Information Notice No. 79-15, Deficient Procedures
IN79015
June 7, 1979
MEMORANDUM FOR: B. H. Grier, Director, Region I
J. P. O'Reilly, Director, Region II
J. G. Keppler, Director, Region III
K. V. Seyfrit, Director, Region IV
R. H. Engelken, Director, Region V
FROM: Norman C. Moseley, Director, Division of Reactor
Operations Inspections, IE
SUBJECT: Information Notice No. 79-15, DEFICIENT PROCEDURES
The subject document is transmitted for issuance on June 7, 1979. The
Information Notice should be issued to all holders of Reactor Operating
Licenses and Construction Permits.
Also enclosed is a draft copy of the transmittal letter.
Norman C. Moseley, Director
Division of Reactor Operation
Inspection
Office of Inspection and Enforcement
Enclosures:
1. IE Information Notice
No. 79-15
2. Draft Transmittal Letter
CONTACT: J. C. Stone, IE
49-28019
.
(Transmittal letter for Information Notice 79-15 to each holder of an NRC
Operating License and Construction Permit.)
Information Notice No. 79-15
Addressee:
This Information Notice is provided as an early notification of a possibly
significant matter. It is expected that recipients will review the
information for possible applicability to their facilities. No specific
action or response is requested at this time. If further NRC evaluations so
indicate, an IE Circular, Bulletin, or NRR Generic Letter will be issued to
recommend or request specific licensee actions. If you have questions
regarding the matter, please contact the Director of the appropriate NRC
Regional Office.
Signature
(Regional Director)
Enclosures:
1. Information Notice No.
No. 79-15
2. List of IE Information
Notices Issued in 1979
.
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF INSPECTION AND ENFORCEMENT
WASHINGTON, D.C. 20555
June 7, 1979
Information Notice No. 79-15
DEFICIENT PROCEDURES
Summary
On June 2, 1979, at Arkansas Nuclear One - Unit 1, while observing
conditions in the control room, an NRC inspector discovered an operational
deficiency that could have resulted in the emergency feedwater system
remaining isolated during subsequent power operation.
Description of Circumstances
On June 2 while Arkansas nuclear One - Unit 1 was preparing for startup, an
NRC inspector in the control room found that during a surveillance test of
the main feedwater check valves, the controls of the emergency feedwater
system were positioned so that the system could not automatically respond if
needed. The NRC inspector found that the test procedure being used by the
licensed operators did not include, as it should have, instructions either
to bypass the emergency feedwater system or to return it to normal. The
plant operators, without approved procedures covering this aspect of the
test, bypassed the controls that would have started the feedwater system
automatically. Lacking a procedural requirement to return the system to
normal, there was no assurance that emergency feedwater would be provided
automatically if needed.
Following the Three Mile Island accident, the NRC required that operators be
trained to initiate promptly the emergency feedwater system manually if it
does not come on automatically. Thus, while no immediate safety hazard
existed at the Arkansas Unit 1 plant because of the improper action, the NRC
staff is concerned about the potential safety hazard of leaving the
emergency feedwater system in the bypassed condition, about the possibility
that other procedures at the Arkansas plant may be deficient and about the
fact that the operators deviated from procedures in performing the
surveillance test.
Arkansas Power and Light Company has returned the plant to cold shutdown.
The June 2, 1979, NRC Order confirmed the requirement for a cold shutdown
until the Commission staff is satisfied with the utility's method of
controlling the development of operating procedures, the adequacy of
existing procedures, and until there is assurance that operators will not
deviate from those procedures.
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Information Notice No. 79-15 June 7, 1979
Page 2 of 3
The need for including the actions of operators and other staff members in
the safety-related procedures of nuclear power plants is identified in the
Technical Specifications and in Appendix B to 10 CFR Part 50, Criterion V.,
Instructions, Procedures, and Drawings:
"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. Instructions,
procedures or drawings shall include appropriate quantitative or,
qualitative acceptance criteria for determining that important
activities have been satisfactorily accomplished."
Further, Regulatory Guide 1.33, "Quality Assurance Program Requirements
(Operation)", endorses American National Standard ANSI N18.7-1976,
"Administrative Controls and Quality Assurance for the Operational Phase of
Nuclear Power Plants", which provides extensive guidance on preparation,
contents and use of procedures. This standard reiterates the Appendix B
statement in section 5.3, "Preparation of Instructions and Procedures", and
further states:
"These procedures shall provide an approved preplanned method of
conducting operations. Procedures shall be prepared and approved
prior to implementation..."
