United States Nuclear Regulatory Commission - Protecting People and the Environment

EA-96-070 - Braidwood 1 & 2 (Commonwealth Edison Company)

May 6, 1996

EA 96-070
EA 96-102

Mr. Thomas J. Maiman
Senior Vice President,
Nuclear Operations Division
Commonwealth Edison Company
Executive Towers West III
1400 Opus Place, Suite 300
Downers Grove, IL 60515

SUBJECT: BRAIDWOOD STATION - UNITS 1 AND 2
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY - $100,000 (NRC INSPECTION REPORT NOS. 50-456/96005(DRP); 50-457/96005(DRP))


Dear Mr. Maiman:

This refers to the special inspection conducted on January 23 through March 21, 1996, at the Braidwood Station. The purpose of the inspection was to review the circumstances surrounding mispositioning of the Unit 2 hydrogen monitor valves on January 23 and 24, 1996, and performing work on the Unit 2 safety injection system outside the established out of service boundary on March 4 and 5, 1996. Configuration control and out of service problem trends in 1995 and 1996 were also reviewed. The report documenting the inspection was sent by letter dated April 5, 1996, and a predecisional enforcement conference was conducted on April 26, 1996. You reported the Unit 2 safety injection event in a Licensee Event Report dated April 4, 1996.

Based on the information developed during the inspection and the information that was provided during the conference, the NRC has determined that violations of NRC requirements occurred. The 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.

On January 23, 1996, during surveillance testing, an operator rendered the 2B hydrogen monitor inoperable by shutting two throttle valves without using a procedure or knowing the function or correct position of the valves (slightly throttled open about 1/8 turn). During the following shift, the valves were restored to their correct position after the 2B hydrogen monitor failed its shiftly channel check. The next day operators again inappropriately shut throttle valves on the 2A and 2B hydrogen monitors rendering both trains inoperable. The error was discovered before exceeding the technical specification allowable outage time of 72 hours. Additionally, at the time of this event there was a year-old outstanding engineering request to replace the V-5 hydrogen monitor throttle valves with valves having a finer throttling control. This engineering request had been generated in response to a similar error involving inadvertent closure of a V-5 throttle valve in December 1994.

On March 5, 1996, NRC inspectors observed water flowing from a loosened flange on the discharge line of the 2B safety injection pump, which was out of service for maintenance. After the control room was contacted, operators determined that the flange was not included in the out of service boundary for work on the inoperable 2B safety injection pump, and the loosened flange created a flow path from the refueling water storage tank through the 2A safety injection pump and a cross-tie valve. The loosened flange rendered the 2A safety injection pump inoperable, as well, making both trains of safety injection inoperable. The work planner failed to provide, as required, a marked-up drawing with the appropriate isolation points indicated to the operator who prepared the out of service. Operators also failed to understand the scope of the flange work when preparing the out of service document. On March 22, 1996, your staff concluded, after a detailed engineering analysis, that the 2A safety injection pump would have performed its intended safety function with the loosened flange.

In addition, the NRC inspectors' review of your configuration control and out of service programs determined there had been numerous problems throughout 1995. In October, November, and December 1995, Site Quality Verification reports documented the problems in September through November 1995. In November 1995 your staff also documented an adverse trend in the area of configuration control. However, after the above events occurred and as of the March 21, 1996 NRC exit meeting, your staff had not taken sufficient action to correct the configuration control and out of service problems, in that similar errors continued to frequently occur. For example, an auxiliary building ventilation supply fan was approved for operation on March 12, 1996, following maintenance even though it was still disassembled; a Unit 1 containment chilled water pump was uncoupled without proper authorization on March 13, 1996; a low pressurizer level signal was inadvertently generated while de-energizing two panels to hang out of service cards on March 18, 1996; Unit 2 reactor coolant loop drain valves were mispositioned on March 23, 1996; a wrong valve was taken out of service to isolate an inoperable containment isolation valve on March 25, 1996; three thousand gallons of water were spilled because a primary water valve had its internals removed without the valve being isolated on April 16, 1996; and the service air system was cross-connected to a water system on April 24, 1996.

These failures to properly control the configuration and alignment of plant systems are a significant regulatory concern. In addition, potentially making both safety injection pumps inoperable while operating at power, and making both trains of the hydrogen monitors inoperable were significant events. These events and the other errors discussed above indicate that your personnel did not always exhibit conservative operating practices including a questioning attitude when encountering anomalous equipment situations and attentiveness when changing equipment configurations. Finally, it is not apparent whether management oversight of operations was sufficient to change this pattern of repeated personnel errors.

Your trend analysis of these problems identified a number of root causes including poor accountability and commitment, poor planning and scheduling, unclear expectations, poor communications, and poor root cause investigations. The failure to properly implement the configuration control and out of service programs is a recurrent problem and collectively represents a significant lack of attention towards licensed responsibilities. Therefore, the 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,1 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. Credit was not warranted for identification because the NRC identified the failure to promptly identify and correct the configuration control and out of service program problem. Credit was not warranted for corrective action because configuration control and out of service errors continued to frequently occur after the exit meeting up to the time of the enforcement conference. Additionally, many of your long term corrective actions were presented at the enforcement conference without scheduled completion dates. These long term corrective actions included, but were not limited to, enhanced training on out of services, co-locating the out of service group and maintenance to enhance communication, implementing an enhanced out of service procedure, improving outage planning, performing line-ups inside the out of service boundaries upon return to service, maintaining line-ups current, limiting or freezing the scope of work covered under out of services, performing corrective action effectiveness reviews, improving the root cause team evaluation process, and increasing senior management involvement with the corrective action program.

