EA-96-202 - Cooper (Nebraska Public Power District)

September 30, 1996

EA 96-202

Guy R. Horn, Vice President - Nuclear
Nebraska Public Power District
1414 15th Street
Columbus, Nebraska 68601

SUBJECT: NOTICE OF VIOLATION (NRC Inspection Report 50-298/95-18 and Investigation Case No. 4-96-002)

Dear Mr. Horn:

This refers to the matters discussed at the predecisional enforcement conference conducted on August 5, 1996, at the NRC's office in Arlington, Texas. As indicated in our letter dated June 27, 1996, the conference was conducted to discuss apparent violations related to a control rod mispositioning event that occurred on January 7, 1996, at the Cooper Nuclear Station (CNS). A summary of the predecisional enforcement conference, including the information presented by the Nebraska Public Power District (NPPD) at the conference, was issued on August 7, 1996. Subsequent to the conference with NPPD, the NRC also conducted individual conferences with two former CNS licensed operators who were involved in the rod mispositioning event.

Based on the information developed during the inspection and investigation, a review of NPPD's investigation of this matter, and the information obtained from the conferences, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation (Notice). Each involves a failure by licensed operating personnel to follow procedural requirements, including: 1) a failure to insert control rods in the proper sequence following a loss of a reactor recirculation pump; 2) a failure to notify shift supervision of an unexpected situation, i.e., a mispositioned control rod, for approximately 20 minutes; and 3) a failure to obtain the concurrence of the shift supervisor and reactor engineer in developing a recovery plan for a mispositioned control rod.

This event began when the involved operators, after being directed to insert control rods in reverse sequence following a reactor recirculation pump trip, mistakenly inserted control rods on the wrong page of the control rod sequence book. The operators recognized their mistake but continued inserting control rods without notifying shift supervisory personnel of their error and without seeking concurrence in a recovery plan. This event was investigated by NPPD and resulted in NPPD terminating the involved licensed operators.

The NRC agrees with NPPD's expectation that the operators should have promptly informed shift supervisory personnel of their mistake and the abnormal conditions that developed. The information available to the NRC, however, does not support a conclusion that they intentionally violated any CNS procedural requirements. Although their actions violated CNS procedures and NPPD management expectations, the operators appear to have been focused on inserting control rods to avoid exceeding plant administrative limits and an automatic plant trip. And, while they should have been mindful of the procedural requirements, they were not. The facts that they maintained accurate logs and informed the reactor engineer of the mistake when he approached the panel do not suggest a deliberate intent to cover up their mistake or violate procedures.

The NRC recognizes that the actions taken by the involved operators did not place the plant in an unsafe condition. Nonetheless, there is regulatory significance to licensed operators not recognizing their obligation to obtain shift supervisor and reactor engineer concurrence before proceeding to insert control rods in this situation. The NRC also attaches regulatory significance to the fact that the control room supervisor, despite being aware that the operators were inserting rods on the Emergency Control Rod Movement sheet, an unusual situation, did not take action to determine what was occurring and to understand the situation. As noted in NPPD's investigation of this matter, the control room supervisor's attention appears to have been focused heavily on balance-of-plant activities. While the NRC does not conclude that the control room supervisor's actions violated the Conduct of Operations procedures, an apparent violation discussed at the conference, this remains a concern. Finally, the NRC notes that NPPD's investigation team found inconsistent crew members' knowledge of the requirements of CNS procedure 10.13, "Control Rod Sequence and Movement Control," which calls into question the adequacy of CNS's training on the specific requirements of this procedure.

Based on the regulatory significance of these violations, they have been categorized 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 civil penalty, with a base value of $50,000, is considered for a Severity Level III problem. Because your facility has been the subject of escalated enforcement actions within the 2 years preceding the identification of this problem,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.

These violations were identified as a result of the involved operators informing NPPD managers of their mistake, and NPPD's follow-up investigation into this matter. Thus, credit for identification is warranted. The NRC also has determined that NPPD is deserving of credit for its corrective actions, which consisted of: immediate actions to assure the safety of the facility and assure that thermal limits had not been exceeded; meetings with all operating crews to discuss issues arising from this event; initiation of an independent review team investigation; disciplinary action against the involved operators; clarification and revisions to procedures and Ops Instructions; and assessment of the environment for reporting errors.

Therefore, to encourage prompt identification and comprehensive correction of violations, I have been authorized, after consultation with the Director, Office of Enforcement, not to propose a civil penalty in this case. However, significant violations in the future could result in a civil penalty.

