United States Nuclear Regulatory Commission - Protecting People and the Environment

EA-97-567 & EA-97-569 - Palisades (Consumers Power Company)

April 2, 1998

EA 97-567 & EA 97-569

Mr. T. Palmisano
Site Vice President and General Manager
Palisades Nuclear Power Generating Plant
27780 Blue Star Memorial Highway
Covert, Ml 49043-9630

SUBJECT : NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES $55,000
(NRC SPECIAL INSPECTION REPORT 50-255/97014(DRS))

Dear Mr. Palmisano:

This refers to the special inspection conducted on October 28 through November 19, 1997, at the Palisades Nuclear Power Plant. The purpose of this inspection was to review the circumstances surrounding the removal of all control rods from service to conduct maintenance during power operation. These issues and the need for effective corrective actions were discussed during a public exit meeting on November 19, 1997. The report documenting our inspection activities was issued December 12, 1997. Due to the significance of these issues a predecisional enforcement conference was conducted on December 19, 1997.

Based on the information developed during the inspection and the information provided during the predecisional enforcement conference, the NRC has determined that six violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation (Notice) and Proposed Imposition of Civil Penalties. The circumstances surrounding each violation are described in detail in the subject inspection report.

The violations refer to both conduct of operations errors made by a shift operating crew and failures to follow maintenance-related procedures by maintenance personnel when power was removed from all of the control rod drives during power operation to facilitate the repair of a single control rod drive. These errors reflected significant weaknesses in pre-evolutionary preparations, communications, and supervision that resulted in the breakdown of oversight and control of operations and maintenance activities.

Specifically, during the preplanning of this activity, the operating crew failed to implement a plant procedure mandating that a safety assessment be conducted to ensure the system configuration was acceptable for the current plant status. The crew incorrectly removed power from all of the control rod drives without communicating that system configuration to the shift supervisor. Five of the on shift licensed operators did not realize that removing power to all of the control rod drives, during power operation, was a system configuration that the Technical Specifications only permitted for a limited time. Before removing power from all of the control rods, the operating crew erroneously referenced a previous tag out that had removed power from all of the control rod drives during shutdown conditions. Before starting the repair, maintenance personnel incorrectly documented that power to only one control rod drive motor was removed; the system configuration required by the maintenance procedure prerequisites. If maintenance personnel had complied with the procedure requirements and correctly verified the prerequisite, this work request could either have been deferred until the specified system configuration was established or changed to accommodate the expanded work scope. During the repair, maintenance personnel inadvertently expanded the scope of the authorized work when they removed and reinstalled relays for three additional control rod drive motors. This was accomplished without documenting the additional work activity. The shift management team failed to exercise its oversight responsibilities by failing to stop the maintenance activity or expand the scope of the post maintenance test after observing a mechanic exceed the scope of the maintenance activity by removing and reinstalling the additional relays. As a result, an inadequate post maintenance test was performed because the change in scope was not adequately communicated to maintenance or operations personnel. When the expanded maintenance scope was discussed with the operations manager, the post maintenance test was still not revised to include the expanded maintenance scope. Inherent in the failure of your staff to recognize the increased maintenance work scope and the need for additional post maintenance testing was your staff's incorrect interpretation that removing and inspecting the relays did not constitute maintenance that could adversely affect system operation.

While the NRC acknowledges that the control rods remained trippable, both manually and automatically, which ensured that the reactor protection functions provided by the control rods were available and that the control room crew had discussed contingencies needed to respond to an operational transient, the failures present in this case represent a significant lack of attention to licensed responsibilities and, therefore, a significant regulatory concern. The procedural violations evidenced by both maintenance and operations personnel, in light of their root causes discussed above, could in different circumstances present actual or potential safety consequences. Accordingly, the violations in the Notice are classified in the aggregate, in accordance with NUREG-1600, "General Statement of Policy and Procedure for NRC Enforcement Actions (Enforcement Policy)," as a Severity Level lIl problem.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $55,000 is considered for each Severity Level III problem. Because the Palisades 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. The NRC recognizes that the Palisades site management team identified many of the violations. However, the site management team did not identify the inadequate pre-evolutionary preparations, ineffective communications, and lack of supervision; that collectively these violations represented. As a result, the NRC interceded to focus the attention of plant management on the broader programmatic nature of the problem. Therefore Identification credit was not warranted. Corrective Action credit was evaluated and determined to be warranted. Corrective Actions consisted of, but were not limited to: (1) removing licensed operators from shift duties and conducting remedial training for the operations personnel on duty at the time of the event; (2) meeting with all shift operating crew members to discuss crew communications, emergent work planning, and adherence to Technical Specifications; (3) briefing maintenance workers about the event and the lessons learned from the incident; and (4) improving the mechanisms for managing emergent work and error likely situations.

