EA-96-124 - Wolf Creek 1 (Wolf Creek Nuclear Operating Corp.)

July 1, 1996

EA 96-124

Neil S. Carns, President and
Chief Executive Officer
Wolf Creek Nuclear Operating Corporation
P.O. Box 411
Burlington, Kansas 66839

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES - $300,000 (NRC Inspection Report Nos. 50-482/96-05 and 50-482/96-03)

Dear Mr. Carns:

This refers to the predecisional enforcement conference held in the NRC's Arlington, Texas office on May 10, 1996. The purpose of the conference was to discuss apparent violations related to a frazil ice situation that occurred at the Wolf Creek Generating Station on January 30-31, 1996. Wolf Creek personnel first reported the event to the NRC on January 30, 1996, in accordance with 10 CFR 50.72.

An NRC Augmented Inspection Team (AIT) examined the facts surrounding the event during the period of February 6-15, 1996, and the results of the inspection were documented in NRC Inspection Report 50-482/96-05, issued on March 7, 1996. The scope of the AIT was fact-finding and did not include the identification of any potential violations of regulatory requirements. A subsequent special inspection was conducted on March 18-25, 1996, to determine whether activities were conducted safely and in accordance with NRC requirements, and ten apparent violations were identified. The results of this special inspection were discussed with members of your staff during an exit briefing on April 5, 1996, and were documented in NRC Inspection Report 50-482/96-03, issued on April 24, 1996.

As described in the April 24, 1996 inspection report, the apparent violations stemmed from the NRC's review of the event that involved icing on the circulation water system/service water system traveling screens and trash racks which resulted in the decision to manually trip the reactor, and the subsequent event recovery actions. The NRC's AIT noted the event was safety significant in that ice formation on the essential service water (ESW) system trash racks resulted in the loss of one train (Train A) of the ultimate heat sink and jeopardized the other (Train B). This event also showed significant weaknesses in engineering, operations, and maintenance.

The NRC has determined that the circumstances surrounding the event are of very significant regulatory concern because: (1) the event was safety-significant; (2) the event was preventable; (3) although ultimately, Wolf Creek personnel took positive actions to terminate the event, the plant operations staff made errors in the early stages which actually complicated, rather than mitigated, the event; and (4) preventable problems with the packing on the turbine-driven auxiliary feedwater (TDAFW) pump, a safety-related pump, distracted plant personnel from focusing on a response to the problems with the ESW system. Based on the information obtained during the NRC inspections, and the information provided during the predecisional enforcement conference, the NRC has determined that violations of regulatory requirements occurred. These violations are listed in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice). The more significant violations are grouped into three issues and are described below.

The first issue (Violation I.A in the enclosed Notice) is a violation involving a failure to assure that inadequate ESW system warming line flow, a condition adverse to quality, was promptly identified and corrected. This failure, which directly contributed to the January 30-31, 1996 frazil icing event, involved at least four opportunities to have assessed the design basis of the system and to have identified and corrected the inadequate warming line flow. Although not reviewed during the inspections associated with the January 30, 1996, event and not cited in the Notice, Generic Letter 89-13, "Service Water System Problems Affecting Safety Related Equipment," was another possible opportunity for the identification of the deficiency in the ESW warming lines. The failure to assure adequate warming line flow and the missed opportunities to identify and correct the problem is of significant regulatory concern. Therefore, this violation is categorized in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, as a Severity Level III violation.

The second issue (Violation I.B in the Notice) is a violation involving a failure to follow plant procedures while aligning the ESW system. The operator who performed the initial alignment did so without a procedure and had concerns about the accuracy of his actions and an excessive period of time elapsed (about 6 hours) before ESW valve misalignments were corrected. This failure resulted in valve misalignments that contributed to, and hastened, the failure of ESW Train A and the degradation of ESW Train B, further complicating the event. This failure is also of significant regulatory concern. Therefore, this violation is categorized in accordance with the Enforcement Policy as a Severity Level III violation.

