ML18037A982
| ML18037A982 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 07/06/1994 |
| From: | Machon R TENNESSEE VALLEY AUTHORITY |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9407140049 | |
| Download: ML18037A982 (26) | |
Text
A LXL~ AXE (ACCELERATED RIDS PROCESSING)
REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
CESSION NBR: 9407140049 DOC. DATE: 94/07/06 NOTARIZED:
NO FACIL:50-259 Browns Ferry Nuclear Power Station, Unit 1, Tennessee 50-260 Browns Ferry Nuclear Power Station, Unit 2, Tennessee 50-296 Browns Ferry Nuclear Power Station, Unit 3, Tennessee AUTH.NAME AUTHOR AFFILIATION MACHON,R.D.
Tennessee Valley Authority RECIP.NAME RECIPIENT AFFILIATION
Document Control Branch (Document Control Desk)
DOCKET g
05000259 05000260 05000296 P
SUBJECT:
Responds to NRC 940606 ltr re violations noted in insp rept 50-259/94-09,50-260/94-09
& 50-296/94-09.Corrective action:
bulletins were distributed to describe managements expectations
& heighten awareness of BFN personnel.
DISTRIBUTION CODE:
IEOID COPIES RECEIVED:LTR l ENCLj SIZE: /E TITLE: General (50 Dkt)-Insp Rept/Notice of Violation Response NOTES:
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RECIPIENT ID CODE/NAME PD2-4-PD WILLIAMS,J.
COPIES LTTR ENCL 1
1 1
1 RECIPIENT ID CODE/NAME TRIMBLE,D COPIES LTTR ENCL 1
1 INTERNAL: ACRS AEOD/DSP/ROAB AEOD/TTC NRR/DORS/OEAB NRR/PMAS/ILPBl NUDOCS-ABSTRACT OGC/HDS3 RES/HFB EXTERNAL: EG&G/BRYCE,J. H.
NSIC 2
AEOD/DEIB 1
AEOD/DSP/TPAB 1
DEDRO 1
NRR/DRCH/HHFB 1
NRR/PMAS/IRCB-E OE~-
1 G FIL 02 1
GN2 FILE 01 1
1 NRC PDR 1
1 1
1 1
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1 1
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NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE! CONTACTTHE DOCUMENTCONTROL DESK, ROOM Pl-37 (EXT. 504-2083 ) TO ELIMINATEYOUR NAMEFROM DISTRIBUTIONLISTS FOR DOCUMENTS YOU DON'T NEEDI TAL NUMBER OF COPIES REQUIRED:
LTTR 23 ENCL 23
4
Tennessee Vattey Autnority, Post Othe Box 2000, Decatur ~ Alabama 35609.2000 R. D. (Rick) Machon Vce President, Browns Ferry Nootear Ptant July 6, 1994 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C.
20555 10 CFR 2 Appendix C
Gentleman:
In the Matter of Tennessee Valley Authority Docket Nos.
50-259 50-260 50-296 BROWNS FERRY NUCLEAR PLANT (BFN) - NRC INSPECTION REPORT 50 259 50 260 r 50 296/94 09 REPLY TO NOTICE OF VIOLATION (NOV).
This letter provides our reply to the violation with three examples for inadequate drawings and failure to follow work instructions transmitted by letter from Jon R. Johnson,
- NRC, to O.
D. Kingsley Jr.,
TVA, dated June 6,
1994.
We admit that each example of the violation occurred as described.
I share your concerns regarding the events that led to the issuance of this NOV.
Your concerns are consistent with the message I am receiving from the quality assurance organization and the results of ongoing self assessment programs.
I am not satisfied with the progress we have made to date as evidenced by the additional examples that have been identified since issuance of this NOV, therefore, I have initiated a Level A Problem Evaluation Report chartering a
broad based investigation team.
Although the individual instances are for the most part non-consequential taken together they indicate a condition that is unacceptable to me.
