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EA-95-126 - Crystal River 3 (Florida Power Corp.)EA 95-126 Mr. P. M. Beard, Jr.
SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL
PENALTIES - $500,000
(NRC Inspection Report Nos. 50-302/95-13 and 50-302/95-22 and Investigation
Report Nos. 2-94-036 and 2-94-036S)
Dear Mr. Beard: This refers to investigations conducted by the Nuclear Regulatory Commission (NRC) Office of Investigations (OI) completed on May 24, 1995, and February 13, 1996; and NRC inspections conducted during the period September 5, 1994, through December 15, 1995, and documented in NRC Inspection Report Nos. 50-302/95-13 and 50-302/95-22. These inspection reports also summarize related findings discussed in NRC Inspection Report Nos. 50-302/94-22, 95-02, 95-07, 95-08 and 95-09. During these reviews, the NRC examined the facts and circumstances surrounding events involving control of the pressure and level for the reactor coolant system (RCS) make-up tank (MUT) between June 1994 and September 1994 and reviewed the adequacy of design control and corrective actions that affected operability of emergency core cooling system (ECCS) pumps. By letters dated July 7, 1995, and March 8, 1996, you were provided synopses of the OI investigation reports in this case and given an opportunity to attend a predecisional enforcement conference to discuss the apparent violations, their cause, and the corrective actions to preclude recurrence. A closed, transcribed conference was conducted on March 27, 1996, in the Region II office in Atlanta, Georgia. A summary of the conference was sent to you by letter dated April 2, 1996. Subsequently, on April 4, 1996, you submitted supplemental information to the NRC regarding information which was not available at the time of the conference. Based on the information developed during the inspections and investigations as well as the information you provided during the conference and in your subsequent submittal, the NRC has determined that a number of significant violations of NRC requirements occurred. Enclosure 2 contains a Notice of Violation and Proposed Imposition of Civil Penalties (Notice) that describes the violations. The violations are discussed in more detail in Enclosure 1, and the circumstances surrounding them are described in detail in the subject inspection reports and investigation report synopses. The violations in the Notice are grouped as follows: Part I contains the violations for which civil penalties have been assessed. Item I.A involves numerous instances in which operating procedures were violated, demonstrating poor performance of the operations department in that operating limits associated with operating procedure OP-103B, Curve 8, were routinely exceeded. While there were numerous instances where operating procedures were violated, the Notice identifies examples in which operating limits were exceeded for more than 30 minutes with some as long as three hours. Item I.B involves a violation in which a crew of licensed operators conducted unauthorized tests on two separate occasions in an effort to resolve safety concerns that had not promptly been addressed by the licensee. Item I.C involves two separate violations involving the failure to promptly identify and correct conditions adverse to quality. First, the licensee failed to identify promptly that the operating curve questioned by licensed operators was, in fact, nonconservative and, second, the licensee's first three attempts at corrective action were inadequate. Item I.D consists of two separate violations involving inadequate performance by engineering in design control. The first violation involves the issuance of an inaccurate, nonconservative, design basis curve to operators to be used as an operating curve. The second violation involves the use of an inaccurate, nonconservative setpoint for the swap over of the suction for emergency core cooling system pumps from the borated water storage tank to the reactor building sump. Part II consists of additional violations that were not assessed a civil penalty: an additional Severity Level III violation for inadequate design control and two Severity Level IV violations. Although these violations did not result in any actual impact on the public health and safety, the circumstances surrounding these violations represent significant regulatory concerns. In particular, licensee management failed to exercise effective oversight in several areas that are each of vital importance in assuring the safe operation of a nuclear facility. Operations management was unaware that essentially all control room shifts were routinely violating an operating curve, yet these violations were being committed in attempts by operators to meet a chemistry goal set by senior management. Furthermore, despite the fact that the safety adequacy of the curve was formally questioned in a problem report by licensed operators, not only did management not require that the safety concern be resolved promptly, but management insisted that the plant be maintained at a hydrogen concentration that resulted in operating on or near the maximum point of the questioned curve during the several months the issue was being considered. The operating environment maintained contributed to the perceived need to conduct the September 4-5, 1994 evolutions to resolve the matter. Management oversight of engineering failed to ensure that the safety concern raised by licensed operators -- stated by the licensee not to be a routine occurrence -- with an engineering-derived curve was not aggressively pursued with a high degree of rigor. Not only did