IR 05000295/1997002

Predecisional Enforcement Conference Rept on 970703.Areas Discussed:Violations Noted in Insp Repts 50-295/97-02, 50-304/97-02,50-295/97-07 & 50-304/97-07 on 970206-0402 & 0312-0428 & Corrective Actions

ML20149H996
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	07/16/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20149H989	List: ML20149H986 ML20149H996
References
50-295-97-02, 50-295-97-07, 50-295-97-2, 50-295-97-7, 50-304-97-02, 50-304-97-07, 50-304-97-2, 50-304-97-7, NUDOCS 9707250279
Download: ML20149H996 (64)

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U.lS. NUCLEAR REGULATORY COMMISSION l

REGION lli-

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. Docket Nos:

50 295; 50-304 Licori::9 Nos:

DPR 39; DPR-48 l

Licensee:

Commonwealth Edison Company Facility:

. Zion Generating Station I

- Dates:

July 3,1997

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. Meeting Location:

Region Ill Office 801 Warrenville Road -

Lisle, IL 60532-4351

' Type of Meeting:

Predecisional Enforcement Conference Inspection:

Zion Station February 6 - April 2,1997 March 12 - April 28,1997 Inspectors:

A. Vegel, Senior Resident inspector D. Calhoun, Resident inspector E. Cobey, Resident inspector M. Bailey, Operator Licensing Examiner, Rill G. Galletti, Human Factors Branch, NRR Approved By:

Marc L. Dapas, Chief Reactor Projects Branch 2 Meetina Summarv Predecisional Enforc_qment C_gnference on Julv 3,1997 Areas Discussed: Apparent violations identified during the inspections were discussed, along with the corrective actions taken or planned by the licensee. The apparent violations

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L concerned performance deficiencies exhibited during the reactivity control event on

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February 21,1997, improper removal of reactor coolant system flow instrumentation from service on February 22,1997, and the reactor vessel voiding event on March 8,1997.

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9707250279 970716

PDR ADOCK 05000295 G

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i Beport Details

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Persons Present at Conference '

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.Gomingnwealth Edison Comoany iComEdl.

' H. Keiser, Chief Nuclear Operating Officer, Comed T. Maiman, Senior Vice President, Comed

. J. Mueller, Site Vice President, Zion S. Perry, Site Vice President. Dresden-

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K. Graesser, Site Vice President, Byron G. Stanley, Site Vice President, Braidwood

E. Kraf ti Site Vice President, Guad Cities l

W. Subalusky, Site Vice President, LaSalle

D. Sager, Vice President, Generation Support, Comed R

R. Starkey, Plant General Manager, Zion i

R. O'Connor, Recovery Plan Manager, Zica R. Zyduck, Site Quality Verification Director, Zion

T. Luke, Engineering, Manager, Zion

- G. Vanderheyden, Operations Manager, Zion

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l L. Kelley,: Acting Training Manager, Zion.

j K. Dickerson, Executive Assistant, Zion R. Godley, Regulatory Assurance Manager, Zion D. Farr, Operations Manager, LaSalle

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l R. Wegner, Operations Manager, Byron

D. Cooper, Corrective Action Manager, Comed T. Gierich, Operations Manager, Byron

D. Cook, Operations Manager, Quad Cities i

T. Palanyk, Acting Assistant Shift Operations Supervisor, Dresden.

D. Ferg, Lead Offsite Reviewer, Comed M. Burns, Acting System Engineering Supervisor,. Zion M.-Korchynsky, Shif t Manager, Dresden i

l B. Kugelbery, Communications Director, Comed l

H Kim, PWR Safety Analysis Supervisor, Comed J. Lewand, Corporate Licensing, Comed D. Smith, Nuclear Communications, Comed p

1. Johnson, Licensing Director, Comed l

F. Spangenberg, Regulatory Assurance Manager, Dresden H

L. Holden, Nuclear Licensing Administrator, Comed L

C. Peterson, Regulatory Affairs, Quad Cities

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l T. Peterson, Nuclear Licensing Administrator, Quad Cities G. Wald, Nuclear Communications Administrator, Comed R. Temple, Comed

D. Jankins, Law Department, Comed b

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!). S. Nuclear Reaulatory Commission i

A. Beach, Regional Administratcs, idll R. Capra, Director, Projects Division ill-2, NRR G. Grant, Director, Division of Reactor Projects (DRP), Rill J. Lieberman, Director, Office of Enforcement (by telecon)

i B. Berson, Regional Counsel, Rill

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M. Ring, Chief, Engineering Branch, Rlli M. Leach, Chief, Operator Licensing Branch, Rill M. Dapas, Chief, DRP Branch 2, Ritt M. Parker, Acting Chief, DRP Branch 2, Rlli D. Hills, Project Engineer, Rill A. Vogel, Senior Resident inspector, Rlli C. Shiraki, Project Manager, NRR E. Cobey, Resident inspector, Rlli J. Heller, Enforcement, Rlli J. Strasma, Public Affairs Q1hE F. Tomczyk, Area Manager, Westinghouse R. Vollmer, Consultant, Indos Energy Group M. Wilson, Reporter, WKRS Radio C. Nicodemos, Reporter, Chicago Sun-Times P. Kendall, Chicago Tribune J. Yesinowski Resident Engineer, Illinois Department of Nuclear Safety

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11.

Ergd_qgigjnnal Enforcement Coqf.erencm A Predecisional Enforcement Conference was held in the NRC Region lil Office on July 3,1997. This conference was conducted as a result of the findings of two inspections conducted from February 6 through April 2,1997, and from March 12 through April 28,1997, in which apparent violations of NRC regulations were identified. Inspection findings were documented in inspection Report

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Nos. 50-295/97002; 50 304/97002 and 50-295/97007; 50-304/97007, transmitted to the licensee by letters dated June 4 and May 21,1997, respectively.

