EA-97-076 - Beaver Valley 1 & 2 (Duquesne Light Company, DLC)

March 24, 1997

EA 97-076

Mr. J. E. Cross, President
Generation Group
Duquesne Light Company (DLC)
Post Office Box 4
Shippingport, Pennsylvania 15077

(NRC Inspection Report Nos. 50-334/96-10, 50-412/96-10)

Dear Mr. Cross:

This letter refers to the NRC inspection conducted between December 22, 1996, and February 8, 1997 at the Beaver Valley Power Station facility, the findings of which were discussed with you and members of your staff during exit meetings on February 18 and 19, 1997. During the inspections, apparent violations of NRC requirements were identified, as described in the NRC inspection report sent to you with our letter, dated February 21, 1997. On March 7, 1997, a Predecisional Enforcement Conference was conducted with you and members of your staff to discuss the violations, their causes, and your corrective actions.

Based on the information developed during the inspections, and the information provided during the conference, three violations are being cited and are described in the enclosed Notice of Violation. The violations involve (1) the failure by your staff, on numerous occasions, to follow procedures and implement appropriate work practices and controls, resulting in numerous valves and switches being in an other than normal position; (2) operators inadvertently deenergizing the waste gas decay tank (WGDT) oxygen analyzers because of operator error in that the operators misoperated the oxygen analyzer control switches, and also failed to monitor oxygen concentration when running the degassifier to the WGDT; and (3) failure to take appropriate corrective action, despite numerous configuration control deficiencies being identified in 1995, to ensure that the general problem of configuration control, was adequately corrected.

The NRC recognizes that the numerous 1997 examples of mispositioned valves and switches were identified by your staff, and that you have demonstrated a low threshold for identifying component misconfigurations at Beaver Valley which have contributed to these findings. Nonetheless, the NRC is concerned that broader corrective actions were not taken in 1995 to preclude recurrence of components being mispositioned. One of the recent findings of particular concern was the fact that operators and chemistry technicians were not properly implementing station procedures when repeatedly depressurizing the Unit 2 residual heat removal (RHS) system from January 23 to January 30, 1997, resulting in the mispositioning of a RHS system sample valve. In that case, chemists also entered multiple procedures in parallel, each of which specified different positions for a specific component, which was not permitted by station procedures. In another case, operators failed to properly implement station procedures when securing a component cooling water (CCR) pump in January 1997.

Specifically, the operators did not shut a CCR pump discharge valve and did not annotate system configuration drawings and procedures to reflect this change. Both of these examples are of additional significance given that licensed personnel were involved in not adhering to station procedures.

At the enforcement conference, you acknowledged that inadequate work practices, not implementing existing procedures, not implementing appropriate work controls, inadequate communications among the operations staff at shift turnovers, and procedural inadequacies contributed to these violations. Also, at the conference, you discussed a memorandum from your Vice-President Operations, dated February 13, 1997, entitled "Plant Valve Manipulations," which informed your staff of the importance of precluding and correcting such problems, noting that the improper valve manipulations are precursors to events which could lead to major plant problems. The NRC agrees. Given the number of recent examples of not maintaining appropriate configuration control at Beaver Valley, the repetitive nature of this concern, and the inadequate work practices and work controls that contributed to these problems, the violations collectively represent a potentially significant lack of attention toward licensed responsibilities and therefore, have been classified in the aggregate as a Severity Level III problem in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.