Therefore, to emphasize the importance of implementing work controls for systems that are vital to plant safety, the importance of procedural compliance, and emphasize the breakdown in the conduct of operations activities, I have been authorized, after consultation with the Director, Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the base amount of $55,000.

You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In developing your corrective actions, you should address actions planned or taken, if any, to address the adequacy of your corrective actions in response to previous procedural violations involving work control and control room activities. 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.

Sincerely,



A. Bill Beach
Regional Administrator

Docket No. 50-255

Enclosure: Notice of Violation and Proposed Imposition of Civil Penalties

cc w/encl:
Robert A. Fenech, Senior Vice
President, Nuclear, Fossil
and Hydro Operations
Thomas C. Bordine, Manager
Licensing Department
Richard Whale, Michigan
Public Service Commission
Michigan Department of
Environmental Quality
Department of Attorney General (MI)


NOTICE OF VIOLATION
AND
PROPOSED IMPOSITION OF CIVIL PENALTIES

Consumers Power Company
Palisades Nuclear Generating Plant
Docket No. 50-255
License No. DPR-20
EA 97-567 & EA 97-569

During an NRC inspection conducted from October 28 to November 19, 1997, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG 1600, the NRC 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:

Palisades Nuclear Power Plant Technical Specification 6.4.1.a (Amendment 174), "Procedures," requires, in part, that written procedures shall be implemented covering the applicable procedures recommended in Regulatory Guide (RG) 1.33, Revision 2, Appendix A, "Typical Procedures for Pressurized Water Reactors and Boiling Water Reactors," February 1978.
RG 1.33, Revision 2, Appendix A, states, in part, that the following are typical safety-related activities that should be covered by written procedures: authorities and responsibilities for safe operation (Section 1.b); equipment control (Section 1.c); maintenance that can affect the performance of safety-related equipment (Section 9.a); and control of maintenance (Section 9.e).
1. Administrative Procedure 4.00 (Revision 20 - 7/18/97), "Operations Organization, Responsibilities and Conduct," a procedure required by Section 1.b of RG 1.33, at Step 4.2.3.b.6, required that the Control Room Supervisor shall keep the Shift Supervisor informed of plant and equipment status.
Contrary to the above, on October 17, 1997, the Control Room Supervisor failed to properly implement Administrative Procedure 4.00 in that the Shift Supervisor was not kept informed that power would be removed from all of the control rod drive motors in order to facilitate maintenance on control rod 38. (01013)
2. Administrative Procedure 4.10 (Revision 6 - 4/30/97), "Personnel Protective Tagging," a procedure required by Section 1.c of RG 1.33, at Step 7.2.2 required that the Shift Supervisor shall ensure that equipment may be removed from service by ensuring that the Technical Specification requirements, including the Limiting Conditions for Operations and Action Statements, are met.
Palisades Nuclear Power Plant Technical Specification 3.10.4.b, Amendment 169, states, in part, that a control rod is considered inoperable if it cannot be moved by its operator and if more than one control rod becomes inoperable then the reactor shall be placed in hot shutdown within 12 hours.
Contrary to the above, on October 17, 1997, the Shift Supervisor (and the Control Room Supervisor, Shift Engineer (all licensed senior reactor operators)) failed to ensure that equipment could be removed from service by failing to ensure that Technical Specification requirements, including the Limiting Condition for Operation and Action Statements, were met prior to removing all the control rods from service. Specifically, power was removed from all the rods and the licensed operator failed to realize that removing power from more than one control rod required entry into a 12 hour action to shut down the plant. (01023)
3. Administrative Procedure 4.02 (Revision 15 - 6/27/97) "Control of Equipment," a procedure required by Section 1.c of RG 1.33, at the NOTE before step 1 of Attachment 8, "Safety Assessment for Removal of Plant Equipment (SSCs) From Service," required that Attachment 8, or an equivalent risk-based assessment, be completed for maintenance activities that met all of the following conditions:
a) entry into unplanned maintenance outages
b) involved high safety significant systems identified in Attachment 10
c) would render the system incapable of performing its Maintenance Rule function
d) did not occur with the equipment positioned in its designed safety position prior to removing its power source.