The purpose of this conference was to discuss the violations, root causes, contributing factors, and the licensee's corrective actions.

During the Predecisional Enforcement Conference, the licensee acknowledged most of the vio!ations. However, the licensee maintained that a failure to report the reactor vessel voiding event was not a violation of NRC requirements, but that a voluntary report would have been appropriate. The licensee's presentation included characterization of each event's safety significance and the status of correctiva action implementation for each of the events. Copies of the NRC's and the licensee's handouts are attached to this report.

Attachments: As stated

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ATTACHMENT NRC HANDOUT i

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1he apparent violations discussed in the predecisional enforcon.ent ccetererte are subject to further review and are subject to change prior to any resulting enformmnt action 1.

10 CFR Part 50, Appendix B Criterion V. " Instructions, Procedures, and Drawings," requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings.

Zion Administrative Procedure (ZAP) ZAP 300-01, " Conduct of a.

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Operations," Revision 3,Section VI.A, states that the Shift Engineer SHAll, maintain a broad perspective of operational conditions affectir'g the safety of the station as a matter of highest priority at all times.

Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, while the licensee was performing a Unit 1 shutdown, the Shift Engineer failed to maintain a broad perspective on operational conditions

affecting safety of the station as a matter of highest priority, in that, significant control rod manipulations made by the primary Nuclear Station Operator went unnoticed.

b-ZAP 300-01, " Conduct of Operations," Revision 3,Section VI.A, states that operations personnel SliALL be attentive to the condition of the plant at all times.

i Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, while the licensee was performing a Unit 1 shutdown, the Unit Supervisor failed to be attentive to the condition of the plant at all times, in that, significant control rod manipulations made by the primary Nuclear Station Operator went unnoticed by him.

The cppan,nt violeu orm discussed in the preaeu uunal entonement w ence are subJeCl LO turt her review co1 arr subject to change pi ior to any result inq onf m ent action

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The apparent violations discussed in the predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement action

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ZAP 300-01 A, " Control Room Access and Conduct," Revision 4 Section i

Vill.A, requires that Control Room business SHALL be conducted at a location and in such a manner that neither on-shift licensed personnel i.

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attentiveness nor the professional atmosphere is compromised.

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Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, the presence of an excessively large number of individuals in the control room and other numerous distractions caused a loud and -

disruptive environment. As a result, licensed personnel attentiveness and

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the professional atmosphere of the control room were compromised.

d.

ZAP 300-01, " Conduct of Operations," Revision 3,Section VI.A, defines infrequently performed evolutions as evolutions whereby the performance frequency is greater than annually AND the evolution requires the coordination of two or more departments or three or more individuals AND has the potential to adversely affect reactivity control OR core cooling and required a briefing be conducted prior to the evolution.

Contrary to the above, an activity affecting quality was not accomplished J

in accordance with the applicable procedure. Specifically, on February i

21,1997, the licensee performed an evolution to maintain the reactor at the point of adding heat - an evolution which had not been performed in the last 12 months, required the coordination of three or more people, and had the potential for adversely affecting reactivity control-without conducting a pre-evolutionar / briefing for this infrequently performed

. evolution.

t ZAP 300-09, " Station Operational Communications," Revision 3, Section e.

i Vll A.3, requires that if the receiver does not understand the communication, then the receiver must promptly inform the sender and ask the sender to repeat or rephrase the message.

I Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February i

21,1997, the primary Nuclear Station Operator failed to promptly inform

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the unit supervisor (the sender) that he did not understand the

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communication concerning driving in control rods and ask the unit l

supervisor to repeat or rephrase his message.

tre accarent violations discussed i'1 the riredecisionn) enforcemem mnf erence are sonmct

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c aer ruiew and are sutuect to chnrme prior h am teu tno em imwt ar t im I

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. The apparent violations discussed in the predecisional enforcement conference are subject to

.further review and are subject to change prior to any resulting enforcement action

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ZAP 300-09, " Station Operational Communications," Revision 3, Section L.

Vll.A.3, requires that all operational communications.Sil LL utilize three-A

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way communications. The procedure further defines three-way communication as "The technique of the sender issuing a communication

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' that is repeated back by the receiver of the communication and confirmed by the sender to be the correct communication."

Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, the primary Nuclear Station Operator (the sender) and the Unit Supervisor (the receiver) failed to use three-way communications, in that,

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l after the primary Nuclear Station Operator announced the low rod insertion limit, the Unit Supervisor did not verbally repeat the alarm and the primary Nuclear Station Operator did not confirm the communication.

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ZAP 300-01, " Conduct of Operations," Revision 3,Section VI.A,' requires that all planned reactivity changes are done in a controlled manner, that the effects of reactivity changes are known and monitored, and that any.

anomalous indication is met with conservative action.

l Contrary to the above, an activity affecting quality was not accomplished

in accordance with the applicable procedure. Specifically, on February 21,1997, the primary Nuclear Station Operator failed to perform reactivity changes in a controlled manner by excessively inserting control rods and then withdrawing control rods.

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ZAP 300-018, " Reactivity Management Guidelines," Revision 1, Section G.2.c, states that strict reactivity controls are required to minimize the potential for core damage, and that all plant personnel, particularly operators, must stop and question unexpected situations involving reactivity, criticality, power level, or core anomalies.

Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, the primary Nuclear Station Operator failed to utilize strict

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reactivity controls when he did not stop and question unexpected changes -

in reactivity and power level as he continuously inserted control rods. As a result the primary Nuclear Station Operator made the reactor

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substantially sub-critical and then attempted to retum the reactor to the point of adding heat by continuously withdrawing control rods.