The violations are cited to emphasize the importance of strict adherence to procedural requirements to ensure components are in their proper position. The violations also reveal the need for greater technical inquisitiveness among your staff and the need for greater sensitivity to maintaining configuration control and promptly identifying and correcting when such control is not maintained. With respect to identification, the NRC does commend the actions of the operator who, while performing a tour of the facility, identified problems with an emergency diesel generator governor cooling water outlet ball valve being in the wrong position. If not for his inquisitiveness, this problem likely would have remained undetected and uncorrected. You should continue to encourage similar inquisitiveness by all your staff.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $55,000 is considered for that Severity Level III violation1 or problem. Your facility has been the subject of escalated enforcement actions within the last 2 years (for example, a Severity Level III violation without a civil penalty was issued on September 11, 1996, for failure to comply with 10 CFR 50.62(c)(1), in that, the ATWS Mitigation System Circuitry (AMSAC) had not been designed to perform its function in a reliable manner (EA 96-244)). Therefore, 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. Credit is warranted for identification because the violations were identified by your staff. Credit is also warranted for corrective actions. Important in this regard are steps you have taken to strengthen station corrective action processes to address broader performance issues. These actions include establishing a lower threshold for identifying and documenting problems, strengthening self-assessment efforts, and increasing management involvement in verifying effectiveness of corrective actions. Other actions, specific to the configuration control violation, included, but were not limited to: (1) enhancing the number of system lineups to be performed to assure appropriate positioning of the valves; (2) having your ISEG group perform a review of the identified deficiencies to evaluate performance trends; (3) issuing a memorandum to all staff emphasizing the importance of appropriate adherence to procedures, as well as providing an additional letter to operations personnel for further emphasis; (4) reviewing all valves to ensure proper positioning and immobilizing certain valves; (5) instituting a process for discussion of all Condition Reports at the routine morning meetings; (6) revising procedures and logs to ensure oxygen concentration is monitored when sending gas to the WGDT; (7) initiating a procedure validation project to ensure procedures return components to their normal position or effectively track exceptions; and (8) evaluating work around activities at the station to determine areas where components are particularly vulnerable to inadvertent operation.

Therefore, to encourage prompt and comprehensive identification and 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. The NRC did consider whether to exercise discretion and issue a civil penalty in this case, given the involvement of licensed staff in some of these findings. However, the NRC has decided not to exercise such discretion in light of your aggressive corrective actions, and in recognition of the broader changes ongoing at Beaver Valley to more aggressively identify problems and improve overall performance. The NRC recently issued a $160,000 civil penalty to you on March 10, 1997, for, in part, a violation that involved a valve being in the wrong position for several years despite prior opportunities to identify and correct this condition. Similar findings of inadequate configuration control in the future could result in additional enforcement action.

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, and its enclosure, and your response, will be placed in the NRC Public Document Room (PDR).

Sincerely, ORIGINAL SIGNED BY Hubert J. Miller Regional Administrator

Docket Nos. 50-334; 50-412
License Nos. DPR-66; NPF-73

Enclosure: Notice of Violation

cc w/encl:
S. Jain, Vice President, Nuclear Services
R. LeGrand, Vice President, Nuclear Operations
L. Freeland, Manager, Nuclear Engineering Department
B. Tuite, General Manager, Nuclear Operations Unit
K. Ostrowski, Manager, Quality Services Unit
R. Brosi, Manager, Nuclear Safety Department
M. Clancy, Mayor
Commonwealth of Pennsylvania
State of Ohio


Duquesne Light Company (DLC)
Beaver Valley Power Station
Docket Nos. 50-334; 50-412
License Nos. PDR-66;NFP-73
EA 96-076

During NRC inspections conducted between December 22, 1996, to February 8, 1997 for which exit meetings were held on February 18 and 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 particular violations are set forth below:

A. Technical Specification (TS) 6.8.1.a requires that written procedures be properly established and implemented covering activities recommended in Appendix A to NRC Regulatory Guide 1.33, Revision 2, "Quality Assurance Program Requirements (Operation)." Section 3 of Appendix A to Regulatory Guide 1.33 specifies that procedures be established for operation of safety related systems. Procedure 1/2 OM-48.2.C, "Adherence and Familiarization to Operating Procedures," Rev 17, NPDAM 1.2.1, "Establishment of written directives and procedures," Rev. 3; and Chemistry Manual Chapter 3, "Sampling and Testing," Rev. 7, specify criteria for implementing procedures as written.