engineering fail to address the concern promptly, despite the fact that the plant was then operating in the very area of the curve questioned by the operators, but also the conclusion reached by engineering was wrong because calculational assumptions and evaluations failed to consider fundamental principles (e.g., gas absorption). These engineering performance inadequacies are of even greater concern because the questioned curve, although known by some engineers to be a design basis curve, had not been identified to operations as such and was being used as an operating curve even as its safety adequacy was in dispute. Furthermore, once the curve was confirmed to be wrong, the actions taken to correct the problem were repeatedly inadequate. Corrective action inadequacies were also demonstrated in the licensee's review of the September 5, 1994 evolution. Although several individuals within both the operations and engineering departments had knowledge of a similar evolution conducted on the previous day, the licensee's investigation was limited to interviews only with the two senior reactor operators on shift, and did not identify the occurrence of the previous evolution. A detailed event review and root cause analysis was not performed. Moreover, it was not until August 1995, about a year after the event, that a more comprehensive investigation was conducted into this matter. The NRC is very concerned about the ineffective management oversight of engineering, operations, and corrective action activities demonstrated by these violations. The NRC expects licensees to promptly address safety concerns, especially those raised by licensed operators, and to resolve them with a high degree of rigor. You did not meet these expectations in this case: managers appeared insensitive to safety concerns and did not aggressively pursue them, engineers overlooked basic scientific principles and produced inaccurate analyses, and investigations failed to identify important case facts and underlying root causes. In consideration of the high regulatory significance that the NRC finds in these violations, I have been authorized, after consultation with the Director, Office of Enforcement, the Deputy Executive Director for Reactor Regulation, Regional Operations and Research, and the Commission, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the total amount of $500,000 for the violations discussed above. The assessment process for these penalties is more fully discussed in Enclosure 1. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. I further note that the NRC is continuing to review whether there were other unauthorized evolutions at Crystal River, and further enforcement actions may be taken if additional violations are identified. In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosures, and your response will be placed in the NRC Public Document Room (PDR). To the extent possible, your response should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. Should you have any questions concerning this letter, please contact us.
Sincerely,
Original Signed by
Luis A. Reyes
Stewart D. Ebneter
Regional Administrator
Docket No. 50-302 Enclosures: cc w/encls: B. J. Hickle, Director L. C. Kelley, Director (SA2A) Rodney E. Gaddy Attorney General Bill Passetti Joe Myers, Director Chairman Robert B. Borsum Richard W. Hendrix, Esquire Bruce H. Morris, Esquire A. Failure to Follow Procedures Violation A in Part I of the Notice involves nine instances where operators violated plant procedures for maximum MUT overpressure. Specifically, during the period July 23 through September 5, 1994, operators, while adding hydrogen to the MUT for RCS chemistry control, exceeded the maximum MUT overpressure limit as defined by OP-103B, Curve 8 on numerous occasions. In addition, when plant alarms annunciated during these additions, indicating that the overpressure limit had been exceeded, operators failed to take timely action to reduce pressure to within the acceptable operating region. In one case, operation outside of the acceptable region persisted for a period of approximately three hours. B. Conduct of Unauthorized Tests Violation B in Part I of the Notice involves the conduct of unauthorized tests of MUT overpressure without preparation of the required written safety evaluations, contrary to 10 CFR 50.59. On September 4 and 5, 1994, operators planned and executed evolutions, not required by plant conditions, to collect data in order to test the validity of an operating curve, specifically, OP-103B, Curve 8. In performing these unauthorized tests, procedures also were violated when the operators permitted the MUT pressure to exceed the acceptable operating region defined by OP-103B, Curve 8 and failed to take timely action to restore MUT pressure to within limits when a valid alarm was received. In fact, during the evolutions, operators continued to take actions (i.e., decreasing MUT level) which caused MUT pressure to diverge further into the unacceptable region of OP-103B, Curve 8 in order to collect data to support their safety concern. On November 16, 1994, the licensee's evaluation determined that OP-103B, Curve 8 was in error, was non-conservative, and was a design basis limit. Therefore, during these unauthorized tests, the design basis limits for pressure/level of the MUT were exceeded. C. Corrective Action Violations Violations C.1 and C.2 in Part I of the Notice involve your failure to take adequate actions to correct design deficiencies associated with the MUT maximum overpressure curve. Regarding Violation C.1, operators had expressed concerns regarding OP-103B, Curve 8, and the concerns