The particulars in the NOV focus on maintenance, however, internal indications show similar issues in other site organizations and, therefore, we are responding to the issue from a site-wide perspective.
r~ r'~+
p 9407i40009'4070k PDR ADOCK 0500025'st Q
U.S. Nuclear Regulatory Commission Page 2
July 6, 1994 In addition to the corrective actions taken to address each of the examples discussed in the
- NOV, we have and will be taking additional action to make procedural compliance a
site-wide issue.
For example, we have been monitoring maintenance work order closures via a peer review and have noted improvement.
Enclosure 3 provides a summary of our work order peer review program results.
Based upon the posit:ive result:s achieved through this process we will apply it to the work in progress phase.
I am convinced that our employees know my expectations including the need to be intrusive and self critical concerning procedural adherence, however, I am not convinced that the message is consistently implemented.
Therefore, we are taking the next step; holding our managers, supervisors and employees directly accountable.
I have completed a
maint:enance work stand down.
During the break I have reaffirmed my expectations specifically to mid-level management on full compliance with procedures and personally informed them that I intend to make full use of our disciplinary policy at every level in the organization.
I have directed my senior management to exercise the above approach with each of their departments.
We have also observed some reluctance by our employees to report individually non-consequential procedure adherence problems.
- Instead, they believe that correcting the problem on the spot is adequate.
Failure to document, these types of problems is precluding management's ability t:o trend and correct the underlying causes.
We have taken the first step to correct reporting problems.
On April 1994, we enhanced our corrective action program to include reporting of minor items.
- However, we are still on a learning curve.
Low threshold issues are still not consistently reported in accordance with my expectations.
0
U.S. Nuclear Regulatory Commission Page 3
July 6, 1994 As previously discussed, I am assembling a team to conduct a
broad based investigation and report to me.
In order to gain an independent perspective, the team will include members having no responsibility for the operation of Browns Ferry.
The focus of the investigation will be the identification of the underlying causes and recommending corrective actions to achieve and sustain long term improvement.
We expect to complete the initial phase of this investigation by August 26,
- 1994, and will share the results with you.
Finally, in order to assess the effectiveness of our actions, not only in maintenance, but the remaining site organizations, I have tasked the Nuclear Assurance Department to increase the monitoring and trending of procedural compliance issues.
In order to maintain wide spread visibility of their findings, we are creating a new window in our trend report to deal specifically with procedural adherence.
This window will be colored red initially.
That signifies, my belief that this is an area with "significant weaknesses."
I have instructed that the first time that the window is considered for change from red to yellow--an area where improvement is needed and from yellow to white satisfactory--that the Nuclear Assurance and Licensing Manager must personally concur with the change.
Enclosure 1 provides TVA's "Reply to the Notice of Violation" (10 CFR 2.201).
Enclosure 2 provides details of additional instances found by the NRC Resident Inspectors after this report was issued and examples of those identified by our QA organization.
Enclosure 4 contains commitments made in the reply.
If you have any questions regarding this reply, please telephone Pedro Salas at (205) 729-2636.
Sincerely, R.
D. Machon Enclosures see page 4
9
U.S. Nuclear Regulatory Commission Page 4
July 6, 1994 cc (Enclosures):
Mr. Mark S. Lesser, Section Chief U.S. Nuclear Regulatory Commission Region II 101 Marietta Street, NW, Suite 2900
- Atlanta, Georgia 30323 NRC Resident Inspector Browns Ferry Nuclear Plant Route 12, Box 637
- Athens, Alabama 35611 Mr. J.
F. Williams, Project Manager U.S. Nuclear Regulatory Commission One White Flint, North 11555 Rockville Pike Rockville, Maryland 20852 Mr. D. C. Trimble, Project Manager U.S. Nuclear Regulatory Commission One White Flint, North 11555 Rockville Pike Rockville, Maryland 20852
ENCLOSURE 1
TENNESSEE VALLEY AUTHORITY BROWNS FERRY NUCLEAR PLANT (BFN)
REPLY TO NOTICE OF VIOLATION (NOV)
INSPECTION REPORT NUMBER 50 259 I 260 I 296/94 06 RESTATEMENT OF VIOLATION 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Contrary to the above:
1.
