EA-96-040 - Saint Lucie 1 (Florida Power & Light Co.)

March 28, 1996

EA 96-040

Florida Power and Light Company
ATTN: Mr. T. F. Plunkett
President - Nuclear Division
P. O. Box 14000
Juno Beach, Florida 33408-0420

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY - $50,000 (NRC Inspection Report No. 50-335/96-03 and 50-389/96-03)

Dear Mr. Plunkett:

This refers to the special followup inspection at the St. Lucie facility conducted on January 26-30 and February 8, 1996, with regard to a Unit 1 overdilution event which occurred on January 22, 1996. The results of our inspection were sent to you by letter dated February 22, 1996. A closed predecisional enforcement conference was conducted in the Region II office on March 8, 1996, with members of your staff (including the licensed operators involved in the event) to discuss the apparent violations, the root causes, and your corrective actions to preclude recurrence. A summary of the conference was sent to you by letter dated March 13, 1996.

Based on the information developed during the inspection and the information that you provided during the conference, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) and the circumstances surrounding them are described in detail in the subject inspection report. Violation A, described in the enclosed Notice, involved a serious lapse of attention to control room activities by a licensed operator. The operator failed to follow procedures for reactor coolant system boron dilution and failed to monitor a planned dilution evolution requiring the addition of between 25 and 40 gallons of primary makeup water which should have taken less than a minute to perform. This resulted in an unplanned reactivity addition in that the operator failed to stop the addition of primary makeup water until approximately 400 gallons were added. In addition, the operator and other crew members conducted an inadequate watch turnover. During the event, the temporary relief operator at the controls and the senior reactor operator were unaware that a boron dilution was in progress. The event also demonstrated operator performance problems in that: (1) the method routinely used by St. Lucie operators to dilute the reactor coolant system was not authorized by procedure; (2) the method used was not as described in the Updated Final Safety Analysis Report (UFSAR); (3) operators routinely performed the dilution procedure from memory when the dilution procedure was designated by administrative requirements as one requiring referral to the written procedure; and (4) operators failed to give prompt verbal notification to the Operations Supervisor of the unplanned reactivity change that had occurred. As a result of these operator errors, 100 percent reactor power was exceeded on January 22, 1996.

Violation B involved inadequate design control in that the method stated in the UFSAR for adding demineralized water and boric acid to the reactor coolant system was not appropriately translated into plant operating procedures. This condition has existed since plant licensing in January 1976 and during the periodic reviews of this procedure required by Technical Specification 6.8.2, you failed to identify the discrepancy. The root cause of this violation was the failure to implement a comprehensive review of procedural requirements against the operational methods described in the UFSAR.

Violation C involved a change that was made to the Unit 1 operating procedure for reactor coolant system boron dilution on January 23, 1996, that again differed from the method stated in the UFSAR, without performing a required safety evaluation. The UFSAR states that boron dilution must be conducted in automatic and described a flow path into the volume control tank. However, under a temporary change to the operating procedure, instructions were added for dilution in manual mode with a flowpath directly to the suction of the charging pumps. The temporary change allowed the addition of positive reactivity faster than the method described in the UFSAR and without an automatic shutoff. The temporary change was implemented on January 23, 1996, without a written safety evaluation providing a basis for this change. The root cause of Violation C was a weakness in the screening process for 10 CFR 50.59 safety evaluations of procedural changes.

The safe operation of your nuclear facility requires strict attention to plant operating conditions particularly when reactivity changes are in progress. The actual safety consequences of this event were low because the operator recognized his error and the crew took prompt actions to restore plant parameters. Consequently, 100 percent power level was exceeded for only a short period of time. However, the event is of significant regulatory concern due to the poor performance practices exhibited by your licensed operating staff and the inadequate control and evaluation of operating procedure requirements before and after the event. In addition, the NRC is concerned that management failed to set clear standards regarding operator attentiveness, watch station turnovers, and oversight of control room activities and protocol. Other weaknesses were identified with regard to operating experience feedback, instrumentation and alarm settings, and management guidance on maintaining operating parameters close to Technical Specification limits. Therefore, these violations are classified in the aggregate in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, as a Severity Level III problem.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $50,000 is considered for a Severity Level III problem. Because your facility has been the subject of escalated enforcement actions within the last 2 years, the NRC considered whether credit was warranted for Identification and Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. In this case, the NRC has concluded that it would not be appropriate to give credit for Identification because the violations were identified as a result of an event and there were prior opportunities to identify and correct the deficiencies. We are also concerned that your operating experience program failed to ensure that adequate corrective action was taken when you were advised of a similar overdilution event at Florida Power and Light Company's Turkey Point facility. With regard to consideration for Corrective Action, your immediate corrective actions included restoring plant parameters and conducting an investigation of the event. Your planned long-term corrective actions were comprehensive and included, in part: (1) corrective actions to address management issues and clarify management expectations for operating crew performance; (2) revisions of appropriate procedures and policies for reactor coolant system dilution; (3) comprehensive review of compliance with the UFSAR; (4) changes to the 10 CFR 50.59 screening process; and (5) counseling and training plant staff. The NRC determined that credit was warranted for the factor of Corrective Action, and that a base civil penalty is appropriate.