The third issue (Violations I.C.1 and I.C.2 in the Notice) involves two separate violations involving (1) a failure to include all work instructions for installing packing on the TDAFW pump; and (2) inadequate corrective action for a problem with the TDAFW pump. The first violation contributed to the packing failure of the TDAFW on January 30, 1996, while the second violation represents a missed opportunity to have identified and adequately corrected the packing installation problem. It is questionable whether the TDAFW pump would have been able to perform its intended safety function if it had been called upon to function. Given the safety significance of the TDAFW pump and the distractions the leaking pump caused during the frazil ice event, these violations are of significant regulatory concern and warrant being classified in the aggregate as a Severity Level III problem.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $50,000 is normally considered for each Severity Level III violation or problem. However, each of these violations (Violations I.A, I.B, and I.C) reflect significant weaknesses in engineering, operations, and maintenance that contributed to the frazil ice event and complicated the recovery from a risk-significant event that was entirely preventable. These violations reflect particularly poor performance characterized by missed opportunities to identify and correct significant design problems, inappropriate operator actions that severely challenged event mitigation, and TDAFW pump maintenance and corrective action deficiencies that resulted in distractions in recovery from the event. In view of this particularly poor performance that substantially contributed to, and severely complicated the recovery from this risk-significant event, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Reactor Regulation, Regional Operations and Research, to exercise discretion pursuant to Section VII A.1 of the Enforcement Policy and to propose a civil penalty in the amount of $100,000 for each of the two Severity Level III violations and the Severity Level III problem. Accordingly, to emphasize the significance of the problems these violations represent, to encourage improvement in performance, and to emphasis the need for lasting comprehensive corrective actions, I have issued the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice) in the total amount of $300,000.

Five additional violations are cited in the attached Notice for which no civil penalties are assessed. The first involves a failure to assure that the ESW system design bases were appropriately translated into specifications and drawings in that design errors were made which caused the ESW system not to be protected against freezing. Specifically, incorrect assumptions regarding warming line temperature and flow rates resulted in significant degradation in the freeze protection capability provided by the warming lines. The errors had existed since original startup of the plant. This violation is significant because the failure to design the ESW system properly was a principal contributor to the icing event. Therefore, this violation has been categorized in accordance with the Enforcement Policy at Severity Level III. In accordance with the Enforcement Policy, a civil penalty is normally considered for a Severity Level III violation. However, in this case no civil penalty is proposed for this violation because the violation occurred beyond the 5-year statute of limitations for imposing civil penalties.

The four remaining violations, categorized at Severity Level IV, involve failures to: (1) ensure that copies of station procedures were available in the control room, (2) comply with a technical specification limiting condition for operation when the plant did not achieve hot shutdown in the required 6-hour timeframe, (3) determine whether less than full thread engagement for the TDAFW pump inboard packing gland follower nuts was acceptable, and (4) follow maintenance work instructions contributing to TDAFW pump packing loss.

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, org signed by Samuel J. Collins L. J. Callan Regional Administrator

Docket No. 50-482
License No. NPF-42

Enclosure: Notice of Violation and
Proposed Imposition of Civil Penalties

cc w/enclosure:
Vice President Plant Operations
Wolf Creek Nuclear Operating Corp.
P.O. Box 411
Burlington, Kansas 66839

Jay Silberg, Esq.
Shaw, Pittman, Potts & Trowbridge
2300 N Street, NW
Washington, D.C. 20037

Supervisor Licensing
Wolf Creek Nuclear Operating Corp.
P.O. Box 411
Burlington, Kansas 66839

Supervisor Regulatory Compliance Wolf Creek Nuclear Operating Corp.
P.O. Box 411
Burlington, Kansas 66839

Assistant Manager
Energy Department
Missouri Public Service Commission
P.O. Box 360
Jefferson City, Missouri 65102

Chief Engineer
Utilities Division
Kansas Corporation Commission
1500 SW Arrowhead Rd.
Topeka, Kansas 66604-4027

