EA-96-325 - LaSalle 1 & 2 (Commonwealth Edison Company)

January 24, 1997

EA 96-325

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

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES - $650,000 (NRC Special Inspection Report No(s). 50-373/96-09; 50-374/96-09)

Dear Mr. Maiman:

This refers to the inspection conducted on July 17 through August 20, 1996, at the LaSalle County Station. The inspection reviewed the circumstances surrounding two service water transients that occurred on June 19 and June 24, 1996, and the resulting discovery of the potential for a common mode failure of the ultimate heat sink for both LaSalle units. An Augmented Team Inspection (AIT) was conducted and documented in an inspection report dated August 2, 1996. Subsequent to the AIT, a followup inspection was conducted to further review the issues and concerns identified in the AIT report. This inspection was documented in an inspection report dated September 11, 1996. A predecisional enforcement conference was held on September 27, 1996, to discuss these matters with your staff.

Based on the information developed during the AIT, the followup inspection and the information that you provided during the conference, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the attached Notice of Violation and Proposed Imposition of Civil Penalties (Notice) and the circumstances surrounding them were described in detail in both the August 2 AIT report, and in the September 11 inspection report.

These violations are very significant. The potential for a common mode failure of the ultimate heat sink was caused by repetitive fouling of the service water system due to the injection of foam sealant material from the repair of minor cracks above the safety-related service water intake tunnel. Because your staff had not appropriately analyzed or controlled this work activity, the injection of foam sealant material resulted in the introduction of large quantities of the material into the safety-related service water intake structure. The injected foam sealant material created a significant safety issue and the potential for a common mode failure, by threatening to block the intake of both units' safety-related service water systems, systems required to mitigate the consequences of a design basis accident.

This event identified that significant weaknesses existed in planning of work activities and oversight of contractor maintenance on safety-related structures; engineering support for plant operations; and identification, evaluation, and correction of significant safety issues at the LaSalle County Station. Of particular concern was the lack of appropriate safety focus and lack of a questioning attitude.

The violations described in Section I.A of the Notice are indicative of inadequate oversight of maintenance activities performed by vendors and poor corrective actions following the identification of fouling of the non-essential service water strainers. Two violations of both failure to follow procedures or inadequate procedures are identified in Section I.A.1 of the Notice. These violations represent inadequate work planning, controls and procedures and are in and of themselves considered a significant regulatory concern. The violations demonstrate what can happen when uncontrolled work occurs in safety-related systems.

The failure to adequately correct repetitive fouling of service water systems described in Violation I.A.2 for a period of 17 days is also egregious. Following the June 19 non-essential service water strainer transient, plant operators returned the plant to full power without fully understanding the safety consequence of the transient. Operability evaluations of the safety-related service water systems, performed subsequent to the June 19 and June 24 transients, relied on erroneous information. The initial operability determination on June 19 assumed that the strainers were clogged by corn cob material used in sandblasting the exterior of the Lake Screen House. This operability evaluation was accepted by your staff in spite of available, but disregarded, information that indicated that the corn cob material was insufficient in both size and configuration to clog the non-essential service water strainers. On June 24, your staff again erred by inappropriately relying on explanations from the foam sealant vendor that the sealant material was buoyant without confirming the validity of this information. Subsequent inspections of the service water tunnel confirmed that the material was not buoyant, and presented a threat to the operation of the safety-related service water systems for both units.

Of further concern to the NRC is that even after the erroneous information concerning the buoyancy of the sealant material was identified, significant NRC involvement, including the issuance of a supplemental Confirmatory Action Letter (CAL) on July 5, 1996, was needed to direct your staff's attention to the potential safety consequences stemming from the clogging of service water systems and loss of the ultimate heat sink. Specifically, the supplemental CAL confirmed dual unit shutdown, additional inspection of suction strainers for all safety-related systems, surveillance testing of diesel generators, and the maintenance of plant systems necessary to remove heat from the plant until the potential impact of the injection of foam sealant material was identified and corrected. These actions were necessary for the NRC to assure that conservative and comprehensive corrective actions were taken to evaluate and resolve the full extent of this very safety significant issue.

Actions were not taken despite your staff having more than sufficient indications that fouling was occurring and continuing to degrade the functionality of the non-essential service water systems and to challenge the operability of the safety-related service water systems. The NRC also considers violation I.A.2 a significant regulatory concern due to the consequences to safety created by challenging these necessary heat removal systems.

