However, as of January 1996, the NRC identified that NSRAC had not been forwarded approximately one-third (60) of the Level I evaluations. (Reference PR 96.0025) 4

D j , 1.. Reasons for Violation  ;

l The cause of this problem was a failure to follow the requirements of nuclear operating ,

i procedure (NOP) 92Ai, Section 6.5.3[5] which states, "The PR Coordinator should l

forward all Significance Level 1 completed evaluations to the NSRAC Coordinator for  !

9 . information purposes only." This failure to follow procedure is attributable to inattention '

to detail on the part of the cognizant Problem Report Coordinator. Contributing to this failure was the lack of an administrative process to ensure the required evaluations were 4

sent for NSRAC review. j j I l 2. Corrective Actions Taken and Results Achieved The Problem Report Coordinator responsible for forwarding the required evaluations is l

l no longer employed by Boston Edison Company. Also, the sixty items that should have j been sent to NSRAC were identified and forwarded to NSRAC for their review.

Additionally, a reporting mechanism has been established in the corrective action

program database to ensure all required evaluations are forwarded for distribution to NSRAC.

The NSRAC routinely receives all required information. No further problems have been ,

identified.  !

3. Corrective Actions Planned 1 No further corrective actions are planned. 1

4. Completion Date for Full Compliance Full compliance was achieved upon completion of the improvements to the corrective action database in February 1996.

D. Mispositioned Valve I On July 31,1996, valve MO-1001-16A ("A" RHR loop heat exchanger bypass) became misposinoned when a reactor operator failed to follow the established RHR procedure when securing torus cooling. The valve was mispositioned for approximately 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br />. (Reference PR 96.9383)

1. Reasons for Violation The first causal factor was failure to follow procedure. The operator did not intentionally fail to perform the procedural step to open the subject valve nor did he forget how to close the valve; bl.t rather, the operator forgot to perform the step. Although operators are committed to strict adherence to procedures, they are not necessarily required to l have the procedure in hand while executing an evolution, particularly if the evolution is performed frequently. In this case, the operator had referred to the procedure prior to commencing the evolution. Contributing to the operator's error were distractions that diverted his attention during this evolution (i.e., a communications page that required a response).

Another reason for the error was failure of the control room supervisor to maintain proper oversight of ongoing activities. Contributing to the supervisor's error was overconfidence in the operator's ability not to make an error.

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b l The remaining causes are associated with the failure to discover the mispositioned valve

during two shift tumovers. The cause was inattention to deta5 during shift tumover walkdowns of control boards.

2. Corrective Actions Taken and Results Achieved All operations shifts were briefed on the incident and the procedure 1.3.34 requirements.

Also, management expectations were reviewed for 1) procedural adherence, particularly the 2.2. series operating procedures which do not have to be in hand,2) supervisory oversight of critical evolutions, and 3) control board walkdowns at shift tumover.

The operator and supervisor involved in the mispositioning event were counseled by the Operations Department Manager, as were the operators and supervisors who failed to discover the mispositioned talve during tumover. All the errors were logged in the operations human performance matrix for trending. The supervisor involved was removed from the watchb5 to receive additional training because of a declining performance trend for this individual. The supervisor successfully completed additional training and was placed back on the watchbill after successfully completing interviews with the Operations Training Department Manager, Operations Department Manager, and the Plant Manager.

Refresher training on self-checking techniques is periodically provided to licensed operators who are also reminded that managers expect these techniques to be applied when following procedures and during preshift tumover contro' board walkdowns.

No further valve mispositioning events have since occurred.

3. Corrective Actions Planned The Operations Department Manager will have an independent assessment performed by licensed industry peers of Pilgrim Station conduct of operations in 1997.

4. Completion Date for Full Compliance Full compliance will be achieved by the end of 1997.

E. Hardness Tester Calibration In February 1995, a calibration problem on the 'B' scale of the Rockwell Hardness Tester machine was adverse to quality and was not promptly identified or corrected. Quality control inspectors relied on verbal advice from an outside vendor rather than contacting the BECo measurement and test equipment personnel, as specified in the M&TE program, or initiating a

- problem report in accordance with NOP 92A1, ' Problem Report Program'. Also, the degradation of a related BECo calibration block has not adequately been addressed to date.

(Reference PR 96.0369 and Quality Assurance Surveillance Report 96-066)

Rockwell Hardness Tester HDT-002 is maintained by BECo M&TE personnel and operated by receipt inspection personnel. M&TE personnel are responsible for ensuring the tester is calibrated in accordance with the M&TE Program as controlled by procedure 1.3.36. The tester is calibrated by the vendor (Wilson Instruments) annually under this program. The tester is issued to receipt inspection personnel on a long-term basis, and they are responsible for performing calibration checks prior tc use.