Activities were not accomplished in accordance with instructions in that on April 19,
- 1994, work order 93-15668 for performing an 18 month preventive maintenance task on a scram pilot air header pressure regulator was not followed during isolation of the regulator.
Two valves not specified in the work order were closed resulting in a loss of air pressure and a Unit 2 reactor trip.
2.
Plant configuration controlled drawing 2-47E2610-85-7, Mechanical Control Diagram Control Rod Drive Hydraulic System was inadequate, in that on April 19, 1994, it depicted the position of Valve 2-HV-85-244, scram air header regulator outlet crossover, improperly as open, contrary to the actual closed position of the valve, the position depicted in flow diagram 2-47E820 and the licensee's system status file.
3.
Activities were not accomplished in accordance with instructions in that on April 13, 1994 and May 10,
- 1994, the prerequisite signatures for work orders 94-05786 and 94-01893 were not completed prior to the commencement of work.
These matters constitute a repeat of violation 259,260,296/93-02-01.
This is a Severity Level IV Violation (Supplement I).
The following sections provide TVA's responses to address the specifics of each of the NOV examples.
TVA's Re 1
to Ex le 1
Reason For Ex le 1 This event primarily resulted from inappropriate personnel action during maintenance on the Scram Pilot Air Header.
An Assistant Shift Operations Supervisor decided to isolate the downstream side of a pressure regulator'as a precautionary measure against
- leakage, but failed to ensure that the resulting valve, lineup would not adversely affect plant operation.
The steps to isolate the downstream side of the pressure regulator were not described in the Work Order(WO).
The individual should have taken action to verify the correct valve position before manipulating the component isolation valves.
This personnel error directly led to the reactor scram.
Contributing to this event was a discrepancy between the plant Mechanical Control Diagram and the Mechanical Flow Diagram regarding the position of cross-tie valve 2-HV 244, which, if open would have prevented the reactor trip.
The Mechanical Control Diagram depicted the correct position of the cross tie valve as open.
The Mechanical Flow Diagram depicted the normal position of the cross tie valve as closed.
2.
Corrective Ste s Taken and Results Achieved 3.
Appropriate personnel corrective actions were taken regarding the individuals involved in this event.
The corrective steps taken to resolve the drawing discrepancies are discussed below in TVA's response to Example 2.
A site-wide Bulletin was distributed to describe management's expectations for adherence to procedures (including Work Orders) for the safe and reliable operation of the plant.
Corrective Ste s That [have been or] Will Be Taken To Prevent Recurrence To heighten the awareness of BFN personnel to this typ'e of event, this event is being reviewed by the affected organizations (i.e., Operations, Maintenance, and Technical Support personnel).
TVA is developing controls which provide additional reviews for activities which have the potential to cause a reactor scram on the operating unit.
These controls provide an additional layer of oversight prior to sensitive work activities being performed.
0 TVA has revised appropriate procedures to specify the methods and controls used for documenting approval of component manipulation if it is outside the prescribed steps of a work order.
4, Date When Full Co liance Will Be Achieved Full compliance will be achieved by July 15,
- 1994, upon completion of the above corrective actions.
TVA's Reply to Example 2
Reason For Ex le 2 The reason for this event was that TVA did not maintain the valve position depicted on Mechanical Control Diagrams up-to-date.
2.
Corrective Ste s Taken and Results Achieved The immediate corrective actions were:
TVA issued Night Orders emphasizing the requirement that the Mechanical Control Diagrams are not to be utilized for valve alignments.
The Night Orders stated that Mechanical Flow Diagrams are to be used for valve manipulations.
The drawing discrepancy which contributed to this event was corrected.
TVA reviewed the Mechanical Control Diagrams for the Control Rod Drive and Control Air systems, other minor discrepancies identified by the review were corrected.
3.
Corrective Ste s That
[have been or] Will Be Taken To Prevent Recurrence 4.
Primary and critical drawings for safety systems were reviewed and similar problems will be corrected.
Date When Full Co liance Will Be Achieved Full compliance will be achieved on August 2, 1994 when the drawing discrepancies are resolved.