Contrary to the above, on October 17, 1997, the licensee failed to complete Administrative Procedure 4.02, Attachment 8, or perform an equivalent risk-based assessment for the maintenance on control rod 38. Specifically, this maintenance activity: (1) was an unplanned maintenance outage because the corrective maintenance on control rod 38 was emergent work; (2) involved the control rod drive system which was a high safety significant system identified in Attachment 10; (3) rendered the control rod drive system incapable of performing its maintenance rule function of manual operation; and (4) did not occur with control rod 38 positioned in its designed safety position of fully inserted prior to removing its power source. (01033)
4. Maintenance Procedure CRD-E-32 (Revision 7 - 2/21/95), "CRDM [Control Rod Drive Motor] Control Relays Cleaning and Inspection," a procedure required by Section 9.a of RG 1.33, at Step 3.4.2.e, required during plant operation with rods withdrawn and the clutch power supply energized that only one relay set and its related fuses be removed from service at a time.
Contrary to the above, on October 17, 1997, during implementation of work order 24714120, maintenance on control rod 38, licensee personnel failed to properly implement Maintenance Procedure CRD-E-32 in that more than one control rod relay set and its related fuses were simultaneously removed from service and inspected. (01043)
5. Administrative Procedure 5.01 (Revision 21 - 5/12/97), "Processing Work Requests/Work Orders," a procedure required by Section 9.e of RG 1.33, Attachment 2, "Work Order Scheduling, Performance, and Completion," at Step 2.3.c, required the Assigned Supervisor to review scheduled work orders to determine the work could be performed as scheduled, and if not notify the Shift Supervisor ("scheduled" includes both the time of occurrence and manner of conduct). Step 6.1 of Attachment 2, required the work order to be replanned, per the requirements of this procedure, if the Assigned Supervisor determined that the work required to correct the problem was not adequately described in the work order job plan. Step 5.11.b required the repairperson to document the "as found" conditions and the repairs/adjustments made.
Contrary to the above, on October 17, 1997, during implementation of work order 24714120, maintenance on control rod 38, licensee personnel failed to properly implement Administrative Procedure 5.01 in that three additional control rod drive relay contactors for control rods 3, 40, and an unidentified Group III control rod were removed, inspected, and reinstalled. This represented a condition not allowed by the work procedure and was an unplanned and undocumented expansion of the approved work scope without the required notification to the Shift Supervisor. (01053)
6. Administrative Procedure 5.19 (Revision 6 - 4/15/97), "Post Maintenance Testing," a procedure required by Section 9.e of RG 1.33, at Step 5.2.e, required the Operations Manager to ensure that Post Maintenance Testing was properly performed prior to declaring the equipment operable. Step 5.4.c required the Maintenance Supervisor to ensure that the specified post maintenance testing was revised, as necessary, if the scope of maintenance performed was changed after initial planning.
Administrative Procedure 4.02 (Revision 15 - 6/27/97), "Control of Equipment," a procedure required by Section 1.c of RG 1.33, at Step 9.3.b, required operability testing to be performed on safety-related equipment following any maintenance activity which had the potential to affect the equipment's operability.
Contrary to the above, following implementation of work order 24714120, maintenance on control rod 38, on October 17, 1997, licensee personnel failed to properly implement Administrative Procedures 5.19 and 4.02. Specifically, more than one control rod relay set and its related fuses were removed from service and inspected which represented a change in the scope of maintenance after initial planning. However, the specified post maintenance testing was not revised as necessary. Consequently, appropriate Post Maintenance Testing was not identified or performed. (01063)

These violations represent a Severity Level III problem (Supplement I). Civil Penalty $55,000.

Pursuant to the provisions of 10 CFR 2.201, Consumers Power 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 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 cumulative amount of the civil penalties 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 civil penalties.

Upon failure to pay any civil penalties 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 penalties, 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: 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 Palisades Plant.

Because your response will be placed in the NRC Public Document Room, to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the Public Document Room 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 Lisle, Illinois
this 2nd day of April 1998


1. A Severity Level III violation and a $50,000 civil penalty were issued on August 13, 1996, for violations of 10 CFR Part 50, Appendix R (EA 96-131).

Page Last Reviewed/Updated Thursday, March 29, 2012