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lThe apparent violat' ions discussed in the predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement action i-i.

ZAP 300-01B, " Reactivity Management Guidelines," Revision 1, Section l

G.1.1, requires the Qualified Nuclear Engineer to implement the reactivity management policy by providing technical advice on assigned system and reactivity related matters.

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Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, the Qualified Nuclear Engineer failed to provide technical advice to the primary Nuclear Station Operator concerning the excessive control i

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rod manipulations.

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ZAP 300-01, " Conduct of Operations," Revi.s. ion 3,Section IX.E. requires the individual who is to perform the activity is responsible to adequately review the procedure.

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Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February

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21,1997, the primary Nuclear Station Operator, Unit Supervisor and Shift Engineer failed to adequately review General Operating Procedure (GOP)

4, " Plant Shutdown and Cooldown," prior to performing the Unit 1 shutdown.

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ZAP 300-02, "Use of Procedures in Operating Department," Revision 10,Section VI, requires that 1E an activity or evolution should not or cannot continue per the governing procedure as written, THEN; immediately notify the responsible supervisor.

Contrary to the above, an activity affecting quality was not accompiished in accordance with the applicable procedure. Specifically, on February 21,1997, upon determining that the reactivity changes should not continue per GOP-4, step 5.21 f ine primary Nuclear Station Operatur continued to perform reactivity manipulations and did not notify the Unit Supervisor.

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GOP-4, " Plant Shutdown and Cooldown," Revision 13, step 5.21.f, states,

" Hold "#363, ROD MOTION CONTROL" switch IN to minimize dumping steam and establish power at or less than the Point of Adding Heat (2.5 x 10E-2% intermediate range (IR))."

Contrary to the above, an activity affecting quality was not accomplished in accordance with the applicable procedure. Specifically, on February 21,1997, the primary Nuclear Station Operator failed to follow GOP-04, step 5.21.f, in that, he failed to manipulate the control rods to establish reactor power at the point of adding heat.

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The apparent notat ions discussed in t he ;;reaecisional einormwn1, on w -w e oro forther revies and are subject 1o chance or mr t e anv + wit o'

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lhe apparent violations discussed in the predecisional enforcement conference are subject to further review arid are subject to chanqe prior to any resulting enforcement action 2.

10 CFR Part 50, Appendix B, Criterion XVI," Corrective Actions," requires that rneasures be established to assure that conditions adverse to quality are promptly corrected, and in the case of significant conditions adverse to quality, that measures be established to assure that the cause of the condition is determined and corrective actions taken to preclude recurrence, Contrary to the above, on February 23,1997, conditions adverse to a.

quality -- such as command and control, reactivity management, and communication deficiencies - were not promptly corrected prior to retuming licensed operators that were involved in the February 21,1997, reactivity management event to licensed duties.

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Contrary to the above, from February 28,1996, to February 21,1997, following the identification of an adverse trend in reactivity management activities -- a significant condition adverse to quality -- measures were not established to determined the cause of the adverse trend and corrective actions were not taken to preclude recurrence as demonstrated by the February 21,1997, reactivity management event.

Contrary to the above, from April 8,1996, to February 21,1997, following c.

receipt of a Notice of Violation (50-304/96005-03) that identified an inadvertent mode change -- a significant condition adverse to quality that was caused by poor communications, weak command and control, and poor reactivity management - corrective actions taken to preclude recurrence were not adequate to preclude recurrence as demonstrated by j

the February 21,1997, reactivity management event.

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Contrary to the above, from September 16,1996, to February 21,1997, corrective actions taken to preclude recurrence of conditions adverse to quality -- such as command and control, communication, and reactivity management problems --identified during the Unit 1 startup were not adequate to preclude recurrence as demonstrated by the February 21, 1997, reactivity management event.

hee car ent violations discussed in the predecisional enf orcement conf erence are subject to furth0r nmew and are subject to change prior to any resulting enforcemont action l

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The apparent violations discussed in the predecisional enforcement conference aro subject to further review and are subject to change prior to any resulting enforcement action

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Technical Specification (TS) 3.1. " Reactor Protection Instrumentation and Logic."

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requires, that with the minimum number of operable channels below the limits

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specified by Table 3.1-1, " Reactor Protection System - Limiting Operation i

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. Conditions and Setpoints," plant operation shall be as specified in Column 5 of

' Table 3.1-1 which required that if minimum conditions are not met within 24

hours, the unit shall be in Cold Shutdown conditions within an additional 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.

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Contrary to the above, on February 24,1997, the licensee failed to comply with-the Limiting Condition for Operation of TS 3.1 when Unit 1 was not placed in cold shutdown conditions within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of rendering all three-reactor coolant system loop "A" flow instrumentation channels inoperable.

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10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Actions," requires that measures be established to assure that conditions adverse to quality are

.promptly identified and corrected, and in the case of significant conditions adverse to quality, that measures be established to assure that the cause of the condition is determined and corrective actions taken to preclude recurrence Contrary to the above, from September 2,1996, through March 8,1997, the licensee had not established measures to assure that the cause of a significant condition adverse to quality - gas accumulation within the Unit 1 reactor vessel head, on September 2,1996 -- were determined and corrective actions taken to preclude recurrence. As a result, the event recurred and a significant gas accumulation was identified within the Unit 1 and Unit 2 reactor vessel head en March 8,1997. Additionally, the licensee had not adequately evaluated and implemented timely and effective corrective action for generic industry information pertaining to the accumulation of gas in the reactor coolant system.

inaccurate water levelindication while shutdown, loss of reactor coolant inventory while shutdown, and gas transfer from the volume control tank to

various safety related systems, which could have precluded the September 1996 and March 1997 events from occurring.