TVA's Re 1
to Ex le 3 Reason For Ex le 3 The reason for this example was personnel error in not ensuring that all instructions associated with the WO were followed.
In situations such as those noted in the violation, the WO is intended to be an administrative work authorization document that requires personnel to perform preventive and/or corrective maintenance using an approved implementing procedure/instruction.
Often, the precautions
authorization document that requires personnel to perform preventive and/or corrective maintenance using an approved implementing procedure/instruction.
Often, the precautions and prerequisites in the WOs are general in nature (e. g.,
contact radiological control prior to working on a contaminated instrument or system) and are general provisions provided for the safety of the workers and normally do not impact safe plant operation.
In these situations, the precautions/prerequisites applicable to safe plant operation are described in the implementing procedure/instruction.
The individuals involved in the two examples noted in the violation considered that the precautions and prerequisites stated in the implementing procedure/instruction were more specific to the work being conducted.
Consequently, the individuals involved in the two WOs did not ensure that the precaution and prerequisites steps in the WO were properly signed prior to the performance of subsequent steps.
Corrective Ste s Taken and Results Achieved The Plant Manager in a Plan-of-the-Day meeting directed his reports to discuss with their staffs the specifics of this example to emphasize the need to pay more attention to WO steps and to ensure that WOs be followed to the same extent as an implementing procedure/instruction.
The Plant Manager distributed copies of the inspection report describing the circumstances surrounding this NOV at a Plan-of-the-Day
- meeting, required his direct reports to discuss it with their personnel, and report to him that this action was completed.
A site-wide Bulletin was distributed to express management s
expectations for adherence to procedures (including WO) for the safe and reliable operation of the plant.
This NOV will be included in 1994 initial/requalification General Employee Training to further heighten personnel awareness regarding these events.
This training will continue until we have an acceptable level of performance.
The Maintenance and Modifications Manager has informed WO planners to evaluate precautions and prerequisites steps to ensure they do not duplicate implementing procedure/instruction steps to preclude desensitizing plant workers to WO steps.
Corrective Ste s That [have been or] Will Be Taken To Prevent Recurrence The corrective actions described above are considered to be adequate in preventing recurrence of this situation.
These actions will ensure that personnel document WO activities in the same manner as work instructions/procedures.
No
additional corrective actions are required.
The Nuclear Assurance
{NA) Department will assess these examples and other recent procedural events to ensure that the correct course of action is being taken and that the actions being taken are appropriate and effective over the long term.
(See Enclosure 2)
Date When Full Co liance Will Be Achieved Full compliance will be achieved with the completion of the above corrective actions by November 15, 1994.
El-5
ENCLOSURE 2 TENNESSEE VALLEY AUTHORITY BRONNS FERRY NUCLEAR PLANT (BFN)
REPLY TO NOTICE OF VIOLATION (NOV)
INSPECTION REPORT NUMBER 50-259,260,296/94-09 NUCLEAR ASSURANCE (NA) OVERVIEW PROBLEM EVALUATION REPORT NA has initiated an overview Problem evaluation report (PER) for identified BFN events similar to the examples (10 CFR 50, Appendix B, Criterion V) cited in the violation.
TVA has decided to review these isolated events to determine the aggregate effect.
This review will be tracked by TVA's PER process.
At this time, at least two similar events have been identified:
1.
On December 15, 1993, it was determined that Operators had installed the wrong fuses in a valve's control circuits.
When relocating a power supply from one compartment to another the fuses in the relocated power supply had the wrong fuses for its new application. Corrective actions were taken to preclude a recurrence.
This event was considered to be an isolated event.
2.
During an NA evaluation of the BFN Maintenance, Modification, and Technical Support groups from March 8, through July 2,
- 1993, NA cited three events where personnel did not follow their work instructions:
(1) Craft personnel using a mobile floor jack rolled a control room emergency ventilation system over an equipment hatch contrary to the work instruction; (2) A support was rotated 180 degrees from that shown on an approved drawing prior to an advance authorized field design change notice; and (3) Craft personnel performed a cut approximately two inches from an existing valve stem extension rod without prior authorization.
