United States Nuclear Regulatory Commission - Protecting People and the Environment

EA-97-589 - Waterford 3 (Entergy Operations, Inc.)

February 5, 1998

EA 97-589

Charles M. Dugger, Vice President
Operations - Waterford 3
Entergy Operations, Inc.
P.O. Box B
Killona, Louisiana 70066

SUBJECT: NOTICE OF VIOLATION (NRC INSPECTION REPORT 50-382/97-26)

Dear Mr. Dugger:

This refers to the predecisional enforcement conference conducted January 23, 1998, in the NRC's Arlington, Texas office. The conference was conducted to discuss several apparent violations related to a November 1997 incident involving a mispositioned valve controller in the auxiliary component cooling water system at the Waterford Steam Electric Station, Unit 3 (Waterford-3). The apparent violations were identified during an NRC inspection that concluded on December 15, 1997, when the inspection findings were conveyed to Entergy Operations, Inc. (Entergy) by telephone, and were documented in the subject inspection reporton January 5, 1998.

Based on the information developed during the inspection, and our consideration of the information that you provided during the conference, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation (Notice) and the circumstances surrounding them were described in detail in the subject inspection report. In brief, the violations are related to a failure to return the controller for Valve ACC-126A to automatic operation following its use on November 9, 1997, an error which went unrecognized for 15 hours despite several control board walkdowns by operators and a shift turnover. The failure to return this valve to automatic rendered Train A of the auxiliary component cooling water system inoperable. Operators compounded this error by removing Train B of the auxiliary component cooling water system from service for routine maintenance on November 10, 1997, without first physically verifying the operability of Train A. Both trains of this system remained inoperable for approximately 7.5 hours. The problem was ultimately corrected on November 10, 1997, when a relief operator walked down the control boards and discovered the mispositioned valve. Train A was immediately restored to service.

The violations include the procedural error that resulted in the mispositioned valve controller,the failure to verify the operability of Train A before taking Train B out of service, and the failure to discover the mispositioned controller during control board walkdowns and shift turnover. We recognize that the Waterford-3 auxiliary component cooling water system, which supports the component cooling water system, may not have been necessary to support the safety function of the ultimate heat sink, given the meteorological conditions that existed at the time of this incident, and the likelihood that operators could have restored Train A operability after receiving a high temperature alarm on the component cooling water system. The NRC also recognizes that no audible or visible alarms were triggered as a result of the controller being in the wrong position. Nonetheless, these violations are safety significant because a safety system which is designed to remove heat under certain accident conditions, and which was required to be operable at the time, was rendered incapable of operating automatically as designed. In addition, as discussed at some length during the conference, corrective actions for previous,similar events involving mispositioned switches and valves (NRC inspection report 50-382/96-13) were not effectively implemented in this case, as evidenced by the many missed opportunities to have discovered this error earlier.

Accordingly, these violations are 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. In accordance with the Enforcement Policy, a civil penalty with a base value of $55,000 is considered for a Severity Level III problem. Because your facility has been the subject of escalated enforcement actions within the last two years, 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. Given that the mispositioned valve controller was discovered by a Waterford-3 operator and not revealed by an event, and that the failures to identify the error earlier also were discovered by Entergy, the NRC concludes that credit for identification is warranted. We also conclude that credit for corrective actions is warranted. Your corrective actions included: immediate action to restore system operability and walk down all control boards; debrief of all operators on duty when ACC-126A was mispositioned; meetings with all shift personnel to reinforce expectations for walkdowns and shift turnover; procedural revision to eliminate two actions in one step in OP-002-001; implementation of control board assessments by shift technical advisor during shift turnover; enhancement of shift turnover control board walkdown procedure; and plans for a corrective action effectiveness review within six months.

