EA-97-432 - Fort Calhoun (Omaha Public Power District)

October 24, 1997

EA 97-432

S. K. Gambhir, Division Manager
Engineering and Operations Support
Omaha Public Power District
Fort Calhoun Station FC-2-4 Adm.
P.O. Box 399
Hwy. 75 - North of Fort Calhoun
Fort Calhoun, Nebraska 68023-0399

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY - $110,000 (NRC SPECIAL INSPECTION REPORT 50-285/97-17)

Dear Mr. Gambhir:

This is in reference to the predecisional enforcement conference conducted in the NRC's Arlington, Texas office on October 7, 1997, with representatives of Omaha Public Power District (OPPD). The conference was conducted to discuss four apparent violations of NRC requirements related to an August 21, 1997 incident which resulted in the disabling of the containment spray system at the Fort Calhoun Station (Fort Calhoun) reactor facility. The NRC's inspection of this was completed on August 29, 1997, and an inspection report was issued September 19, 1997. A conference summary document, which included the information OPPD provided to the NRC at the conference, was issued October 4, 1997.

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; the circumstances surrounding them were described in detail in the subject inspection report. In brief, the violations involve: 1) a licensed operator's mispositioning of containment spray valve control switches during a surveillance test; 2) a failure to shut down the unit as required when both trains of containment spray were disabled by this error; 3) a failure by licensed operators to conduct a proper shift turnover which should have revealed that the containment spray system was inoperable; and 4) a failure by licensed operators to make proper log entries.

The containment spray system was rendered inoperable when an operator erroneously placed the control switches for containment spray header isolation valves in the "override" position during a surveillance test. These switches remained in this position for approximately 12 hours, with the plant operating at 100 percent power. Had a loss-of-coolant accident occurred during this time, the containment spray system would not have operated automatically, as designed, to spray down containment and help minimize pressure buildup in the containment building. The NRC acknowledges that a licensed operator (other than the one who made the error) discovered the mispositioned control switches for the containment spray valves approximately 12 hours after the initial error was made, and promptly restored containment spray to an operable status. We also acknowledge that OPPD promptly reported this incident to the NRC, and that significant corrective actions were taken as a result.

Although other systems at Fort Calhoun also are designed to minimize containment pressure in the event of an accident, the NRC views the August 21, 1997, event seriously because licensed operating personnel defeated a safety system and then missed several opportunities to detect it. The primary missed opportunities involved: 1) a failure to determine the cause of spray valve "off-normal" alarms which occurred when the valve switches were placed in override; and 2) a failure to recognize or question the presence of this annunciator or abnormal switch positions and indicating lights during a subsequent shift turnover and periodic control board observations. In addition, this is the second time an incident of this type has occurred at Fort Calhoun in 18 months. As OPPD acknowledged at the conference, there were similarities between this incident and a previous incident in March 1996 (EA 96-204)¹. The corrective actions you took for the previous incident included actions (e.g., shift turnover and alarm response enhancements) that should have prevented or resulted in the prompt detection of the August 21, 1997, disabling of containment spray. Both incidents involved a lack of attention to detail and poor questioning attitude, a failure to recognize that safety features were defeated, weaknesses in responding to annunciators in the control room, poor supervisory oversight, and inadequate shift turnover.

The first three violations discussed above have been classified in the aggregate at Severity Level III in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, because they involve defeating a safety system for 12 hours and violating plant Technical Specifications as a result. Although classification at Severity Level II was considered, in that containment spray would not have functioned if called upon, the NRC determined that classification at Severity Level III was more appropriate based on plant design and the contribution that the containment cooling system would make to maintain containment pressures below design assumptions. Nonetheless, the NRC's concern is focused on the root causes of these violations, in that errors of a similar nature could result in defeating safety systems that could have a greater impact on reactor safety.

In accordance with the Enforcement Policy, a civil penalty at a base value of $55,000 is considered for a Severity Level III problem. Because your facility has been the subject of escalated enforcement actions within the last 2 years, as previously discussed, 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.

