EA-96-216 - Zion 1 & 2 (Commonwealth Edison Co.)

August 23, 1996

EA 96-216

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

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY - $50,000 (NRC INSPECTION REPORT NOS. 50-295/304/96007(DRP))

Dear Mr. Maiman:

This refers to the inspections conducted on January 27 through March 8, 1996, and April 20 through June 7, 1996, at the Zion Nuclear Station. The inspections were conducted to evaluate a series of eight operational errors and unplanned changes to the status of safety-related equipment that occurred between February 8 and May 21, 1996. The reports documenting our inspections and eight apparent violations were sent to you by letter dated April 5 and July 5, 1996. A predecisional enforcement conference was held on July 19, 1995, to discuss the apparent violations, their causes, and your corrective actions. The report documenting the conference was sent to you by letter dated August 6, 1996.

Based on the information developed during the inspection and the information that Commonwealth Edison provided during the predecisional enforcement conference, the NRC has determined that five violations of NRC requirements have occurred. The violations are cited in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty and the circumstances surrounding them are described in detail in the subject inspection reports. The violations involved operational errors and unplanned changes to the status of safety-related equipment that occurred during the period February through May 1996.

These violations are of concern because operators made fundamental errors which demonstrated insufficient attention to detail during the performance of required duties and the corrective actions to prevent recurrence were either ineffective or untimely. Specifically, a series of personnel errors and inadvertent entries into Technical Specification Limiting Condition for Operations (LCOs) occurred during the four month period beginning in February of this year. For example, operators repeatedly misaligned safety-related equipment and changed equipment operating status without following procedures applicable for the equipment. A contributing factor to these errors was the absence of supervision in the field to monitor operations and maintenance personnel and provide guidance during the performance of safety-related activities.

Some of these violations are indicative of recurrent errors where Commonwealth Edison has not implemented effective corrective actions. For example, a similar valve lineup error for an OB lake discharge tank overflow event in January occurred in July 1996 involving service water for the emergency diesel generators. Additionally, an identical error involving mis-operation of an emergency diesel generator control rheostat in May reoccurred in July 1996.

These violations are similar to concerns documented in the NRC's most recent Systematic Assessment of Licensee Performance (SALP) report dated February 15, 1996. In the functional area of operations, performance was characterized as inconsistent, primarily due to the frequent occurrence of personnel errors caused by a lack of attention to equipment status. These personnel errors have continued, reinforcing our conclusion that these errors and the lack of effective actions by the Zion Station staff are of significant concern.

The violations collectively represent a significant regulatory concern and, therefore, in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," (Enforcement Policy) NUREG-1600 (60 FR 34381, June 30, 1995), the violations have been 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 considered for a Severity Level III problem. Where there has been escalated enforcement within the last 2 years ¹ Section VI.B.2 of the NRC Enforcement Policy requires consideration of credit for both Identification and Corrective Action. Credit was given for identification because Commonwealth Edison identified each of the violations. However, credit was not warranted for corrective actions. Although in the enforcement conference, a number of corrective actions were discussed, the Zion staff was unable to show a nexus between the root cause of the specific violation discussed and the corrective actions that were implemented or planned. In addition, specific corrective actions to control equipment and personnel errors were neither prompt nor comprehensive. For example, as of May 1996, your corrective actions to reenforce expectations for non-licensed operators subsequent to an OB lake discharge tank overfill event in January were not promptly completed. Consequently, another event occurred due to a valve lineup error on May 19, 1996, when the 2A diesel generator was run without service water. Following the trip of the 2A diesel generator due to operator error on May 19, 1996, comprehensive corrective actions were not taken to preclude recurrence of this type of error, as evidenced by a nearly identical error occurring in July 1996 involving the 2B diesel generator.

Therefore, to emphasize the importance of operator attention to equipment status and of prompt and comprehensive correction of violations and in recognition of your previous enforcement action, I have been authorized, after consultation with the Director, Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the base amount of $50,000 for this 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. In your response, Commonwealth Edison should document the specific actions taken in response to each example cited, and indicate how the corrective action for the specific incidents will be broadened to ensure it is effective. On August 9, 1996, Mr. John Mueller, Site Vice President, requested a management meeting to discuss the initiatives being implemented to resolve these violations. We will schedule a transcribed meeting in the near future following your response to this action. After this meeting and 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, A. Bill Beach Regional Administrator

Docket Nos. 50-295; 50-304
License Nos. DPR-39; DPR-48

Enclosure: Notice of Violation and
Proposed Imposition of Civil Penalty

cc w/encl:
J. H. Mueller, Site Vice President
D. A. Sagar, Vice President, Generation Support
H. W. Keiser, Chief Nuclear Operating Officer
G. Schwartz, Station Manager
W. Stone, Regulatory Assurance Supervisor
D. Farrar, Nuclear Regulatory Services Manager
Document Control Room - Licensing
Richard Hubbard
Nathan Schloss, Economist
Office of the Attorney General
Mayor, City of Zion
State Liaison Officer, Wisconsin
State Liaison Officer
Chairman, Illinois Commerce Commission