Therefore, to encourage identification and comprehensive correction of violations before eventsoccur, I have been authorized, after consultation with the Director, Office of Enforcement, not to assess a civil penalty in this case. However, significant violations of this nature 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,



Ellis W. Merschoff
Regional Administrator

Docket No.: 50-382
License No.: NPF-38

Enclosure: Notice of Violation

cc w/Enclosure:
Executive Vice President and
Chief Operating Officer
Entergy Operations, Inc.
P.O. Box 31995
Jackson, Mississippi 39286-1995

Vice President, Operations Support
Entergy Operations, Inc.
P.O. Box 31995
Jackson, Mississippi 39286-1995

Wise, Carter, Child & Caraway
P.O. Box 651
Jackson, Mississippi 39205

General Manager, Plant Operations
Waterford 3 SES
Entergy Operations, Inc.
P.O. Box B
Killona, Louisiana 70066

Manager - Licensing Manager
Waterford 3 SES
Entergy Operations, Inc.
P.O. Box B
Killona, Louisiana 70066

Chairman
Louisiana Public Service Commission
One American Place, Suite 1630
Baton Rouge, Louisiana 70825-1697

Director, Nuclear Safety &
Regulatory Affairs
Waterford 3 SES
Entergy Operations, Inc.
P.O. Box B
Killona, Louisiana 70066

William H. Spell, Administrator
Louisiana Radiation Protection Division
P.O. Box 82135
Baton Rouge, Louisiana 70884-2135

Parish President
St. Charles Parish
P.O. Box 302
Hahnville, Louisiana 70057

Mr. William A. Cross
Bethesda Licensing Office
3 Metro Center
Suite 610
Bethesda, Maryland 20814

Winston & Strawn
1400 L Street, N.W.
Washington, D.C. 20005-3502


NOTICE OF VIOLATION

Entergy Operations, Inc.
Waterford Steam Electric Station, Unit 3
Docket No. 50-382
License No. NPF-38
EA 97-589

During an NRC inspection completed December 15, 1997, 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. Technical Specification 3.7.3 states that at least two independent trains of auxiliary component cooling water shall be operable while in Modes 1, 2, 3, and 4.

Contrary to the above, on November 10, 1997, two independent trains of auxiliary component cooling water were not maintained operable in Mode 1. Specifically, both trains of the auxiliary component cooling water were inoperable for approximately 7.5 hours with the plant in Mode 1. (01013)

B. Technical Specification 6.8.1.a states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operations)," Revision 2, February 1978. Regulatory Guide 1.33,Item 1.b requires that administrative procedures be established for safe operation and shutdown of the facility.

Procedure OP-100-001, "Duties and Responsibilities of Operators on Duty,"Revision 12, described the responsibilities for the control room supervisor and the nuclear plant operators related to personnel conduct and control of operating activities. These responsibilities are described, in part, by the following steps in this procedure:

Step 4.4.5: Nuclear plant operators will "Continuously monitor performance of plant control systems and Control Room instrumentation to verify operability."

Step 5.4.1.1: "On-duty operators shall be attentive to all status indicators and plant parameters and investigate abnormal conditions or trends."

Step 5.4.1.2: "On-duty Operators must make every effort to keep themselves aware of the status of safety systems and major power generating components."

Contrary to the above, on November 9-10, 1997, the control room supervisor, primary nuclear plant operator, and secondary nuclear plant operator failed to continuously monitor performance of Control Room instrumentation to verify operability, to remain attentive to all status indicators, and to keep themselves aware of the status of safety systems as stated in Steps 4.4.5, 5.4.1.1 and 5.4.1.2, respectively. Specifically, the operators failed to recognize that the manual/auto controller for Valve ACC-126A was not in the required automatic position, rendering Train A of the ACCW system inoperable. (01023)

C. Technical Specification 6.8.1.a states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Regulatory Guide 1.33, Item 1.b requires that administrative procedures be established for safe operation and shutdown of the facility.

Procedure OP-100-001, Revision 12, Step 4.3.2.4 stated, in part, that the control room supervisor will "Monitor the Nuclear Plant Operators in the performance of their duties."

Contrary to the above, on November 9-10, 1997, the control room supervisor failed to monitor the activities of the secondary nuclear plant operator who secured Auxiliary Component Cooling Water Pump A without placing the manual/auto controller for Valve ACC-126A in automatic. (01033)

D. Technical Specification 6.8.1.a states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Regulatory Guide 1.33, Item 1.b requires that administrative procedures be established for safe operation and shutdown of the facility.