In summary, the NRC considers the failure to properly plan, control and follow procedures during the injection of foam sealant material in cracks above the service water intake structure and the failure to take adequate actions to correct the cause of repetitive fouling of the non-essential service water system, to represent a very significant safety problem because of the potential for affecting the safety-related service water system. Therefore, these violations have been classified in the aggregate, in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, as a Severity Level II problem.

The five examples of a violation in Section I.B.1 involve procedures required by 10 CFR Part 50, Appendix B, Criterion V and Technical Specifications for testing, backwashing, and cleaning strainers in the safety-related Emergency Core Cooling Water and Residual Heat Removal Systems and non-essential service water systems. The violations in Section I.B.2 pertain to failures to complete unreviewed safety question evaluations for backwash flow for the emergency diesel generator service water system strainers being lower than that described in the FSAR and a mesh size for the non-essential service water strainers larger that described in the FSAR. The NRC considers these violations as representing a significant lack of attention in controlling safety-related activities associated with service water system strainers. The violations identified in Section I.B.1 and I.B.2 have been classified in the aggregate as a Severity Level III problem, in accordance with the Enforcement Policy.

The violation in Section II addresses the failure to maintain records that furnished evidence of activities affecting quality for the work performed on the Unit 2 residual heat removal service water strainer D300A on July 6 and 12, and on Unit 2 residual heat removal service water strainer D300B on July 12, 1996. Although unrelated to the service water clogging problems, this violation, categorized at Severity Level IV, was indicative of a weakness in the quality assurance program at the LaSalle Station.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $80,000 is normally considered for a Severity Level II problem. As to the violations in Section I.A.1, the NRC considers that these violations, if considered singularly, would in and of themselves be classified at Severity Level III. Violation I.A.2, which represents the balance of the Severity Level II problem, is a continuing violation extending over a significant period of time and would also in itself be considered as a Severity Level III violation. If this violation were to be addressed singularly, the NRC could assess daily civil penalties for each of the 17 days the violation continued. However, despite the NRC considering that the violation described in Section I.A.2 of the Notice continued until July 5, NRC recognizes that you shut down both units on June 28. This action subsequently reduced the safety consequences of this continuing violation, limiting the most risk significant period to the 10 days from when the violation began on June 19 until your staff shut down both units on June 28, 1996.

Based on consideration of the individual merits of this case, the NRC has decided to exercise enforcement discretion, in accordance with Section VII.(a) of the Enforcement Policy, and propose civil penalties in the amount of $600,000 for the Severity Level II problem described in Section I.A of the Notice. The proposed civil penalties are based on $50,000 per day being assessed for the 10 day period that the units operated while the corrective action violation described in Section I.A.2 of the Notice continued, in addition to $100,000 being proposed for the procedural violations described in Section I.A.1 of the Notice. The NRC is taking this very significant action in light of the particularly poor performance in this event. Specifically, as noted above, this problem revealed very significant and fundamental weaknesses in the areas of plant management, operations, and engineering's knowledge of a safety-related structure, the Lake Screen House; planning and control of safety-related maintenance; conservative operability evaluations; and identification and correction of significant conditions adverse to quality at the LaSalle Station. In addition, extensive NRC involvement was needed to fully understand the extensiveness of this event.

As to the violations described in Section I.B.1 and I.B.2 of the Notice, in accordance with the Enforcement Policy, a base civil penalty in the amount of $50,000 is considered for a Severity Level III problem. As your facility had not been the subject of escalated enforcement actions within the last 2 years, the NRC considered whether credit was warranted for your Corrective Action, in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. In this case, credit is not warranted for the factor of corrective action, due to the degree of NRC involvement needed to assure that conservative and comprehensive corrective actions were taken to evaluate and resolve these safety significant issues. Accordingly, the civil penalty proposed for this Severity Level III problem is $50,000.

Therefore, to emphasize the importance of detailed knowledge by management, engineering and operations of safety-related plant structures, adequate planning and controls over safety-related maintenance, conservative operability evaluations, and identification and correction of significant conditions adverse to quality, I have been authorized, after consultation with the Commission, to issue the attached Notice of Violation and Proposed Imposition of Civil Penalties (Notice) in the amount of $650,000 for the Severity Level II problem and the Severity Level III problem.

You are required to respond to this letter and should follow the instructions specified in the attached 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 attachment, and your response will be placed in the NRC Public Document Room.