were formally documented in a May 1994 Problem Report (PR) following a failed high pressure injection flow surveillance test. Engineering reviews associated with the PR failed to identify errors and improper assumptions in the OP-103B, Curve 8 calculations. The errors were subsequently identified during engineering evaluations performed following initiation of PR 94-0267 which documented the results of the operators' unauthorized test on September 5, 1994. D. Design Control Violations Violations D.1 and D.2 in Part I and Violation A in Part II of the Notice involve the failure to incorporate the design basis of the ECCS into plant procedures as well as the Final Safety Analysis Report (FSAR). Violation D.1 in Part I of the Notice, involves your failure to assure that, from the time OP-103B, Curve 8 was procedurally established in January 1993 until issuance of the STI on September 9, 1994, an adequate safety margin was provided to ensure the availability of HPI for certain LOCA scenarios. The NRC is particularly concerned with this violation which reflects the inadequate engineering and technical efforts that went into the development of OP-103B, Curve 8. Specifically, evaluations and assumptions which formed the technical basis for the MUT overpressure calculations failed to consider fundamental engineering principles (e.g., gas absorption) which resulted in significant errors in OP-103B, Curve 8. In addition, although known to certain engineers, no one informed operations and personnel using OP-103B, Curve 8 that it was a design basis limit rather than an administrative limit. These violations resulted from fundamental engineering errors and lack of attention to detail and significantly contributed to the other violations described herein; therefore, this violation has been categorized as a Severity Level III violation. E. Other Violations In addition, Part II of the Notice includes two Severity Level IV violations. The violations involve: (1) the failure to implement timely corrective actions for a previous emergency diesel generator fuel oil tank level deficiency which could have identified earlier the BWST level swap over issue identified in Violation D.2 in Part I of the Notice; and (2) the failure of your fire protection surveillance procedures to verify the minimum required water volume for the fire water storage tanks. Both violations involved untimely corrective actions for Licensee Event Report (LER) No. 92-003. Florida Power Corporation Docket No. 50-302 Crystal River Nuclear Plant License No. DPR-72 Unit 3 EA 95-126 During NRC inspections conducted during the period September 5, 1994, through December 15, 1995, and Office of Investigations investigations completed on May 24, 1995, and February 13, 1996, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions," NUREG-1600, the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below: I. Violations Assessed Civil Penalties A. Technical Specification 5.6.1.1 requires, in part, that procedures be implemented covering activities as recommended in Regulatory Guide 1.33, Revision 2, Appendix A, of February 1978. Appendix A recommends administrative procedures to cover the authorities and responsibilities for safe operation and shutdown, and operating procedures for the reactor coolant system make-up system. The licensee implemented the above Appendix A recommendations, in part, through Procedure AI-500, "Conduct of Operations," and Procedure OP-402, "Make-up and Purification System." This is a Severity Level III problem (Supplement I) B. 10 CFR 50.59, "Changes, Tests, and Experiments," in part, allows the licensed facility to conduct tests not described in the safety analysis report, without prior Commission approval, unless the proposed test involves an unreviewed safety question. A proposed test shall be deemed to involve an unreviewed safety question if the probability of occurrence or the consequences of an accident or malfunction of equipment important to safety previously evaluated in the safety analysis report may be increased. The licensee shall maintain records of tests carried out pursuant to this section, including a written safety evaluation which provides the basis for the determination that the test does not involve an unreviewed safety question. This is a Severity Level III violation. (Supplement I) C. 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such as nonconformances, are promptly identified and corrected. In the case of significant conditions adverse to quality, measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.(1) Contrary to the above, significant conditions adverse to quality were not promptly identified and corrected, and action was not taken to preclude repetition. Specifically, the licensee failed to perform an adequate review of Problem Report 94-0149, issued on May 10, 1994, that identified licensed operator concerns with the accuracy of OP-103B, Curve 8. The review failed to identify promptly the significant errors that were present in OP-103B, Curve 8 and in the calculations that were the basis for the curve. As a result, plant operations using the curve frequently were outside the design bases of the facility. (03013) This is a Severity Level III violation (Supplement I) (2) Contrary to the above, significant conditions adverse to quality were not promptly identified and corrected, and action was not taken to preclude repetition. Specifically, Short Term Instruction (STI) 94-019 issued on September 9, 1994, STI-021 issued on September 11, 1994, and Revision 13 to OP-103B, "Plant Operating Curves," issued on January 30, 1995 were corrective actions once problems with the make-up tank overpressure curve were identified but were inadequate to prevent operation outside of the design basis. (04013) This is a Severity Level III violation (Supplement I) D. 10 CFR Part 50, Appendix B, Criterion III, "Design Control," in part, requires that measures be established to assure that applicable regulatory requirements and the design basis, as defined in 10 CFR 50.2, "Definitions," and as specified in the license application, are correctly translated into procedures and instructions.