Procedure OP-100-001, Revision 12, described the responsibilities of the control room supervisor and the nuclear plant operators related to personnel conduct and control ofoperating activities. Specifically, these responsibilities are described by the following steps in this procedure:

Step 4.3.2.9: The control room supervisor will, in part, "Direct the preparation and installation of Danger tags, verifying that Technical Specification requirements are observed."

Step 5.8.2.1.B: "Redundant subsystems or components shall be verified to be operable, Upon discovery of inoperable components, or prior to initiating maintenance on components required by Technical Specification Limiting Condition for Operation, their redundant counterparts shall be verified to be operable."

Contrary to the above, on November 10, 1997, at 3 a.m. (CST) the control room supervisor failed to direct the preparation of Danger tags, verifying that Technical Specification requirements were observed; and the nuclear plant operators failed to verify redundant subsystems were operable and failed to verify a redundant counterpart to an auxiliary component cooling water train was operable prior to initiating maintenance on the opposite train. Specifically, nuclear plant operators removed Auxiliary Component Cooling Water Train B from service, which included placing Danger tags, for routine maintenance without ensuring operability of Auxiliary Component Cooling Water Train A. (01043)

E. Technical Specification 6.8.1.a states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Regulatory Guide 1.33, Item 1.d states requirements will be established for procedure adherence and temporary change methods and Item 3.m states requirements for startup, operation, and shutdown of the service water system.

Procedure OP-100-001, Revision 12, described the responsibilities of the nuclear plant operators related to use of procedures. Specifically, these responsibilities are described by the following steps in this procedure:

Step 4.4.11: Nuclear plant operators will "Operate plant systems in accordance with plant procedures and as directed by the SS/CRS."

Step 5.13.8: "Operators shall comply with both the content and intent of approved procedures."

Procedure OP-002-001, "Auxiliary Component Cooling Water System," Revision 11, Section 7, Step 6 required operators to set the manual/auto controller setpoint for Valve ACC-126A(B), auxiliary component cooling water system flow control, to 95F and to place the controller in automatic.

Contrary to the above, on November 9-10, 1997, the secondary nuclear plant operator failed to comply with the intent of Procedure OP-002-001 for securing an auxiliary component cooling water train. Specifically, the operator failed to perform Procedure OP-002-001, Section 7, Step 6 that required placing the manual/auto controller for Valve ACC-126A to automatic. (01053)

F. Technical Specification 6.8.1.a states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Regulatory Guide 1.33, Item 1.g states that requirements be established in administrative procedures for shift relief and turnover.

Procedure OP-100-007, "Shift Turnover," Revision 16, described the requirements for control room operators to perform control panel walkdowns during shift turnover and during the shift. Specifically, Step 5.1.7 stated, "Every shift the Shift Superintendent, Control Room Supervisor, Primary Nuclear Plant Operator, and the Secondary Nuclear Plant Operator shall perform two control board walkdowns. One control board walkdown per watchstander shall be documented by signing the control board walkdown signature block of the appropriate turnover sheet." Step 5.1.8 stated, "A complete control board walkdown is performed by thoughtfully observing every light, everyindicator, every switch, and every button. Further, Step 5.5.3 stated, "The oncoming and off-going NPOs should walk down the control panels together. Discussions should include, but are not limited to, the following items: Status of safety-related systems; operating equipment and system alignments; . . ."

Contrary to the above, on November 9-10, 1997, numerous opportunities existed for the night shift watchstanders to identify the mispositioned indicator when evaluating every indicator and every switch as specified in Procedure OP-100-007, Steps 5.1.7 and 5.1.8. Also, several missed opportunities occurred during shift turnover control panel walkdowns while the nuclear plant operators discussed the status of the safety-related auxiliary component cooling water system and the respective equipment status/alignment. Specifically, from 7:21 p.m. on November 9 until 10:25 a.m. (CST) on November 10, 1997, several operators failed to comply with Procedure OP-100-007, inthat, at least eight opportunities during the night shift and at least three opportunities during shift turnover occurred to identify that the controller for Valve ACC-126A was misaligned. (01063)

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

Pursuant to the provisions of 10 CFR 2.201, Entergy Operations, Inc., 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, 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 or severity level, (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.

If you contest this enforcement action, you should also provide a copy of your response to the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001.

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 by10 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 5th day of February 1998

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