The apparent violations discussed in the predecisional enforcement conference are suh.jea o further review and are subject to change prior to ary resulting enforcment action (

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The apparent violations discussed in the predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement action 5.

10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances

and be accomplished in accordance with these instructions, procedures, or drawings.

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Contrmy to the above, as of March 8,1997, procedures for activities a.

affecting quality such as extended operation in cold shutdown were not

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appropriate to the circumstances. Specifically, no operating procedures were prescribed which provided guidance on maintaining indication of reactor vessel water level while the plant was in cold shutdown.

Consequently, this prevented the timely identification and resolution of gas accumulation within the reactor vessel.

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Contrary to the above, as of April 2,1997, operating procedures utilized for activities affecting quality during cold shutdown conditions were not appropriate to the circumstances in that they did not include measures to i

diagnose or prevent the undetected accumulation of gas in the reactor coolant system. Specilically:

(1)

PT-0, Appendix E-3, Operating Surveillance Checksheet,"

(Nuclear Station Operator's shiftly surveillance while in Mode 5) did not include measures to identify the accumulation of gas, such as monitoring RVLIS. Consequently, when RVLIS was trending downward on Unit 1 from March 4 through 8,1997, operators failed l

to identify that a void was being created in the reactor head.

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Abnormal Operating Procedure 6.3, " Loss of Shutdown Cooling,"

relied on pressurizer fievelinstrumentation for determining reactor vessel water level. Consequently, had the accumulation of gas continued to the point where shutdown cooling was affected, the j

recovery from the event could have been significantly complicated.

i op; ** < + mlat iom disc ussed in the predecisionai enf orcement conter ence ar e subject to

• o f urt h,a revim and are subject to change prior to any result inq enforcement action

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The apparent violations discussed in the predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement action 6.

10 CFR Part 50.72(b)(2)(iii)(B) requires that the licensee shall notify the NRC as soon as practical, and in all cases within four hours, of any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.

Contrary to the above, on March 8,1997, the licensee identified that gas was accumulating in the reactor vessel head on both Unit 1 and Unit 2. This cbndition (undetected gas accumulation in the reactor coolant system) could have potentially caused the loss of both trains of shutdown cooling prior to the gas bubble reaching the size where pressurizer level would have provided direct indication of reactor vessel water level. Additionally, the gas in the reactor coolant system could have accumulated in the steam generators which would have resulted in the obstruction of natural circu' tion cooling. However, the licensee did not make a four-hour non-emergency report to the NRC.

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10 CFR Part 50.73(a)(2)(v)(B) requires that the licensee sha;l submit a Licensee Event Report within 30 days after the discovery of the event, for any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.

Contrary to the above, on March 8,1997, the licensee identified that gas was accurnulating in the reactor vessel head on both Unit 1 and Unit 2. This condition (undetected gas accumulation in the reactor coolant system) could have potentially caused the loss of both trains of shutdown cooling prior to the gas bubble reaching the size where pressurizer level would have provided direct indication of reactor vessel water level. Additionally, the gas in the reactor coolant system could have accumulated in the steam generators which would have resulted in the obstruction of natural circulation cooling. However, the licensee did not submit a Licensee Event Repor1 within 30 days from the discovery of the event.

lurther mm. and m e subst m cnon, primhe apparent nolauons discussed in a.,

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ATTACHMENT

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LICENSEE HANDOUT

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Zion Station i

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Enforcement Conference

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July 3,1997

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Comed - Zion Station

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Agenda

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e Opening Remarks John Mueller i

e Shutdown Chronology Robert Starkey

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e Safety Significance Robert Starkey E. Hak-Soo Kim i

.hael Burns

e Control Rod Movement Timothy O'Connor

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NOD Cross-Site Actions John Mueller/ Harry Keiser

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e Gas Accumulation in the RCS George Vanderheyden

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t e Technical Specification George Vanderheyden Compliance - RCS Flow Instruments

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e Closing Remarks John Mueller

Comed - Zion Station

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I John Mueller

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Site Vice-President - Zion Station Comed - Zion Station

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Control Rod Movement Event Chronology

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t Robert Starkey Plant General Manager - Zion Station

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Shutdown Event Chronology m m - wamrr-

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i 2/19 1020 1C Containment Spray Pump inoperable

2/21 0700 Shift turnover with Unit 1 at 42% power 0800 POD meeting addressees that Unit 1 should be prepared for shutdov/n, action

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plan for 1C CS pump; Qualified Nuclear Engineers (QNEs) told to meet with shift management at 0930 0800 Shift Engineer (SE) and U1 Unit Supervisor (U1 US) engaged in shutdown preparation activities 1040 CS pump 48-hour LCO time expires; Tech Specs require Unit 1 to be in hot shutdown within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> (by 1440)

1100 Site Vice President (SVP) holds discussions re shutdown with Unit 1 operating

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crew management, U1 Shift Operations Supervisor (U1 SOS), U1 Operations Manager (U1 OM), U1 Plant Manager (U1 PM)-- emphasis on safe Unit shutdown 1110 Shutdown briefing held with Unit 1 operating crew

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Shutdown Event Chronology

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2/21 (cont...)

1209 Power reduction began at ramp rate of 1/4% per minute

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1240 Independent Safety Engineering Group engineer discusses LCO expiration time with SE 1255 SE notified the US that LCO had expired at 1020 rather than 1040 and that shutdown clock would expire at 1420 rather than 1440 1405 18 AFW pump started 1405 SE decides that reactor should be kept criticalin Mode 1 1405+

U1 US read steps to Primary NSO (PNSO); PNSO questions whether he should hold the rod motion switch in; U1 US reads step again; PNSO did not further question direction 1407 PNSO began inserting control rods continuously; numerous secondary alarms 1409 During continuous rod insertion, RP1, control bank C Demand Deviation, Control Rod Bank Limit Low and Control Bank Limit Low-Low aiarms received.