Therefore, to emphasize the importance of control over operational activities affecting safe plant operations and in consideration of your previous escalated enforcement actions, I have been authorized, after consultation with the Director, Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) in the base amount of $50,000 for the Severity Level III problem.

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.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, 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.

Sincerely, Original Signed by Stewart D. Ebneter Stewart D. Ebneter Regional Administrator

Docket No. 50-335
License No. DPR-67

Enclosure: Notice of Violation and Proposed
Imposition of Civil Penalty

cc w/encl:
B. Bohlke
Vice President
St. Lucie Nuclear Plant
P. O. Box 128
Ft. Pierce, FL 34954-0128

H. N. Paduano, Manager
Licensing and Special Programs
Florida Power and Light Company
P. O. Box 14000
Juno Beach, FL 33408-0420

J. Scarola
Plant General Manager
St. Lucie Nuclear Plant
P. O. Box 128
Ft. Pierce, FL 34954-0128

E. Weinkam
Plant Licensing Manager
St. Lucie Nuclear Plant
P. O. Box 128
Ft. Pierce, FL 34954-0218

J. R. Newman, Esq.
Morgan, Lewis & Bockius
1800 M Street, NW
Washington, D. C. 20036

John T. Butler, Esq.
Steel, Hector and Davis
4000 Southeast Financial Center
Miami, FL 33131-2398

Bill Passetti
Office of Radiation Control
Department of Health and
Rehabilitative Services
1317 Winewood Boulevard
Tallahassee, FL 32399-0700

Jack Shreve
Public Counsel
Office of the Public Counsel
c/o The Florida Legislature
111 West Madison Avenue, Room 812
Tallahassee, FL 32399-1400

Joe Myers, Director
Division of Emergency Preparedness
Department of Community Affairs
2740 Centerview Drive
Tallahassee, FL 32399-2100
Thomas R. L. Kindred
County Administrator
St. Lucie County
2300 Virginia Avenue
Ft. Pierce, FL 34982

Charles B. Brinkman
Washington Nuclear Operations
ABB Combustion Engineering, Inc.
12300 Twinbrook Parkway, Suite 3300
Rockville, MD 20852

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NOTICE OF VIOLATION
AND
PROPOSED IMPOSITION OF CIVIL PENALTY

Florida Power and Light Company Docket No. 50-335 St. Lucie Unit 1 License No. DPR-67 EA 96-040

During an NRC inspection conducted on January 26-30, 1996, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the Nuclear Regulatory Commission proposes to impose a civil penalty 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 penalty are set forth below:

A. Technical Specification 6.8.1.a requires that written procedures be established, implemented, and maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A includes operating procedures for the chemical and volume control system and administrative procedures for relief turnover, procedural adherence, and authorities and responsibilities for safe operation.

Operating Procedure No. 1-0250020, Boron Concentration Control - Normal Control, Revision 35, step 8.5.14, requires, in part, that when adding a blend of primary makeup water and boric acid to the reactor coolant system by using the manual mode of operation and a flow path directly to the charging pump suction, that operators monitor the water flow totalizer and close valve V2525 after the desired volume was added.

Administrative Procedure No. 0010120, Conduct of Operations, Revision 79, Appendix D, Crew Relief/Shift Turnover, requires, in part, that, for short term watchstander relief, a turnover be conducted including: general watchstation status, off-normal conditions, and tests in progress.

Administrative Procedure No. 0010120, Appendix M, Procedural Compliance and Implementation, requires, in part, that controlled procedures be implemented and complied with in accordance with the instructions provided in QI 5-PR/PSL-1. Procedure QI 5-PR/PSL-1, Preparation, Revision, Review/Approval of Procedures, Revision 67, Section 5.13.2, provides that all procedures shall be strictly adhered to and identified that Operating Procedure 1-0250020 was not considered "skill of the trade" and was not to be performed from memory without referring to the procedure.

Administrative Procedure No. 0010120, Appendix E, Notification of Operations Supervisor/FPL Management, requires, in part, prompt verbal notification of the Operations Supervisor for unplanned reactivity changes.

Contrary to the above:

1. On January 22, 1996, at approximately 2:30 a.m., the licensee failed to implement the requirements of Operating Procedure No. 1-0250020 in that Unit 1 operators failed to monitor the water flow totalizer and failed to close valve V2525 after the desired volume of primary makeup water was added to the reactor coolant system when using the manual mode of operation and a flow path directly to the charging pump suction. Specifically, during a planned addition of between 25 and 40 gallons of primary makeup water, operators failed to stop the addition of primary makeup water until approximately 400 gallons were added which resulted in a power increase over 100 percent reactor power.