Sincerely, Original signed by A. Bill Beach A. Bill Beach Regional Administrator

Docket Nos. 50-373; 50-374
License Nos. NPF-11; NPF-18

Enclosure:
Notice of Violation and Proposed

cc w/encl:
D. A. Sager, Vice President, Generation Support
H. W. Keiser, Chief Nuclear, Operating Officer
W. T. Subalusky, Jr., Site Vice President
D. J. Ray, Station Manager
J. Burns, Regulatory Assurance Supervisor
I. Johnson, Acting Nuclear Regulatory Services Manager
Richard Hubbard
Nathan Schloss, Economist
Office of the Attorney General
State Liaison Officer
Chairman, Illinois Commerce Commission
Document Control Desk-Licensing

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NOTICE OF VIOLATION
AND
PROPOSED IMPOSITION OF CIVIL PENALTIES

Commonwealth Edison Company Docket Nos. 50-373; 50-374 LaSalle County Station License Nos. NPF-11; NPF-18 EA 96-325

During an NRC inspection conducted on July 17 through August 20, 1996, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the NRC proposes to impose civil penalties 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 penalties are set forth below:

I. Violations Assessed Civil Penalties

A. Violations Associated with Foam Sealant Repair, Planning and Corrective Actions

1. 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that activities affecting quality be prescribed by and accomplished in accordance with documented instructions, procedures, or drawings of a type appropriate to the circumstances.

LaSalle Administrative Procedure (LAP) 300-37, "Minor Maintenance Action Request Procedure," Revisions 3 (dated October 2, 1995) and 4 (dated May 13, 1996), step F.1, require, in part, that the Lead Unit Planner with the assistance of the Lead Maintenance Planner screen Action Requests to determine if the Action Request is minor. Step F.1.a defines an Action Request on safety-related equipment as minor when the work activity is limited to packing adjustments, valve handle replacement, tightening of threaded connections, walkdown inspections and troubleshooting which will not effect the safety-related function for any systems or components.

a. Contrary to the above, on December 12, 1995, an activity affecting quality was not accomplished in accordance with LAP 300-37 in that the screening of the Action Request AR950063168 for the sealing of cracks in the safety-related Lake Screen House, performed by the Lead Unit Planner and the Lead Maintenance Planner, failed to determine that the work was not "minor maintenance." (01012)

b. Contrary to the above, between May 21, 1996, and June 20, 1996, an activity affecting quality involving safety-related work performed by a Commonwealth Edison contractor, repair of cracks in the Lake Screen House, was performed without documented instructions, procedures, and drawings appropriate for the activity. (01022)

2. 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, in part, that measures shall 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 action taken to preclude repetition.

Contrary to the above, on June 19, 1996, and continuing until July 5, 1996, Commonwealth Edison failed to promptly identify and evaluate a significant condition adverse to quality, specifically the injection of foam sealant material into the service water tunnel. The injection of the sealant material was a significant condition adverse to quality because the activity introduced debris into the service water tunnel that challenged the functionality of the non-essential and safety-related service water systems because both systems took suction from the service water tunnel. The licensee failed to identify and correct the condition, as evidenced by the following examples:

a. On June 19, 1996, following the determination that all three non-essential service water strainers were fouled, the licensee incorrectly determined that the fouling was caused by corn cob material used in sandblasting the exterior of the lake screen house when, in fact, the fouling occurred from foam sealant material.

b. On June 24, 1996, following a second occurrence of fouling of the non-essential service water strainers and fouling of the diesel-driven fire pump strainers and having recognized that the source of the fouling was foam sealant material, the licensee incorrectly determined that the physical properties of the foam sealant material would not continue to place the service water systems in jeopardy, (i.e., the foam sealant material was attached to the ceiling of the service water tunnel or was buoyant). In fact, the sealant material, was not buoyant and was later identified on the bottom of the service water tunnel in close proximity to the safety-related service water intake resulting in a significant condition adverse to quality created by the material presenting the potential for uptake into and fouling of the safety-related service water system.

c. On June 28, 1996, following the discovery by divers that a significant quantity of foam sealant material was near the bottom of the service water intake tunnel, in close proximity to safety-related service water systems, the licensee incorrectly determined that foam sealant material would not challenge the functionality of the service water systems. (01032)

This is a Severity Level II problem (Supplement I).
Civil Penalty - $600,000 (distributed $100,000 for the violations in I.A.1 and $500,000 for the violations in I.A.2).

B. Violations Associated with Procedural Requirements for Backwashing and Maintaining Cooling Systems

1. 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that activities affecting quality be prescribed by and accomplished in accordance with documented instructions, procedures, or drawings of a type appropriate to the circumstances.

Technical Specification 6.2 requires that the written procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, be established, implemented, and maintained. Regulatory Guide 1.33, Appendix A, recommends procedures be established for the Authorities and Responsibilities for Safe Operation and Shutdown and for the operation of the Service Water System.