Primary QNE (PQNE) saw Bank C inserting and told PNSO that he was uncomfortable with reactor condition

,

Comed - Zion Station

.

-.

.

.

..

.

.

.

_

.

.

-.

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Shutdown Event Chronology

. mm

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2/21 (cont...)

1411 PNSO stops control rod insertion with Control Bank C at step 104 1411 Determined that control rod insertion alone resulted in reactor being in Mode 3 1412 PNSO began control rod withdrawal in attempt to return to POAH (from substantial subcritical condition; PQNE expresses concerns to PNSO who shares view; rod pulls continue; determined that CS pump would not be returned to operability prior to expiration of shutdown timeclock 1414 PNSO stopped control rod withdrawal; US instructed PNSO to trip reactor 1415 Reactor tripped 1500 Two QNEs discussed concern with SE re continuous control rod insertion and withdrawal 1551 PIF prepared, U1 SOS notified 1730 Meeting between ONE, U1 OM, U1 SOS

,

1800 U1 PM contacted by U1 OM re " procedure problem"

'

'

2230 U1 OM notifies U1 PM, updates event status L

,

Comed - Zion Station

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Shutdown Event Chronology

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2/22 0700 U1 PM notifies Plant General Manager (PGM) of event, then notified SVP 0900 Recreation of event on simulator

~0900 NRC notification re shutdown problems

~1000 SVP arrives at simulator; directs both units to be placed in cold shutdown 1230 SVP notifies Executive VP for Nuclear Operations of event; U1'PM contacts NRC Resident inspector 1700 U1 PM, U1 OM, and U1 SOS discuss returning licensed individuals involved in i

event

!

to shift; U1 OM and U1 SOS return crew to shift 2/23 0700 SE, US, PNSO resume shift duties 0850 U1 US initiates PIP re GOP-4, step 5.21.f 1000 Meeting between SVP, PGM, U1 PM, U1 OM -- SVP directs U1 OM to remove crew from licensed duties

1245 SE, US and PNSO formally suspended from licensed duties Comed - Zion Station

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i Robert Starkey

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Plant General Manager - Zion Station

!

.

Dr. Hak-Soo Kim o

PWR Safety Analysis Supervisor - Nuclear Fuel Services l

l Michael Burns -

,

Acting System Engineering Manager - Zion Station

!

Comed - Zion Station

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Control Rod Movement Event

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Safety Significance

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Control Rod Movement Event

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Safety Significance

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CONCLUSIONS Actual safety consequences - None

Potential safety consequences - Minimal Challenges to RPS Inoperable Equipment Effect

- Containment isolation Valves

- Hydrogen Recombiner f

- Diesel-driven Containment Spray Pump

- Main Feedwater Regulating Valve Bypass

- Penetration pressurization air compressor

- Component cooling water pump l

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Comed - Zion Station

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Control Rod Movement Event Safety Significance amm. m-

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e Factors for regulatory significance

Management Oversight Fundamental Knowledge / Training

Planning and Briefing l

t Organizational Behaviors

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Communications Corrective Action Program

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i SQV/ISEG Oversight l

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.

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h Post-Event Activities Immediate Actions

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Directed that both units be placed in cold shutdown i

e Directed that Operators be removed from shift

'

e Requested initiation of Level i PIF investigation by corporate team

,

i

.

e Continuous control room management oversight to cold shut-down

!

!

I e

Limited plant evolutions l

Evolution coverage once in cold shut-down

!

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Comed - Zion Station

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-

_ _ - -

- - -

_

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Control Rod Movement Event Corrective Actions

.

Timothy O'Connor Restart Manager - Zion Station

,

,

Comed - Zion Station

-

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Post-Event Activities Corrective Actions

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Development of Comprehensive Corrective Actions

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e 1997 Business Plan analysis independent Safety Assessment

,

Past NRC and INPO inspections i

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i Comed - Zion Station

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Corrective Actions

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e Demonstration of plant readiness L

e Support to Operations f

Effective corrective action program j

Effective oversight

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Corrective Actions

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Operators

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,

o Operations selection process / crew reconstitution l

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e Operations standards Evolution briefing i

Communication Board awareness

.

Decorum and formality

o Crew remediaton (Phoenix)

Comed - Zion Station

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i Operations Performance (continuedD t

Management Support to Operations

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Defined accountabilities for all Operations positions l

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Clear concise chain of command

Communications flow

'

Responsibilities /accountabilities flow q

e Traming

'

Permanent program changes

,

!

e Support for Operation's laaaership role Procedure change process

,

System Engineering and Operations shift interface improved Technical Specifications implementation i

Professional work spaces

!

Operations Work Control Center l

'

Comed - Zion Station

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Control room corrective work i

Open operabilities j

Annunciator alarms l

Temporary alterations

!

Backlog of open temporary procedures

,

o Modifications on long standing issues e All preventive maintenance tasks current e Plant system performance indicator process

!

-

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Comed - Zion Station

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___ _ ___ _

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Post-Event Activities i

Corrective Actions

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j Management Demonstration of Plant Readiness j

e Plant operational testmg l

e Verification of Operator performance by observation Adherence to standards

,

Preplanning of evolutions

,

Control of evolutions by shift management i

'

Crew communications

Control room decorum and formality f

e Verification of site team's support of Operations

Identification of issues and communications to management Correct issues that affect the operators

'

n Getting work done to support Operations l

Minimal distractions to the control room

f e

Performance evaluation review Comed - Zion Station

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- - - -

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Post-Event Activities

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Management Support to Operations for Continuous

!

