ML18037A982
| ML18037A982 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 07/06/1994 |
| From: | MACHON R D TENNESSEE VALLEY AUTHORITY |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9407140049 | |
| Download: ML18037A982 (26) | |
See also: IR 05000259/1994009
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 ENCL j SIZE:/E TITLE: General (50 Dkt)-Insp Rept/Notice
of Violation Response NOTES: 0 R 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 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D 0 u NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.504-2083)TO ELIMINATE YOUR NAME FROM DISTRIBUTION
LISTS 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 PDR
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).
T he 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-85-244, 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 I 296/94 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