The NRC has determined that credit for identification is not warranted because the condition was discovered when an annunciator failed to clear after operators attempted to restore the containment spray system to normal following the completion of the surveillance test. Thus, the inoperable condition of the containment spray system was revealed by the annunciator. At the conference, OPPD suggested that identification credit was warranted because the problem was identified during a surveillance test (NRC Enforcement Manual, 5.5.2.3). Credit would be considered if the problem was pre-existing (not caused by improper performance of the test) and not apparent for the previous 12 hours by virtue of the annunciator being lit. In summary, credit is not warranted because the problem was self-revealing and because there were missed opportunities to have discovered the problem earlier.

Credit for corrective action was found to be warranted based on the numerous corrective actions you have taken or are planning to take, which were described at the conference. These include, but are not limited to: 1) requiring additional oversight of surveillance tests; 2) identifying and marking annunciators that are expected during tests; 3) requiring senior reactor operator concurrence before disabling safety-related equipment; 4) requiring peer review prior to operating key switches; 5) requiring four-hour "standdowns" for crews returning from long breaks; 6) requiring individual control board walkdowns during shift turnover; 7) improving alarm response procedures; and 8) a formal program to assess the effectiveness of corrective actions for significant events.

While the normal civil penalty assessment would have resulted in a base civil penalty being proposed, the NRC determined that discretion as provided for in Section VII.A.1 of the Enforcement Policy should be applied to assess a penalty at twice the base value. The basis for exercising this discretion is the similarity of this incident to the March 1996 incident and the significance of two such events occurring within 18 months. In addition, we considered the fact that your corrective actions for the previous incident should have prevented this error or caught this error soon after it occurred.

Therefore, to emphasize the significance of disabling plant safety features and the failure to assure that corrective actions for a previous escalated enforcement action were effective, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regulatory Effectiveness, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) in the amount of $110,000.

The fourth violation, involving inadequate log entries, was not deemed to be a contributing cause of the disabling of the containment spray system, and was not a missed opportunity to have discovered the incident. Therefore, this violation is not among those assessed a civil penalty and has been separately classified at Severity Level IV.

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. The NRC will use your response, in part, to determine whether further enforcement action is necessary to ensure compliance with 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).

Sincerely, Ellis W. Merschoff Regional Administrator

Docket No.: 50-285
License No.: DPR-40

Enclosure: Notice of Violation and Proposed Imposition of Civil Penalty

cc w/Enclosure:
James W. Tills, Manager
Nuclear Licensing
Omaha Public Power District
Fort Calhoun Station FC-2-4 Adm.
P.O. Box 399
Hwy. 75 - North of Fort Calhoun
Fort Calhoun, Nebraska 68023-0399

James W. Chase, Manager
Fort Calhoun Station
P.O. Box 399
Fort Calhoun, Nebraska 68023

Perry D. Robinson, Esq.
Winston & Strawn
1400 L. Street, N.W.
Washington, D.C. 20005-3502

Chairman
Washington County Board of Supervisors
Blair, Nebraska 68008

Cheryl Rogers, LLRW Program Manager
Environmental Protection Section
Nebraska Department of Health
301 Centennial Mall, South
P.O. Box 95007
Lincoln, Nebraska 68509-5007

---

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY

Omaha Public Power District Docket No. 50-285 Fort Calhoun Station License No. DPR-40 EA 97-432

During an NRC inspection completed on August 29, 1997, 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. Violations Assessed a Civil Penalty

A. Technical Specification 5.8.1 requires that written procedures and administrative policies be established, implemented and maintained that meet or exceed the minimum requirements of Sections 5.1 and 5.3 of ANSI N18.7-1972 and Appendix A of Regulatory Guide 1.33. Regulatory Guide 1.33, Appendix A, Section 3.f(4) requires procedures for startup, operation, and shutdown of containment cooling systems.

Procedure OP-ST-SI-3008, "Safety Injection and Containment Spray Pump Inservice Test and Valve Exercise Test," Revision 19, established, in part, written procedures for testing the containment spray system. Step 7.10 required that Containment Spray Valves HCV-344 and HCV-345 be placed in the closed position and that the containment spray valve test switches be placed in the test position.