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.

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Implement Corporate Corrective Action Program (NSWPs)

increase management involvement - Condition Review Group j

Improve corrective action effectiveness - Corrective Action Review Board

!

Expand root cause analysis training j

e Operation experience review i

Review previous 5 years of OPEX information f

Screen items for evaluation prior to restart

{

e Department self assessments i

Focus support for Operations Establish critical self assessment capability Comed - Zion Station

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.

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _

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Post-Event Activities

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Verification of Timely and Effective Corrective Actions

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e SQV independent assessments Focused operations assessments

!

Assess effectiveness of the Recovery Plan objectives

!

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Comed - Zion Station

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Comed - Zion Station

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Comed - Zion Station

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Gas Accumulation in the ~

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RCS

,

!

George Vanderheyden Operations Manager - Zio'n Station

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Comed - Zion Station

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____________.__--_______________________________--__________j

-_

-

Gas Accumulation in the RCS

,

Chronology m'.Y.L :.'.' ETT' 1.'..'4 M."Je" J"'9 7.-Di ', ;Trd (I / 7"'

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9/1/96 Gradual decrease in Unit 1 reactor vessel water level noted on RVLIS 9/2/96 U1 reactor vessel head vented; determined that 1028 gals. required to fill vessel; root cause investigation initiated 10/30/96 Root cause investigation, recommended corrective actions approved by j

!

Engineering, forwarded to Operations for approval 11/4/96 SQV notes unresolved CAR 12/14/96 Ops Mgr. delays addressing root cause investigation until after U2 refueling outage j

completion based on lack of immediate concern 1/8/97 SQV update CAR, recognizing that corrective actions are overdue 2/12/97 GOP-04 entered to cool down U2 RCS to allow for thermocouple repair 2/15/97 GOP-04 exited; Mi-01 entered to partially drain the RCV for T/C repair 2/18/97 RVLIS taken OOS for 18 mo. surveillance / calibration

2/20/97 U2 RCV fill and vent completed

2/21/97 U2 RVLIS calibration completed; not returned to service (not required until after RCS solid and pressurized): work to RTS U2 halted following U1 event

,

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l Comed - Zion Station

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Gas Accumulation in the RCS Chronology

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_

3/6/97 Control Room Operator observes increasing U2 VCT and increasing U2 PZR level t

3/7/97 Void confirmed; corrective actions taken -VCT pressure adjusted 3/8/97 U2 vessel vented, RVLIS placed in service (approx. 6,900 gal to fill void; U1 in similar condition -- reactor head vented - 1090 gals required to fill void) PlF written by Operations Manager

,

3/18/97 ISEG submits revision to upgrade unresolved CAR (for 9/96 event) to Severity Level 1

-

3/25/97 System Engineering recognizes ongoing accumulation of U2 vessel head

'

'

gasses 3/29/97 U2 vented gases sampled -- air indicated, results questioned

4/3/97 PT-0, App. E-3, " Operating Surveillance Checksheet" revised to implement Operating

Special Procedure 97-014, " Maintaining RCS Conditions in Mode 5" 4/4/97 Team established to review voiding circumstances and ongoing gas accumulation 4/6/97 U2 gases sampled; gases consistent with VCT gas composition

!

,

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Comed - Zion Station

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_ _ _ _ _ _ _ _.

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!

Gas Accumulation in the RCS

,

i Immediate Corrective Actions

---

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Operators informed senior management j

e i

!

i A procedure was developed and implemented to vent gas j

e

.

!

e Put RVLIS in service l

.

.

i Lowered VCT pressure

.

e i

!

-

Standing order to vent daily e

!

i

!

!

!

Comed - Zion Station

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l

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Gas Accumulation in the RCS

.

Gas Accumulation Analysis

---=L_._

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i

e Primary mechanism for accumulation understood

.

Higher gas solubility in VCT than in RCS Analytical confirmation Validated by effectiveness of corrective measures taken to i

eliminate

!

- Fully effective on Unit 1

- Ongoing accumulation (~10% of original rate) on Unit 2 l

Same mechanism as September 1996 event j

e Ongoing accumulation controlled on Unit 2

'

Procedures for diagnosis

,

Routine venting

Accumulation ceased following pressurizer level increase No accumulation observed since 6/3/97 i

Comed - Zion Station

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_ - -

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.

Gas Accumulation in the RCS Gas Accumulation Ana~ Lysis m-awm3_

y m a c rz. m Reactor vessel and relevant elevations

.

e 591'-0" Vessel flange

,

e 588'-4.5" Water level in vessel e

584'-8" Procedural low limit for mid-loop operation

,

e 584'-6" Surge line is uncovered

[

-

e 584'-3" WCAP-11916 minimum conservative hot leg level that avoids air binding @ 3000 gpm (includes

1" for instrument inaccuracies)

<

e 584'0" Center line of the hot leg e

578'-10" Top of the core Discussion

'

e Self arresting gas accumulation @ el. 584'-6"

e Although Zion has experienced air binding when RCS <584'-6" Pressurizer level adds NPSH to RHR pump

,

e Unlikely that Zion would experience a loss of shutdown cooling e

Core would remain covered Comed - Zion Station

,

.

t

_

- - _ _. _.

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_ _ _ _

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_

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t Gas Accumulation in the RCS

.

Causal Factors

!

__ _ _ _ _,namwem-33;g wrm_

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e Corrective action follow-up incomplete l

!

e Evaluation and implementation of industry information t

!

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Procedure scope l

.

i e Lack of training on RVLIS use during shutdown t

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!

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!

!