(1) Contrary to the above, the design basis was not correctly translated into drawings, procedures, and instructions. Specifically, between approximately April 1993 and September 9, 1994, make-up tank procedure limits for make-up tank pressure failed to meet the emergency core cooling system design basis in that Procedure OP-103B, Curve 8, "Maximum Make-up Tank Overpressure," Rev. 12, did not provide adequate margin to ensure that hydrogen entrainment in the high pressure make-up pumps was prevented when the make-up tank was operated within the specified pressure and level limits. (05013) This is a Severity Level III violation (Supplement I) (2) Contrary to the above, the design basis was not correctly translated into drawings, procedures, and instructions. Specifically, between initial operation on March 13, 1977, and February 2, 1995, except for the time period of June 1990 through April 1993, the licensee failed to correctly translate the design basis for the emergency core cooling system into the Final Safety Analysis Report, Section 6.1.2.1.2; Procedure EOP-07, "Inadequate Core Cooling;" and Procedure EOP-08, "LOCA Cooldown." The Final Safety Analysis Report, Section 6.1.2.1.2; EOP-07; and EOP-08 failed to meet the design basis in that the manual swap over from the borated water storage tank to the reactor building sump was directed to be initiated at a level of five feet or less in the borated water storage tank, which was insufficient to assure that all of the emergency core cooling system pumps would not be damaged by air entrainment from vortexing in the borated water storage tank. Additionally, the licensee had no official design calculation to support the swap over level of five feet that was incorporated into emergency operating procedures in April 1993. The official calculation, I90-0024, supported a swap over level equivalent to approximately 14 feet in the borated water storage tank. An internal engineering memorandum was inappropriately used to support the swap over level of five feet. (06013) This is a Severity Level III violation (Supplement I) II. Violations Not Assessed a Civil Penalty A. 10 CFR Part 50, Appendix B, Criterion III, "Design Control," in part, requires that measures be established to assure that applicable regulatory requirements and the design basis, as defined in 10 CFR 50.2, "Definitions," and as specified in the license application, are correctly translated into procedures and instructions. This is a Severity Level III violation (Supplement I) B. 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such as nonconformances, are promptly identified and corrected. In the case of significant conditions adverse to quality, measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. This is a Severity Level IV violation (Supplement I). C. Crystal River Facility Operating License No. DPR-72, Paragraph 2.C.(9), Fire Protection, required that the licensee implement and maintain in effect all provisions of the approved fire protection program as described in the Final Safety Analysis Report for the facility. This is a Severity Level IV violation (Supplement I). Pursuant to the provisions of 10 CFR 2.201, Florida Power Corporation (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice of Violation and Proposed Imposition of Civil Penalties (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, and if denied, the reasons why, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order or a Demand for Information may be issued as why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalties by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, money order, or electronic transfer payable to the Treasurer of the United States in the amount of the civil penalties proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalties in whole or in part, by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalties will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, in whole or in part, such answer should be clearly marked as an "Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice, in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties. In requesting mitigation of the proposed penalties, the factors addressed in Section VI.B.2 of the Enforcement Policy should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalties. Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. The response noted above (Reply to Notice of Violation, letter with payment of civil penalties, and Answer to a Notice of Violation) should be addressed to: James Lieberman, Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, One White Flint North, 11555 Rockville Pike, Rockville, MD 20852-2738, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II and to the Resident Inspector, Crystal River Nuclear Plant. Because your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. However, if you find it necessary to include such information, you should clearly indicate the specific information that you desire not to be placed in the PDR, and provide the legal basis to support your request for withholding the information from the public. Dated at Atlanta, Georgia |