Contrary to the above:

a. On July 9, 1996, an activity affecting quality, safety-related testing on the diesel generator cooling water strainer backwash lines to determine system flow rates, was performed without the use of documented instructions, procedures and drawings appropriate for the activity.

b. As of August 20, 1995, an activity affecting quality, inspecting and cleaning of both 10 and 40 basket Emergency Core Cooling Water System (ECCS) service water strainers, was inappropriate to the circumstances in that LaSalle Maintenance Procedure LMP-GM-25, "ECCS Service Water Strainer Maintenance," Revision 2, did not address the differences between the two strainers, including the differences in the length of the drive shafts. (This resulted in the discovery on July 14, 1996, of a drive shaft for a 10 basket strainer installed in a 40 basket strainer in a Unit 2 Residual Heat Removal service water system strainer D300B.)

c. As of August 20, 1996, Normal Operating Procedure LOP-DG-04, Revision 18, "Diesel Generator Special Operations," an activity affecting quality, was found inappropriate to the circumstances in that it did not contain the necessary instructions for manual backwashing of the diesel generator service water system strainers.

d. As of August 20, 1996, Normal Operating Procedure LOP-RH-14, Revision 4, "Backwash of the Residual Heat Removal Service Water Strainers," an activity affecting quality, was found inappropriate to the circumstances in that it did not contain the necessary instructions for manual backwashing of the Residual Heat Removal system strainers.

e. As of August 20, 1996, Normal Operating Procedure LOP-WS-05, Revision 3, "Service Water Strainer Operations," a Technical Specification required procedure, was not appropriately maintained in that it did not contain the necessary instructions to allow for backwashing of the non-essential service water strainers. (02013)

2. 10 CFR 50.59, "Changes, Tests and Experiments," paragraph (a), requires, in part, that a licensee may make changes in the facility as described in the safety analysis report, without prior Commission approval, unless the proposed change involves a change in the technical specification incorporated in the license or an unreviewed safety question. Records of changes must include a written safety evaluation which provides the bases for the determination that the change does not involve a unreviewed safety question.

The Core Standby Cooling System (CSCS) is described in Section 9.2.1 of the UFSAR. Section 9.2.1.2 states that the backwash cycle requires 250 gpm at 20 psid. Section 9.2.2.2 states that a 1/16" mesh is installed in the non-essential service water strainers.

Contrary to the above:

a. As of August 20, 1996, a written safety evaluation to provide the bases for a determination that a change to the facility did not involve an unreviewed safety question was not performed for a change to the facility involving the discovery on July 13, 1996, that the backwash flow of the 0, 1A and 2A diesel generator cooling water strainers, a part of the CSCS Equipment Cooling Water System, was determined to be approximately 22 gpm, significantly less than the 250 gpm described in Section 9.2.1.2 of the UFSAR.

b. As of August 20, 1996, a written safety evaluation to provide the bases for a determination that a change to the facility did not involve an unreviewed safety question was not performed for a change to the facility involving the discovery, on June 27, 1996, that the non-essential service water strainers were installed with a 1/8" mesh instead of the 1/16" mesh described in Section 9.2.2.2 of the UFSAR. (02023)

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

II. Violations Not Assessed a Civil Penalty

A. 10 CFR Part 50, Appendix B, Criterion XVII, "Quality Assurance Records," requires, in part, that sufficient records be maintained to furnish evidence of activities affecting quality. Inspection and test records shall, as a minimum, identify the inspector, the type of observation, the results, the acceptability, and the action taken in connection with any deficiencies noted.

Contrary to the above, records were not maintained to furnish evidence of activities affecting quality for the work performed on the Unit 2 residual heat removal service water strainer D300A on July 6 and 12, and on Unit 2 residual heat removal service water strainer D300B on July 12, 1996, in that the records did not identify the inspector, the results, or the action taken in connection with the deficiencies noted. (03014)

This is a Severity Level IV violation (Supplement I).

Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company (Licensee) 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 Penalties (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 violation, (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 penalties 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 penalties will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, in whole or in part, such answer should be clearly marked as an "Answer to a Notice of Violation" and may: (1) deny the violations 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 penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties.

In requesting mitigation of the proposed penalties, the factors addressed in Section VI.B.2 of the Enforcement 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 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 penalties.

Upon failure to pay any civil penalties 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 penalties, 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 (Reply to Notice of Violation, letter with payment of civil penalties, and Answer to a Notice of Violation) should be addressed to: Jim 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, and a copy to the NRC Resident Inspector at the LaSalle County Station.

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 Lisle, Illinois
this 24th day of January 1997