Comed - Zion Station

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Gas Accumulation in the RCS

Causal Factors anc Corrective Actions

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Corrective action follow-up incomplete

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Corrective Action Program enhancements Daily focus on corrective actions

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l Comed - Zion Station

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.

Gas Accumulation in the RCS Causal Factors ancL Corrective Actions

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---

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eCausal Factor Evaluation and implementation of industry information i

eCorrective Actions j

Five year review of past OPEX information New Operating OPEX staff position dedicated to providing j

additional levels of review for-

!

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- Applicability of OPEX, and l

,

- Breadth of responsive actions

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Comed - Zion Station

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-

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Gas Accumulation ~in the RCS i

Causal Factors ancL Corrective Actions

---

_:- -

--

-

e Causal Factor

'

Procedure Scope

.

e Corrective Actions OSP 97-014, " Maintaining RCS Conditions in Mode 5," developed and implemented

.

- Reduce accumulation due to solubility

[

Depressurized VCT e

e Adjust RCS/VCT temperature

- Monitor RVLIS

- Instructions on Venting

Survey industry for best practices

!

!

.

Comed - Zion Station

i

.

- -

-

- -

-

-

- - - - -

_ - - _

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Gas Accumulation in the RCS

.

Causa~ Factors anc. Corrective Actions l

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eCausal Factor

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.

Lack of training on RVLIS use during shutdown

eCorrective Actions

,

!

On-shift training provided to the operators Training added to ILT and LOCT for RVLIS operation and gas f

accumulation when shutdown

-

,

Comed - Zion Station

!

. -

-

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-. -..

Gas Accumulation in the RCS

.

Safety Significance m.

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Regulatory Significance

,

e Response to generic communications

o Corrective action implementation e

Procedures e Training j

Actual Safety Consequences

-

e None

!

Potential Safety Consequences

i e

Minimal

~

New core i

Unlikely to affect shutdown cooling

Reduced RCS inventory l

Becomes self venting

!

-i Comed - Zion Station

'

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_

_- -.

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Gas Accumulation in the RCS

-

Reporting

.

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,

'

o Comed recognizes the importance of voluntary NRC notification for events such as this

,

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e Our evaluation determined:

The event did not actually affect or involve component or train i

The event alone could not affect component or train

,

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Comed - Zion Station

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Gas Accumulation in the RCS

Closing Remarks t

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i John Mueller Site Vice-President - Zion Station

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Comed - Zion Station

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Technical Specification

Compliance - RCS Flow

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Instruments l

!

I (

i George Vanderheyden j

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Operations Manager - Zion Station t

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RCS Flow Instruments Chronology m ~ - -

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2/22 1310 Loop A Flow Transmitters authorized for OOS 1330 Informed that U1 will be going to cold shutdown 1454 Loop A Flow Transmitter OOS 1500 Conducted a brief of GOP-4 to take the unit to cold shutdown 2/23 1601 Started U1 RCS cooldown

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2/24 1900 A review of TS Table 3.1-1 shows that the unit was required to be in a LCO 2/22@14:54. Red phone call, Unusual Event declared.

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2/24 Cleared OOS (Loop A RCS Flow Transmitter)

2/25 2123 Cold shutdown Comed - Zion Station

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RCS Flow Instruments

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i e Operators did not use Technical Specifications to determine Action Requirements

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Corrective Actions

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t e Standards clearly define use of Technical Specifications

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o Created training exercises to train on Technical Specification use o Evaluation of crews performed to verify standards are met e Expectations reinforced on-shift with on-shift monitoring i

and management observation

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Sa ety Significance e

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Regulatory Significance e Technical Specifications must be implemented as written

Actual Safety Consequences e

None

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Potential __Safetv Consequences e

Minimal Instrument basis is that below the P-7 setpoint, all reactor trips on

low flow are not required since no conceivable power distributions

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could occur that would cause a DNB concern at this low power

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level Safety function already performed (trip breakers were open)

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Closino Remarks o

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John Mueller Site Vice-President - Zion Station Comed - Zion Station

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Enforcement Issues Summary

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EEI issues Regulatory Causal Factor (s)

Corrective Action (s)

Number Reference (Areas in Recovery Plan)

97007-O l a The failure of operations supervision Crit V; Planning & Ilricting Action Plans 2, Operator Remediation to conduct an infrequently performed ZAP 300-01 and Training ; 3; Operation's Standards evolution brief to maintain the reactor and Expectations; 4, Ops Readiness at the POAll.

Program; 5, Procedures,9. O ff-shift Command & Control.

97007-O l b The failure of the SE to maintain a Crit V; Management Oversight Action Plans 2, Operator Remediation broad perspective on operational ZA P 300-01 and Training; 3, Operation's Standards conditions affecting safety, which was and Expectations.

reflected in the failure to recognize significant control rod m anipulations.

97007-Olc The failure of the US to be attentive to Crit V:

Management Oversight Action Plans 2, Operator Remediation the condition of the plant at all times ZAP 300-01 and Training; 3, Operation's Standards which was reflected in the failure to and Expectations.

recognize significant control rod manipulations.

97007-O l d Conduct of control room activities Crit V; Organizational llehaviors Action Plans 2, Operator Remediation during the Unit I shutdown in a ZAP 300-01 A and Training; 3, Operation's Standards manner that compromised on-shift and Expectations; 4, Operational licensee personnel attentiveness and Readiness Program.

the professional [ control room]

atmosphere. Specifically, the US and SE were not attentive to ongo:ng control rod manipulations and the noise level in the control room compromised crew communications.