Since the issuance of NOV 94-09, two additional examples of not obtaining required signatures prior to commencing work have been identified by the Resident Inspectors.
These examples are also included in the NA oversight PER.
l.
A signature for a fire operations review that addressed if compensatory measures were in place was missed from a controlling attachment F document.
A review of the situation revealed that the required compensatory measures were in place even though the signature was not obtained.
were in place even though the signature was not obtained.
Personnel corrective actions were rendered in accordance with approved procedures.
A PER (BFPER 940295) was issued.
The Attachment F process will be reviewed to determine if changes are needed to be made.
Attachment Fs that were issued during the last six months will be reviewed for missed signatures.
This PER was incorporated into the NA overview PER. Appropriate corrective actions will be developed, if required, upon the completion of the NA overview.
Work to repair the 'A'lectric fire pump was performed prior to obtaining authorization from operations as required by an approved procedure.
The involved craft personnel admitted to knowing management expectations concerning the need to obtain required signatures.
This acknowledgement was due to the expedient management involvement to heighten the awareness of craft personnel as noted in Enclosure 1 of this reply.
The craft personnel understood management expectations and therefore, this event was a result of personnel error.
Personnel corrective actions were rendered in accordance with approved procedures.
Proper authorized signature was obtained.
A PER (BFN-PER-940286) was issued.
This PER was incorporated into the NA overview PER.
Appropriate corrective actions will be developed, if
- required, upon the completion of the NA overview.
E2-2
ENCLOSURE 3 TENNESSEE VALLEY AUTHORITY BROWNS FERRY NUCLEAR PLANT (BFN)
REPLY TO NOTICE OF VIOLATION (NOV)
INSPECTION REPORT NUMBER 50-259,260,296/94-09
Fiscal Year To Date Goal= Less than 9%
14 12
~
10 P
8 8
o O
P-Good Sept. 93 Oct. 93 Nov. 93 Dec. 93 Jan. 94 Feb. 94 Mar. 94 Apr. 94 May 94 June 94 error percentage errors wos 4 7%
5 0%
4.67%
4.13%
3 91%
3 9%
3 88%
4.19%
4.28%
40 87 124 160 195 247 284 348 405 849 1721 2658 3871 4982 6234 7319 8314 9463 Audit Months with Totai Number of W.O.'s Reveiwed by Craft Peer Reviewer
0
'0 ENCLOSURE 4
TENNESSEE VALLEY AUTHORITY BROWNS FERRY NUCLEAR PLANT (BFN)
REPLY TO NOTICE OF VIOLATION (NOV)
INSPECTION REPORT NUMBER 50 259 260 I296/94 09 COVER MEMO Commitments:
1.
We will apply the peer review process to the work in progress phase.
2.
TVA is assembling a team to conduct a broad based investigation.
The team will include members having no responsibility for the operation of BFN.
Focus of the investigation will be identification of the underlying causes and recommending corrective actions to achieve and sustain long term improvement.
We expect to complete the initial phase of this investigation by August 26,
- 1994, and will share the results with NRC.
1.
To heighten the awareness of BFN personnel to this type of event, this event will be reviewed by the appropriate Operations personnel.
This review will be completed by July 15, 1994.
2.
Controls will be developed which provide additional reviews for activities which have the potential to cause a reactor scram on the operating unit.
These controls will be completed by July 15, 1994.
Ex le 2 1.
Primary and critical drawings for safety systems were reviewed and similar problems will be corrected by August 2, 1994 Ex le 3 1.
Plant Manager's direct reports will discuss the NOV with their staffs.
These discussions will be completed by August 31, 1994.
2.
This, NOV will be included in 1994 initial/ regualification General Employee Training to further heighten personnel awareness regarding these events.
This training will
continue until we have an acceptable level of performance.
Incorporation into GET will be completed by July 28, 1994.
The Nuclear Assurance Department will assess these examples and other recent procedural events to ensure that the correct course of action is being taken and that the actions being taken are appropriate and effective over the long term.
This assessment will be completed by November 15, 1994.
E4-2