Information Notice No. 79-15, Deficient Procedures


                               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 
                                        Office of Inspection and Enforcement
1.   IE Information Notice
       No. 79-15
2.   Draft Transmittal Letter

CONTACT:  J. C. Stone, IE

(Transmittal letter for Information Notice 79-15 to each holder of an NRC 
Operating License and Construction Permit.) 

                                            Information Notice No. 79-15 

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. 

                                        (Regional Director) 

1.   Information Notice No. 
       No. 79-15
2.   List of IE Information
       Notices Issued in 1979

                              UNITED STATES 
                          WASHINGTON, D.C. 20555 
                               June 7, 1979 

                                            Information Notice No. 79-15 



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. 

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 

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. 

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. 

Order issued to Arkansas
  Power and Light Company 

                        UNITED STATES OF AMERICA 

In the Matter of 

ARKANSAS POWER AND LIGHT COMPANY                          Docket No. 50-313 
(Arkansas Nuclear One - Unit No. 1) 



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. 


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 

                                  - 2 -

inspector, the facility should be temporarily placed in a cold shutdown 

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. 


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. 

                                  - 3 -

                              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. 


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