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The timeline for this event is as follows:

January 1994 Calibration performed by vendor March 1994 Repair and calibration by vendor November 1994 Calibration by vendor; replaced damapd 1/16" ball cap February 1995 Receipt inspectors question Channel B calibration. From this point on, Channel B is used twice by receipt inspectors March 1995 Routine annual calibration check performed by BECo M&TE; results satisfactory May 1995 The ball penetrator is impacted by a unistrut channel; vendor assistance is requested by receipt inspection personnel June 14,1995 Calibration check performed by BECo M&TE; Channel B is found out-of-tolerance; a " limited use" status is applied to the tester (the same technician and calibration block were associated with the March 1995 calibration check)

June 21,1995 Calibration of the tester and replacement of ball penetrator performed by vendor; tester found to be in calibration; calibration block (s/n 87H34072) is found out-of-tolerance by the vendor, BECo M&TE removed the block from service Procedurd adherence problems associated with this event occurred in February 1995 when receipt inspection personnel failed to notify BECo M&TE personnel as required by procedure 1.3.36 when they questioned the calibration of the Channel B scale. The BECo M&TE personnel are responsible for contacting the vendor if their expertise is required. Also, receipt inspection personnel did not issue a problem report as required by NOP92A1, Another procedural adherence problem occurred following the June 14 calibration by BECo M&TE when they failed to promptly issue an out of calibration report as required by procedure 1.3.36.

1. Reasons for Violation The reasons for the violation were determined to be knowledge based in that receipt inspection personnel were not fully aware that hardness tester calibration was the responsibility of the M&TE group and, hence, was subject to the procedural requirements of 1.3.36. Also, they were unaware that a problem report should be generated when an out-of-tolerance condition is discovered. Moreover, the M&TE supervisor did not realize procedure 1.3.36 required an out of calibration report be issued promptly upon discovery of the potential out-of-tolerance condition of the tester.

2. Corrective Actions Taken and Results Achieved Personnelin the receipt inspection area have been replaced by others as part of a procurement services contract. They have been trained on procedure 1.3.36 and the need to contact M&TE personnel with any test equipment problems instead of calling 7

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described in NOP92A1.

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The M&TE supervisor and his manager reviewed the 1.3.36 requirement for prompt

documentation on an out of calibration report of M&TE found out of calibration tolerance.

The expectation of procedural adherence was also reinforced. M&TE personnel have

, also been retrained on the importance of reporting problems in a timely manner and in

! accordance with NOP92A1.

6-Aside from the procedural issues, concem about the potential for parts to have been )

inappropriately accepted needed to be evaluated. This concem was alleviated through a  ;

F record search that produced the information used for the above time line. It shows that i j the tester was in calibration at all times even prior to the June 21 calibration (i.e., the

calibration data taken before and after replacement of the ball penetrator was the same, 3

and no adjustments were necessary). Even though the tester had been in calibration, l Channel B of the tester was only used twice to test parts (reference MRIRs 95-1285 and l 95-1190) between February 1995 when calibration first became suspect and June 1995 I when the vendor confirmed the tester was still in calibration. The tested components were either retested satisfactorily using Channel A or installed in non-safety applications.

Moreover, because the tester was always in calibration, it shows that the calibration block (s/n 87H34072) was in tolerance until June 1995 when the discrepancy was noted.

The hardness tester procedure (Quality Control Instruction 7.15) was revised to ensure notification of M&TE personnelif calibration checks are found to be out of tolerance.

Also, it was confirmed that training on the hardness tester includes proper installation of the ball penetrator since proper positioning is not described in the vendor manual nor is the need for delicacy.

No other calibration blocks have been found out-of-tolerance, nor have any further failures been identified to promptly issue out of calibration reports when required.

3. Corrective Actions Planned Based upon historical performance of numerous hardness tester calibration blocks, one  !

calibration block going out-of-tolerance can be viewed as an isolated occurrence.

However, a policy will be implemented to recertify or retire all hardness tester calibration blocks on their fifth year anniversary and every five years thereafter. Additionally, the other five calibration blocks (s/n 89120978, 89P18946, 89120668, 89120491, and 89C94684) bought under the same purchase order as the subject calibration block (NST 009016, MRlR 90-0503) will be recertified to ensure no common cause failure mode was manifested. They will then be retired. These corrective actions will be completed prior to l restart from RFO#11.

4. Completion Date for Full Compliance  !

Full compliance will be achieved when the calibration blocks are checked taen retired prior to restart from RFO#11, 8 ,

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