NRC thus requires that anticipated actions involving safety-related
equipment be planned and prescribed in written procedures. Therefore, steps
should have been included in the test procedures to cover all actions.
Recognizing that emergency conditions do not always follow an expected
course of events, ANSI N18.7 in Section 5.39, "Emergency Procedures",
states: "Since emergencies may not follow anticipated patterns, the
procedures should provide sufficient flexibility to accommodate variations,"
NRC recognizes that unforeseen conditions may be encountered that require
quick action and judgement and could involve deviations from established
procedures for the safety of the public. These deviations should be
documented and reviewed after-the-fact and procedures formally changed if
necessary.
While circumstances in an emergency can dictate the need to depart from
procedures, such action cannot be justified on a routine basis. Rote
following of deficient procedures is not proper. When a question on
procedural requirements arises, the licensee's temporary change procedure
should be used whereby the matter should be referred immediately to the
proper authorities for resolution and appropriate changes made if needed.
Departures from procedures, either additions or deletions, cannot be allowed
for any routine situation.
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Information Notice No. 79-15 June 7, 1979
Page 3 of 3
Each licensee should review his procedures and administrative controls for
procedures to assure that methods and procedures exist to control
safety-related actions. Enclosed is a copy of the Order issued to Arkansas
Power and Light Company.
This Information Notice provides details of a significant occurrence. No
written response is required. If you desire additional information regarding
this matter, contact the Director of the appropriate NRC Regional Office.
Enclosure:
Order issued to Arkansas
Power and Light Company
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UNITED STATES OF AMERICA
NUCLEAR REGULATORY COMMISSION
In the Matter of
ARKANSAS POWER AND LIGHT COMPANY Docket No. 50-313
(Arkansas Nuclear One - Unit No. 1)
ORDER
I.
The Arkansas Power and Light Company (the "'licensee") is the holder of
Facility Operating License No. DPR-51 (the "license") which authorizes
operation of the Arkansas Nuclear One - Unit No. 1 (the "facility") at
steady reactor power levels not in excess of 2568 megawatts thermal (rated
power). The license was issued on May 21, 1974, and has an expiration date
of December 6, 2008. The facility consists of a Babcock and Wilcox designed
pressurized water reactor (PWR), located at the licensee's site in Pope
County, Arkansas.
II.
In the course of authorized return to power from a cold shutdown condition,
operators deviated from the established but apparently deficient procedure
for routine Surveillance test of the check valves in the main feedwater
system. The procedure was deficient because it did not specify that
operators bypass and return the emergency feedwater system to normal. The
plant staff bypassed the controls to automatically start EFS by placing the
control switches in a position that would defeat emergency feedwater. The
plant was in a hot shutdown condition preparing for startup and the
operators apparently took this action because pumping of emergency feedwater
for this test would be undesirable and unnecessary. Lacking a procedural
requirement to return these switches to normal there was no assurance that
emergency feedwater would be provided automatically, if needed, later during
power operation. In view of these circumstances, which were discovered by an
NRC
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inspector, the facility should be temporarily placed in a cold shutdown
condition.
In a telephone conversation on June 2, 1979, the licensee Vice President,
Mr. William Cavanaugh, III, agreed to immediately proceed to a cold shutdown
condition and to remain in that condition until confirmation by the Acting
Director, Office of Inspection and Enforcement, that the conditions for
startup set out in Part III below, have been satisfied. It is desirable to
confirm by order the licensee's agreement to proceed to cold shutdown.
III.
In light of Part II above, IT IS HEREBY ORDERED THAT, pursuant to 10 CFR
Parts 2 and 50, the licensee shall proceed to, and remain in, a cold
shutdown condition and shall not restart until the Acting Director, Office
of Inspection and Enforcement, has confirmed in writing, that the following
actions have been satisfactorily accomplished:
(1) the licensee shall evaluate and modify as appropriate its
methods for the development, review approval of procedure for
all modes of plant operation;
(2) the licensee shall evaluate existing procedures to assure
that such procedures include all actions necessary for
safety; and,
(3) the licensee shall take appropriate steps to assure that all
plant personnel adhere to approved procedures and do not add
unauthorized steps to any procedures.
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FOR THE NUCLEAR REGULATORY COMMISSION
John G. Davis
Acting Director
Office of Inspection
and Enforcement
Dated at Bethesda, Maryland
this 2nd day of June, 1979.
Page Last Reviewed/Updated Tuesday, March 09, 2021
Page Last Reviewed/Updated Tuesday, March 09, 2021