Therefore, to emphasize the need for more conservative operating practices by plant personnel and a more effective corrective action program, I have been authorized, after consultation with the Director, Office of Enforcement, to issue the enclosed Notice in twice the base amount of $100,000 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,

  Hubert J. Miller
Regional Administrator

Docket Nos. 50-456; 50-457
License Nos. NPF-72; NPF-77

Enclosure: Notice of Violation and
Proposed Imposition of Civil Penalty

cc w/encl: K. Kaup, Site Vice President
J. C. Brons, Vice President, Nuclear Support
H. W. Keiser, Chief Nuclear Operating Officer
T. Tulon, Station Manager
T. Simpken, Regulatory Assurance Supervisor
D. Farrar, Nuclear Regulatory Services Manager
Richard Hubbard
Nathan Schloss, Economist,
Office of the Attorney General
State Liaison Officer
Chairman, Illinois Commerce Commission
Document Control Desk-Licensing


NOTICE OF VIOLATION
AND
PROPOSED IMPOSITION OF CIVIL PENALTY

Commonwealth Edison Company
Braidwood Station, Units 1 and 2
  Docket Nos. 50-456; 50-457
License Nos. NPF-72; NPF-77
EA 96-070; 96-102

During an NRC inspection conducted on January 23 through March 21, 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:

I. 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. A. Braidwood Administrative Procedure, BwAP 330-1, Revision 17E1, Step c.2.a, requires if points of isolation required are different from a standard (normal) isolation, marked-up prints or a separate list shall be submitted showing the required isolation points. If the out of service is done on the computer, the prints/list will be sent to the SE office or out of service planning office, with adequate information identifying the associated out of service.

Contrary to the above, as of March 1, 1996, the cognizant work planner did not submit marked-up prints or a separate list to the SE office or out of service planning office showing required isolation points for out of service #960001992 for the 2B safety injection pump. The out of service was performed on computer and the required isolation points were different from a standard isolation. (01013)
B. Braidwood Administrative Procedure, BwAP 330-1, Revision 17E1, Step c.2 requires, in part, that the designated Nuclear Station Operator (NSO) reviews the out of service for completion and information and determines the isolation points as necessary to meet the method of isolation requested by the requestor. For out of services requiring independent verification, the out of service isolation points, sequencing, and positions are reviewed by a second qualified individual. The Unit Supervisor (designee) reviews the out of service, and independently verifies isolation points to assure opposite train operability.
Contrary to the above:
1. On February 23, 1996, the on shift NSO who prepared out of service #960001992, and a second NSO who performed an independent verification, did not adequately determine the isolation points as necessary to meet the method of isolation requested by the requester.
2. On March 1, 1996, the on shift Senior Reactor Operator did not independently verify all isolation points to assure opposite train operability for out of service #960001992, an out of service requiring independent verification. (01023)
C. Contrary to the above, on January 23 and 24, 1996, operators manipulated valves V-4 and V-5 on the 2A and 2B hydrogen monitors, without using instructions or procedures, an activity affecting quality. (01033)

II. 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, in part, that measures be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to the appropriate levels of management.

A. Contrary to the above, as of January 24, 1996, the licensee failed to promptly correct a condition adverse to quality. Specifically, on December 3, 1994, an event occurred where throttle valve V-5 was inadvertently closed on a hydrogen monitor during a surveillance. On February 16, 1995, Engineering Request ER9500287 was initiated to replace the V-5 throttle valve on each of the four hydrogen monitors with a valve having a finer throttling control because it was barely cracked open and any bumping of the valve would cause a flow problem. However, as of January 23, 1996, the licensee had not replaced throttle valve V-5 on each of the four hydrogen monitors nor implemented administrative controls to prevent two similar events from occurring on January 23 and 24, 1996. (01043)
B. Contrary to the above, as of March 21, 1996, the licensee failed to promptly identify and correct recurrent problems in the area of plant configuration control and out of services, a significant condition adverse to quality. Specifically:
  1. Site Quality Verification Reports QVL 20-95-106, QVL 20-95-110, and QVL 20-96-004, for the months of October, November, and December 1995, respectively, identified problems in the areas of plant configuration control and out of services.
  2. On November 20, 1995, the licensee documented a potential adverse trend in the area of plant configuration control (Trend 95-018).
  3. Subsequent trend investigations identified there had been numerous plant configuration control and out of service problems throughout 1995.
However, as a result of these problems not being promptly identified and corrected, a number of subsequent events occurred including uncontrolled valve manipulations which rendered both trains of the Unit 2 hydrogen monitoring system inoperable on January 24, 1996; an inappropriate out of service rendering both trains of Unit 2 safety injection inoperable on March 4, 1996; an auxiliary building ventilation supply fan was approved for operation on March 12, 1996, following maintenance even though it was still disassembled; uncoupling a Unit 1 containment chilled water pump without proper authorization on March 13, 1996; and inadvertently generating a low pressurizer level signal while de-energizing two panels to hang out of service cards on March 18, 1996. (01053)

This is a Severity Level III problem (Supplement I).
Civil Penalty - $100,000.

Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company (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 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 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 violation 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: 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 III, and a copy to the NRC Resident Inspector at the facility that is the subject of this Notice.

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 Lisle, Illinois
this 16th day of May 1996


1. A Severity Level III problem (identified in November 1994) was issued on January 25, 1995 (EA 94-261); a Seerity Level III problem (identified in February 1995) and $100,000 civil penalty was issued on May 2, 1995 (EA 95-041); and a Severity Level III problem (identified in October 1995) was issued on January 29, 1996 (EA 95-265).

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