Contrary to the above, on numerous occasions, licensee staff did not implement procedures as written, as evidenced by the following examples.

  1. When repeatedly depressurizing the Unit 2 residual heat removal (RHS) system from January 23 to January 30, 1997, operators and chemistry technicians did not properly implement station procedures 2OM-10.4.C, "Residual Heat Removal System Shutdown," Rev. 20, and CM 2-3.40 Part D, "RHS Grab Sample Purging to Sample Sink, " Rev. 6. Specifically,

    a. Operators did not perform RHS depressurization as specified in procedure 2OM-10.4.C in that although operators had reviewed 2OM-10.4.C, they continued to depressurize RHS based on their memory of the procedure instead of performing and signing off the procedure step-by-step, as required by Procedure 1/2 OM-48.2.C; and,

    b. Chemistry technicians did not properly perform steps in procedure CM 2-3.40 in that steps to reposition 2SSR-SOV129A1/A2 were performed out of the required sequence in Section D of the procedure, and Valve SS-175, a primary system sample valve, was not returned to the correct position.

    These errors contributed to mispositioning Valve SS-175, which unexpectedly altered the existing RHS depressurization lineup.

  2. On January 14, 1997, Unit 1 operators failed to properly implement station procedures OM 1.15.4.H, "Securing a component cooling water (CCR) pump or placing the spare CCR pump in service," Rev. 1, and "1OM-15.3.B.1, Valve List-1CCR," Rev. 7, when securing the 'C' CCR pump. Specifically, the operators did not shut the 'C' CCR pump discharge valve, 1CCR-9, as specified by the Procedure OM 1.15.4.H, Step IV.C.4.b.2, and also failed to annotate system configuration drawings and procedures to reflect this change, as required by Procedure 1/2 OM-48.2.C, Step VI.B.15.

B. Beaver Valley Power Station Technical Specification requires oxygen concentration to be monitored during waste gas decay tank (WGDT) filling operations to ensure that an explosive gas mixture is not present.

Contrary to the above, operators failed to monitor oxygen concentration when running the degassifier to the waste gas decay tank (WGDT) on November 30, 1996, since operators had inadvertently deenergized both Unit 1 oxygen analyzers on November 25, 1996, a repeat problem caused by corrective actions previously implemented to address a known human factors issue (look-alike control switches) not precluding recurring misoperation of the oxygen analyzer control switches.

C. 10 CFR 50, Appendix B, Criterion XVI, Corrective Actions, requires, in part, that measures be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances 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 actions taken to preclude repetition.

Contrary to the above, following the identification of mispositioned service water valves 2SWS-82 on July 14, 1995, and 2SWS-MOV-105D on October 3, 1995, and other mispositioned components during this time period, which represented a condition adverse to quality involving inadequate management of plant configuration control, the licensee did not take appropriate measures to correct this condition adverse to quality and prevent recurrence, as evidenced by the fact that numerous component mispositionings occurred which were identified by the licensee during the period September 1996 to February 1997. Poor work practices, personnel errors, and failure to properly implement station procedures continued to result in component mispositionings. Several of the affected components were on safety related systems, including the emergency diesel generator, component cooling reactor, service water, and auxiliary feedwater systems.

These violations are classified in the aggregate as a Severity Level III problem (Supplement I).

Pursuant to provisions of 10 CFR 2.201, Duquesne Light Company (DLC) 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 I, 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 Demand for Information may be issued as to why the license should not be modified, suspended, or revoked, or why such other actions 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 King of Prussia, Pennsylvania
this 24th day of March 1997

1On November 12, 1996, the base civil penalty amounts for Severity Level III violations or problems changed from $50,000 to $55,000. Since these violations occurred after November 12, 1996, the base amount for this Severity Level III problem is $55,000.

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