Contrary to the above, on August 21, 1997, Step 7.10 of Procedure OP-ST-SI-3008 was not properly implemented in that in addition to placing the containment spray valves and the containment spray valve test switches in the required position, the control switches for Containment Spray Valves HCV-344 and HCV-345 were placed in the override position. This step, which was not in the procedure, would have prevented the automatic actuation of either containment spray header, if required. (01013)

B. Technical Specification 2.4, "Containment Cooling," limiting condition for operation requires, in part, that Containment Spray Pumps SI-3A, SI-3B, and SI-3C and their associated valves, piping and interlocks be operable during power operation. The modification of minimum requirements for the specification allows for two of these pumps to be inoperable at any one time during power operation.

Technical Specification 2.0.1 requires in part that, in the event that the limiting condition for operation cannot be satisfied because of circumstances in excess of those addressed in the specification, the unit shall be placed in at least hot shutdown within 6 hours, and in at least subcritical and <300F within the next 6 hours.

Contrary to the above, on August 21, 1997, the unit was not placed in at least hot shutdown within 6 hours and was not in at least subcritical and <300F within the next 6 hours when the containment spray system was rendered inoperable from approximately 8 a.m. CST to 8:38 p.m. due to the control switches for both containment spray header isolation valves being placed in the override position. (01023)

C. Technical Specification 5.8.1, requires that written procedures and administrative policies be established, implemented and maintained that meet or exceed the minimum requirements of Sections 5.1 and 5.3 of ANSI N18.7-1972 and Appendix A of Regulatory Guide 1.33. Regulatory Guide 1.33, Appendix A, Section 1.h requires procedures for shift and relief turnover.

Procedure SO-0-1, "Conduct of Operations," Revision 33, provides procedural requirements for the conduct of shift and relief turnover. These requirements include: (1) the oncoming shift shall familiarize themselves with the conditions in areas for which they are responsible; (2) each person will brief his/her relief on the condition and status of that portion of the plant to which he/she is assigned, including abnormal conditions or alignments and inoperable equipment; and (3) prior to assuming the shift, each operator shall personally verify the status of important system operating parameters, especially those relating to safety systems.

Contrary to the above, on August 21, 1997, the licensee failed to conduct an adequate shift turnover in that the oncoming shift did not identify that the control switches for both containment spray valves were in override, rendering the containment spray system inoperable, and that the off-going crew did not brief the oncoming crew about this condition. (01033)

These violations represent a Severity Level III problem (Supplement I).
Civil Penalty - $110,000

II. Violation Not Assessed a Civil Penalty

Technical Specification 5.8.1, requires that written procedures and administrative policies be established, implemented and maintained that meet or exceed the minimum requirements of Sections 5.1 and 5.3 of ANSI N18.7-1972 and Appendix A of Regulatory Guide 1.33. Regulatory Guide 1.33, Appendix A, Section 1.h requires procedures for log entries.

Standing Order SO-0-1, "Conduct of Operations," Revision 33, required that log entries into the official control room log be made when major plant equipment/systems were place in or out of operation, and to document compliance with the requirements of a Technical Specification Limiting Condition for Operation.

Contrary to the above, on August 21, 1997, operators failed to log that the containment spray header isolation valves had been rendered inoperable by placing the control switches in override. In addition, as of 7 p.m. on August 28, operators had failed to log that Containment Spray Pump SI-3C was operable per Technical Specification 2.4(1)b. The pump had been restored to an operable status on August 21. (02014)

This is a Severity Level IV violation (Supplement I).

Pursuant to the provisions of 10 CFR 2.201, Omaha Public Power District (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 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 violation(s) 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 IV, 611 Ryan Plaza Drive, Suite 400, Arlington, Texas 76011, 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. If personal privacy or proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your response that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withholding (e.g., explain why the disclosure of information will create an unwarranted invasion of personal privacy or provide the information required by 10 CFR 2.790(b) to support a request for withholding confidential commercial or financial information). If safeguards information is necessary to provide an acceptable response, please provide the level of protection described in 10 CFR 73.21.

Dated at Arlington, Texas
this 24th day of October 1997

---

¹ The March 1996 incident involved disabling the low-temperature, over-pressure protection afforded by the pressurizer power operated relief valves. A severity level III violation, with no civil penalty (EA 96-204), was issued to OPPD on July 31, 1996.