2. On January 22, 1996, at approximately 2:30 a.m., the licensee failed to implement the requirements of Administrative Procedure No. 0010120 in that the Unit 1 operator at the controls conducted an inadequate short term watchstander relief turnover. Specifically, the operator failed to include general watchstation status and conditions including the RCS boron dilution that was in progress. As a result, the relief operator at the controls was unaware that a boron concentration dilution was in progress and failed to adequately monitor and control the dilution.

3. On January 22, 1996, at approximately 2:30 a.m., the licensee failed to implement the requirements of Administrative Procedure No. 0010120. Specifically, operators performed Operating Procedure 1-0250020 from memory, without referring to the procedure, and without adhering to the procedure.

4. On January 22, 1996, between 2:30 a.m. and 5:45 a.m., the licensee failed to implement the requirements of Administrative Procedure No. 0010120 in that operators failed to give prompt verbal notification to the Operations Supervisor of unplanned reactivity changes that had occurred. (01013)

B. 10 CFR 50, Appendix B, Criterion III, Design Control, requires that measures be established to assure that applicable regulatory requirements and the design basis, as specified in the license application, are correctly translated into procedures.

Units 1 and 2 Technical Specifications (TS) 6.8.2 requires that each procedure of TS 6.8.1 be reviewed periodically as set forth in administrative procedures. TS 6.8.1 requires that written procedures be maintained covering the activities recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A included operating procedures for the chemical and volume control system. Procedure QI 5-PR/PSL-1; Preparation, Revision, Review/Approval of Procedures, Rev. 61; required that all plant procedures shall be reviewed every 36 months.

Section 15.2.4.1 of the Updated Final Safety Analysis Report (UFSAR) states, in part, that during normal operation, concentrated boric acid is mixed with demineralized makeup water... and is automatically introduced into the volume control tank in response to a low water level signal from the volume control. To effect boron dilution, the makeup controller mode selector switch must be set to "Dilute" and the demineralizer water batch quantity set to the desired quantity. When the specific amount has been injected, the demineralizer water control valve is shut off automatically.

Contrary to the above, from approximately January 24, 1976 (before the Unit 1 operating license was issued), through January 23, 1996, the licensee failed to correctly translate the design basis, as specified in UFSAR Section 15.2.4.1, into procedures in that the UFSAR description of the method for adding a mixture of boric acid and demineralized water to the reactor coolant system was not incorporated into the Operating Procedure No. 1-0250020, Boron Concentration Control - Normal Control, Revision 35, for St. Lucie Unit 1. Specifically, Operating Procedure No. 1-0250020 described a method for adding a mixture of boric acid and demineralized water to the reactor coolant system (in manual and directly to the suction of the charging pumps) that was different from the method stated in the UFSAR (in automatic and to the volume control tank). Further, the licensee failed to conduct an adequate periodic review of Operating Procedure No. 1-0250020 as required by TS 6.8.2. Specifically, during periodic reviews, the last of which was accomplished on July 11, 1995, the licensee failed to correct the difference between the procedure and the UFSAR. (01023)

C. 10 CFR 50.59 allows the licensee to make changes to its procedures as described in the Safety Analysis Report (SAR), without prior Commission approval, unless the change involves, in part, an unreviewed safety question. The licensee shall maintain records of changes in procedures made pursuant to this section, to the extent that they constitute changes in procedures as described in the SAR. These records must include a written safety evaluation which provides a basis for the determination that the change does not involve an unreviewed safety question.

Contrary to the above, on January 23, 1996, the licensee made Temporary Change 1-96-017 to Operating Procedure 1-0250020, Boron Concentration Control - Normal Operation, Revision 35, a procedure described in the UFSAR, and failed to include a written safety evaluation which provided a basis for the determination that the change did not involve an unreviewed safety question. Specifically, the licensee added instructions for dilution in manual and directly to the suction of the charging pumps which is contrary to the UFSAR, paragraph 15.2.4.1, which states that boron dilution must be conducted in the "Dilute" mode (such that when the specific amount has been injected, the demineralized water control valve is shut automatically) and described a flow path into the volume control tank. (01033)

These violations represent a Severity Level III problem (Supplement I). This problem is applicable to Unit 1 only.
Civil Penalty - $50,000.

Pursuant to the provisions of 10 CFR 2.201, Florida Power and Light Company 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 Penalty (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 penalty 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 penalty 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 penalty 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 penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, 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 penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.

In requesting mitigation of the proposed penalty, 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 penalty.

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 penalty, and Answer to a Notice of Violation) should be addressed to: Mr. 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 a copy to the NRC Resident Inspector at the St. Lucie facility.

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
this 28th day of March 1996