Comed - Zion Station

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Enforcement Issues

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eel Jssuer Regulatory Cause(s)

Corrective Action (s)

Number Reference (Areas in Recovery Plan)

97007-Ole When the NSO did not understand the Crit V; Com m unications; Action Plans 2 Operator Remediation and guidance from the US concerning ZAP 300-09 Fundamental know ledge /

Training Program; 3, Operation's driving in control rods, the NSO failed training Standards and Expectations; 4, to inform the US to repeat or rephrase Operational Readiness Program: 5, his guidance.

Procedures.

97007-01 f The failure of the NSO and US to use Crit V; Com m unications; Action Plans 2, Operator Remediation and three-way communications.

7. A P 300-09 Fundam ental know ledge /

Training Program; 3, Operation's training Standards and Expectations; 4, Operational Readiness Program; 5 Procedures.

97007-Olg By excessively inserting control rods Crit V; Fundamental knowledge /

Action Plans 2, Operator Remediation and and then non-conservatively ZAP 300-01 training Training Program; 3. Operation's withdrawing control rods, the primary Standards and Expectations; 4, NSO failed to perform reactivity Operational Readiness Program; 5, manipulations in a controlled manner.

Procedures.

97007-Olh The failure of the primary NSO to stop Crit V:

Fundamental knowledge /

Action Plans 2. Operator Remediation and and question the excessive rod ZAP 300-01B training Training Program; 4, Operational manipulation.

Readiness Program; 5, Procedures.

97007-Oli The failure of the QNE to provide Crit V; Com m unications; Action Plan 4, Operational Readiness technical advice for the excessive ZAP 300-0111 Organizational llehaviors Program.

inward and outward control rod manipulations.

97007-O lj The failure of the primary NSO, US Crit V; Planning and Briefing; Action Plans 3, Operation's Standards and and SE to adequately review GOP-4 ZAP 300-01 (!

Organizational Behaviors Expectations; 4, Operational Readiness prior to performing the Unit i IX.E)

Program;i5, Procedures.

shutdown.

Comed - Zion Station

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Enforcement Issues Summary

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eel Issue Regulatory Cause(s)

Corrective Action (s)

Number Reference (Areas in Recovery Plan)

97007-Olk The failure of the NSO to immediately Crit V; Communications; Action Plans 2, Operator Remediation notify the responsible supervisor aRer GOP-4 (Step Fundamental knowledge /

and Training Program: 3, Operation's determining that the continuous 5.21.f); ZAP training Standards and Expectations; 4, control rod insenion and withdrawal 300-02 Operational Readiness Program; 5, should not continue.

Procedures.

97007-011 The failure of the primary NSO to Crit V; Fundamental knowledge /

Action Plans 2. Operator Remediation manipulate control rods to establish GOP-4 (Step training and Training Program; 3, Operation's power level at the POAll.

5.21.0 Standards and Expectations; 4, Operational Readiness Program; 5, Procedures.

97007-02a The licensee's failure to correct Crit. X VI Corrective Actions Action Plans 8, Corrective Actions 9, command and control, reactivity Off-shift management Command &

management, and communication Control deficiencies, exhibited by the SE, US, and primary NSO,and which n;re contributing causes of the February 21 improper control rod manipulation event, before returning the operators to licensed duties.

97007-02b The failure of the licensee to take Crit. XVI Corrective Actions Action Plans 8 Corrective Actions; 9, adequate corrective actions to address Off-shift management Command &

the adverse trend in reactivity Control management activities.

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Comed - Zion Station

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Enforcement Issues Summary

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eel Issue Regulatory Cause(s)

Corrective Action (s)

Number Reference

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97007-02c The failure of the licensee to take C rit. X V I Corrective Actions Action Plans 8, Corrective Actions; 9, adequate corrective action to prevent Off-shif1 management Com mand &

recurrence of command and control, Control communications, and reactivity management problems, identified as a result of an inadvertent mode change in January 1996.

97007-02d The failure of the licensee to take Crit. X VI Correctisc Actions Action Plans 8. Corrective Actions; 9, adequate corrective action to prevent Off-shift management Com mand &

recurrence of command and control, Control.

comm unications, and reactivity management problems, identified as a resuit ofinappropriate control rod manipulations during a Unit I startup.

97007-03 The licensee's failure to comply win I S 3.1 Procedures; Verification Action Plan 9, O ff-shift management

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TS 3.1 and place Unit I in cold Practices; Review Process Command & Control

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shutdown within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> following all three RCS loop "A" flow instrumentation channels being rendered inoperable,is considered an apparent violation.

97002-01 1 he failure to implement timely and Crit. X VI Correctn e Actmns A ction Plans M, Corrective Actions; 9, effective corrective actions for a O ff-shift management Com mand &

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previous instance of undetected gas Control accumulation in the reactor coolant system in Septem ber 1996.

Comed - Zion Station

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Enforcement Issues Summary mn,wn c, anacov

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eel Issue Regulatory Cause(s)

Corrective Action (s)

Number Reference (Arras in Recovery Plan)

97002-02 De failure to have procedures for Crit. V Fundamental knowledge /

Action Plans 8, Corrective Actions, I I extended operation while in cold training; Management Operating Experience shutdown conditions and for operating Oversight; Corrective procedures toinclude measures to Actions diagnose or prevent the undetected accumulation ofgas in the reactor coolant system.

97002-03 De failure to make a four-hour non-10 CFR Part N/A N/A emergency report and submit a written 50.72(b)(2)(iii)(B)

Licensee Event Report within 30 days,

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for a condition that alone could have prevented the fulfillment of the safety function to remove residual feat.

97002-04 The failure to make a four-hour non-10 CFR Part N/A N/A emergency report and submit a written 50.73(a)(2)(v)(B)

Licensee Event Report within 30 days, fora condition that alone could have prevented the fulfillment of the safety function to remove residual heat.

Comed - Zion Station 51