You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. 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, ORIGINAL SIGNED BY L.J. Callan Regional Administrator

Docket No. 50-298
License No.: DPR-46

Enclosure: Notice of Violation

cc w/Enclosure:
John R. McPhail, General Counsel
Nebraska Public Power District
P.O. Box 499
Columbus, Nebraska 68602-0499

John Mueller, Site Manager
Nebraska Public Power District
P.O. Box 98
Brownville, Nebraska 68321

Robert C. Godley, Nuclear Licensing & Safety Manager
Nebraska Public Power District
P.O. Box 98
Brownville, Nebraska 68321

R. J. Singer, Manager-Nuclear
Midwest Power
907 Walnut Street
P.O. Box 657
Des Moines, Iowa 50303

Mr. Ron Stoddard
Lincoln Electric System
11th and O Streets
Lincoln, Nebraska 68508

Randolph Wood, Director
Nebraska Department of Environmental Quality
P.O. Box 98922
Lincoln, Nebraska 68509-8922

Chairman
Nemaha County Board of Commissioners
Nemaha County Courthouse
1824 N Street
Auburn, Nebraska 68305

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

Dr. Mark B. Horton, M.S.P.H.
Director
Nebraska Department of Health
P.O. Box 950070
Lincoln, Nebraska 68509-5007

R. A. Kucera, Department Director
of Intergovernmental Cooperation
Department of Natural Resources
P.O. Box 176
Jefferson City, Missouri 65102

Kansas Radiation Control Program Director

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NOTICE OF VIOLATION

Nebraska Public Power District Docket No. 50-298 Cooper Nuclear Station License No. DPR-46 EA 96-202

During an NRC investigation concluded on May 8, 1996, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violations are listed below:

A. 10 CFR 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that, "Activities affecting quality shall be . . . accomplished in accordance with these instructions, procedures, and drawings."

Step 8.2.6 5 of Cooper Nuclear Station Operations Manual, "Conduct of Operations Procedure 2.0.3," Revision 20, dated August 21, 1995, states, "Operators should notify the control room supervisor and shift supervisor of any unexpected situations encountered in monitoring the main control boards."

Contrary to the above, on January 7, 1996, operators did not notify the control room supervisor and shift supervisor of a mispositioned control rod, an unexpected situation encountered in monitoring the main control boards, until approximately 20 minutes after discovery. (01013)

B. 10 CFR 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that, "Activities affecting quality shall be . . . accomplished in accordance with these instructions, procedures, and drawings."

Step 8.1.5 of Cooper Nuclear Station Operations Manual, Nuclear Performance Procedure 10.13, "Control Rod Sequence and Movement Control," Revision 26, dated December 24, 1995, requires that operators, ". . . not deviate from the sequence unless approved by a reactor engineer (or shift supervisor in an emergency) or per a SORC approved procedure."

Contrary to the above, on January 7, 1996, operators deviated from the approved sequence when operators inserted control rods starting with the incorrect page of the control rod sequence book without the express permission of a reactor engineer or the shift supervisor, or a SORC approved procedure. (01023)

C. 10 CFR 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that, "Activities affecting quality shall be . . . accomplished in accordance with these instructions, procedures, and drawings."

Step 8.4.4 of Cooper Nuclear Station Operations Manual, Nuclear Performance Procedure 10.13, "Control Rod Sequence and Movement Control," Revision 26, dated December 24, 1995, requires that operators, "With concurrence of the shift supervisor and reactor engineer, implement a recovery plan . . . ." when recovering from mispositioned control rods.

Contrary to the above, on January 7, 1996, operators failed to properly implement this procedure when the control room operators took actions to recover from mispositioned control rods using their own judgement rather than a recovery plan which had been concurred in by the shift supervisor and the reactor engineer. (01033)

These violations represent a Severity Level III problem (Supplement I).

Pursuant to the provisions of 10 CFR 2.201, Nebraska Public Power District is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, 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, within 30 days of the date of the letter transmitting this Notice of Violation (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation, or, if contested, the basis for disputing the violation, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Your response may reference or include previous docketed correspondence, if the correspondence adequately addresses the required response. 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 to why the license should not be modified, suspended, or revoked, or why such other action as may be proper should not be taken. Where good cause is shown, consideration will be given to extending the response time.

Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.

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 30th day of September 1996

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¹For example, on December 12, 1994, a Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $300,000 was issued for three Severity Level III problems involving primary containment integrity, electrical buses, and the control room emergency filtration system (EAs 94-164, 94-165, 94-166).