---

NOTICE OF VIOLATION
AND
PROPOSED IMPOSITION OF CIVIL PENALTY

Commonwealth Edison Company Docket Nos. 50-295; 50-304 Zion Nuclear Station License Nos. DPR-39; DPR-48 Units 1 and 2 EA 96-216

During NRC inspections conducted on January 27 through March 8, 1996, and April 20 through June 7, 1996, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600 (60 FR 34381, June 30, 1995), 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. Station Operations Instruction SOI-36J, "Discharge Blowdown Monitor Tanks to Lake Discharge Tank OB," Revision 0, dated May 1, 1992, step 5.5.1 required that valve OAOV-WD0034, "Lake Discharge Tank OB Inlet Valve," be closed and in Step 5.5.2, required that valve OWD-0118, "OB Lake Discharge Tank Inlet," be closed and locked.

Contrary to the above, on January 20, 1996, during discharge of the blowdown monitor tank to the OB lake discharge tank, valves OAOV-WD0034 and OWD-0018 were not closed. (01013)

B. Zion Administrative Procedure 1200-08, Risk Significant On-line Maintenance, Revision 4, dated January 4, 1996, requires:

• In section F.1.d. that the Risk Management Team shall identify compensatory measures and actions required to remove, test or restore the system to service for each voluntary entry into a Limiting Condition for Operation (LCO) or risk significant combination (sic) conditions.
• In section F.3.a that the Work Control Center preplan and coordinate all work activities by all involved work departments in order to minimize the downtime of out of service system(s) and the risk of losing redundant equipment.
• In section F.5 that the Work Control Center shall be responsible for initiating Attachment A, "Voluntary LCO Entry Outage Approval Form."

Contrary to the above, the licensee failed to identify compensatory measures and the actions required to remove, test or restore systems to service during risk significant conditions; work activities associated with the maintenance activities were not preplanned or coordinated with all involved work departments to minimize the risk of losing redundant equipment; and the work control center did not initiate Attachment A, "Voluntary LCO Entry Outage Approval Form;" for the maintenance performed on Unit 1 on the 1B service water pump on February 8, 1996; for the maintenance performed on Unit 2 containment electrical penetration Zone 2 on February 12, 1996; and for the maintenance performed on the Unit 2 containment Zone 2 nitrogen and mechanical penetration pressurization systems on February 15, 1996, which required voluntary entry into LCOs. (01023)

C. Procedure PT-11-DG2A-R, "2A Diesel Generator 24 Hour Loading Test," Revision 1, dated June 16, 1995, the note following step 17 requires that 2HS-AP51 "volts adjust rheostat" be adjusted to maintain 750 KVARS load for the duration of the 2A diesel generator run.

Contrary to the above, on May 19, 1996, during the 2A diesel generator 24 hour loading test, a control room operator adjusted a speed control rheostat instead of the volts adjust rheostat 2HS-AP51 to reduce indicated KVARS, tripping the 2A Diesel Generator. (01033)

D. PT-11-DG2B, "2B Diesel Generator 24 Hour Loading Test," Revision 5, dated June 16, 1995, section 3.1, requires Diesel Generator required auxiliary systems to be in service for the 2B diesel generator.

Contrary to the above, on May 21, 1996, during the 2B diesel generator 24 hour loading test, the 2B diesel generator service water system, a required auxiliary system, was not in service. (01043)

E. Licensee Procedure TSGP-156, "Timing and Adjustment of Safeguards Sequence Timers," dated January 8, 1993, requires in section 3.1 that no other safeguards testing be in progress and in section 4.1 that only one section may be performed at a time.

Contrary to the above, on February 10, 1996, while timing and adjusting a Safety Injection Timer, the licensee failed to identify that other safeguards testing was in progress and failed to ensure that only one section was performed at a time when it inadvertently placed both Safety Injection timers (safeguard sequence timers) of Division 247 out of service at the same time. (01053)

This is a Severity Level III problem (Supplement I).
Civil Penalty - $50,000.

Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company 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 violations, (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 to 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 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 in Section VI.B.2 of the 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 the 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, 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.

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).

Dated at Lisle, Illinois
this 23rd day of August 1996

---

^1. A Severity Level IIII problem (identified in June 6, 1995) regarding 7 failures to meet Technical Specification surveillance requirements was issued on September 11, 1995; a Severity Level III problem (Identified in September 1995) and $50,000 civil penalty was issued on November 18, 1995 (EA 95-144).