Office of the Governor
State of Kansas
Topeka, Kansas 66612

Attorney General
Judicial Center
301 S.W. 10th
2nd Floor
Topeka, Kansas 66612-1597

County Clerk
Coffey County Courthouse
Burlington, Kansas 66839-1798

Public Health Physicist
Division of Environment
Kansas Department of Health
and Environment
Bureau of Air & Radiation
Forbes Field Building 283
Topeka, Kansas 66620

Mr. Frank Moussa
Division of Emergency Preparedness
2800 SW Topeka Blvd
Topeka, Kansas 66611-1287

---

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES
Wolf Creek Nuclear Operating Corporation Docket No. 50-482 Wolf Creek Generating Station License No. NPF-42 EA 96-124

During an NRC inspection conducted on March 18-25, 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 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 a Civil Penalty

A. Appendix B, Criterion XVI, states that measures shall be established to assure that conditions adverse to quality, such as failures and malfunctions, are promptly identified and corrected.

Contrary to the above, as of January 30, 1996, the condition of inadequate essential service water system warming line flow (a condition adverse to quality) was not promptly identified and corrected. There were several opportunities to have identified and corrected the design bases of the system specifically related to warming line flow: (1) during an evaluation performed in 1993 related to a warming line valve only capable of being 50 percent open; (2) while evaluating whether a frazil icing event at another plant in 1993 could occur at Wolf Creek; (3) while answering an internal question in 1991 directly related to a concern for frazil icing; and (4) while reviewing a 1978 NRC Circular related to icing conditions (frazil ice was specifically considered by the licensee's architect-engineer). (01013)

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

B. Technical Specifications Section 6.8.1 states that written procedures shall be established, implemented, and maintained covering the activities recommended in Appendix A, of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33, Revision 2, specifies procedures for abnormal, offnormal, or alarm conditions.

The licensee's alarm response Procedure ALR 00-008B, "SERV WTR PRESS HI LO," Revision 8, directs the operator to establish operation of the essential service water system (ESW) using Procedure SYS EF-200, "Operation of the ESW System." Procedure SYS EF-200 requires that ESW Valves EF HV-37 and -38 be opened, and EF HV-39, -40, -41, and -42 be closed.

Contrary to the above, on January 30, 1996, a control room operator, while aligning the ESW system as directed by alarm response Procedure ALR 00-008B, failed to use system Procedure SYS EF-200, and consequently the control room operator closed Valves EF HV-37 and -38 (to throttled positions), and opened Valves EF HV-39, -40, -41, and -42 which was not in accordance with Procedure SYS EF-200. (02013)

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

C. 1. 10 CFR Part 50, Appendix B, Criterion V, states that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances.

Contrary to the above, on January 25 and 30, 1996, work instructions provided for packing the turbine-driven auxiliary feedwater (TDAFW) pump (an activity affecting quality) for WP 108952, Task 6, and WP 109087, Task 2, were not appropriate to the circumstances in that not all pertinent packing information in Component Change Package 05767, which was contained in the TDAFW pump vendor manual, was included. Specifically, neither WP 108952, Task 6, or WP 109087, Task 2, provided adequate instructions concerning: (1) the proper tightening of the packing gland follower nuts, (2) guidance on proper installation of the packing gland follower into the pump stuffing box, and (3) directions on the pump's post maintenance run time required to obtain proper packing leakoff. (03013)

2. 10 CFR Part 50, Appendix B, Criterion XVI, specifies that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, or deviations 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 recurrence.

Contrary to the above, as of January 30, 1996, a significant condition adverse to quality - improper adjustment of packing on the safety-related TDAFW pump - was identified, but actions were not taken to determine and correct the cause of the deficient condition. Specifically, Performance Improvement Request (PIR) 94-1918 was issued on October 30, 1994 to address the improper adjustment of packing on the TDAFW pump. However, the PIR was closed on the basis of repacking the pump without determining and correcting the cause of the packing installation problem. (03023)

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

II. Violations Not Assessed A Civil Penalty

A. 10 CFR Part 50, Appendix B, Criterion III, states that measures shall be established to assure that applicable regulatory requirements and design bases for those structures, systems, and components to which this appendix applies are correctly translated into specifications, drawings, procedures, and instructions.

Contrary to the above, as of January 30, 1996, design measures failed to assure that the essential service water system design bases (protection against natural phenomena) were appropriately translated into specifications and drawings in that design errors were made which caused the essential service water system not to be freeze protected. Specifically, incorrect assumptions regarding warming line temperature and flow rates (35·F and full pipe flow) resulted in significant degradation in the freeze protection capability provided by the warming lines. (04013)

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

B. Technical Specification section 6.8.1 states that written procedures shall be established, implemented, and maintained covering the activities recommended in Appendix A, of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33, Revision 2, specifies procedures for abnormal, offnormal, or alarm conditions.

Operations Procedure ADM 02-014, "Control of Operations Documents, Revision 5, Section 6.9.3 states that, "Procedures will be filed in the appropriate Procedure File Drawers, Procedural Manuals or field areas as applicable."

Contrary to the above, on January 30 and March 22, 1996, control room procedures were not filed in the appropriate location. Specifically:

1. On January 30, 1996, when needed during the transition from Emergency Procedure EMG E-0, "Response to Reactor Trip or Safety Injection," to Emergency Procedure EMG ES-02, "Reactor Trip Response," EMG ES-02 was determined not to be filed in any of the four emergency operating procedure sets in the control room as required.
2. On March 22, 1996, an NRC inspector determined that alarm response procedure ALR 00-11D, "SL41 Bus Trouble," was not located in the control room after it had been identified as missing during an earlier licensee audit of procedures. (05014)

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

C. Technical Specification Limiting Condition for Operation Action Statement 3.7.2.b specifies that in Modes 1, 2, and 3, "With two auxiliary feedwater pumps inoperable, be in at least HOT STANDBY within 6 hours and in HOT SHUTDOWN within the following 6 hours."

Contrary to the above, on January 30, 1996, when in Mode 3 (Hot Standby) and with two auxiliary feedwater pumps inoperable, hot shutdown was not achieved as specified in Technical Specification Action Statement 3.7.2.b. The second auxiliary feedwater pump (A Train) became inoperable at 7:47 a.m. on January 30, 1996. Hot shutdown, which should have been achieved by 1:47 p.m., was not achieved until 3:31 p.m. on January 30, 1996. (06014)

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

D. 10 CFR Part 50, Appendix B, Criterion XVI, specifies that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, or deviations 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 recurrence.

Contrary to the above, as of January 30, 1996, a significant condition adverse to quality was identified, but actions were not taken to correct the deficiency or to determine the cause of the condition. Specifically, Work Request 60242-94 was issued on October 20, 1994, to correct the TDAFW pump inboard packing gland follower nuts which had insufficient thread engagement; however, the Work Request was closed without further action on the basis that a non-conformance report did not specify full thread engagement was acceptable. (07014)

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

E. Technical Specification Section 6.8.1 states that written procedures shall be established, implemented, and maintained covering the activities recommended in Appendix A, of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33, Revision 2, specifies that maintenance that can affect the performance of safety related equipment should be properly preplanned and performed in accordance with written procedures.

Maintenance Procedure 16C-002, "Work Controls," Revision 2, Step 6.6.7.5 states, "Perform work in accordance with work instructions and referenced documents," Task 2, step 5.4 of work order WP 108952 specified that the packing gland follower nuts be tightened "snug."

Contrary to the above, on January 25, 1996, maintenance personnel failed to follow established procedures in the implementation of work on the TDAFW pump. Specifically, maintenance personnel tightened the nuts only "finger tight," instead of "snug." (08014)

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

Pursuant to the provisions of 10 CFR 2.201, Wolf Creek Nuclear Operating 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 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 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 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 c 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: 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, ATTN: Enforcement Officer, 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. 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 Arlington, Texas,
this 1st day of July 1996