U.S. NUCLEAR REGULATORY COMMISSION

Region III Office of Public Affairs

801 Warrenville Road, Lisle IL 60532-4351

NEWS ANNOUNCEMENT: RIII-96-69 November 22, 1996

CONTACT: Jan Strasma 630/829-9663

Angela Dauginas 630/829-9662

E-mail: opa3@nrc.gov

NRC ISSUES INSPECTION REPORTS ON TWO TEAM INSPECTIONS

AT CLINTON NUCLEAR POWER STATION

The Nuclear Regulatory Commission staff has issued reports

on two team inspections reviewing plant operations at the Clinton

Nuclear Power Plant as a result of a reactor shutdown which

occurred September 5, 1996. The plant, operated by Illinois

Power Company, is near Clinton, Illinois.

The plant was shut down because of the failure of a reactor

recirculation pump seal. One NRC inspection team focused on the

circumstances surrounding the shutdown, and the second team

reviewed plant operations more broadly.

The NRC's letter to the utility transmitting the two reports

is attached.

The full inspection reports are available for review on the

NRC's internet web site. The web address for the reports is: 

<http://www.nrc.gov/OPA/reports>. Copies of the reports are also

available by mail from the NRC Region III Office of Public

Affairs.

* * * * *
November 19, 1996

John G. Cook

Senior Vice President

Illinois Power Company

500 South 27th Street

Decatur, IL 62525

Dear Mr. Cook:

On October 4, 1996, the NRC completed two inspections at your

Clinton facility: a Special Inspection into the circumstances

surrounding the September 5, 1996, recirculation pump seal

package failure and an independently chartered Operational Safety

Team Inspection (OSTI) which was initiated as a result of

operator performance in the recirculation pump seal package

failure event. The enclosures to this letter present the results

of those inspections.

As will be discussed below, on September 5, 1996, the operations

department put in motion a sequence of events which revealed

significant deficiencies throughout the organization at the

Clinton facility. These deficiencies included procedural

adequacy and adherence problems, lack of rigor in conducting

plant operations, and weak engineering support to operations. 

And, most significantly, the deficiencies included serious lapses

in safety focus by both plant management and staff. It appears

that plant management and staff made decisions which placed plant

production ahead of plant operational safety. This matter is the

subject of an ongoing Office of Investigations review.

Our review of the activities associated with the September 5,

event, and additional confirmatory findings from the OSTI,

identified a number of actions and practices which are

inconsistent with procedural and programmatic controls for

assuring safe operation of a nuclear power plant. These actions

and practices were also evident in the April reactor scram when

station management decided to maintain the unit in a hot standby

condition, thereby minimizing down time. This decision resulted

in degraded safety relief valves. In both events, actions

necessary to place the unit in the safest, most stable condition

were not taken. Further, the decision to maintain the unit in

hot standby following the June reactor scram resulted in a lost

opportunity to address the degrading "B" recirculation pump seal

package. 

Specifically during the September 5, event, operators were

attempting to place the unit in single loop operation to allow

continued unit operation by isolating a reactor coolant leak in

the “B” reactor recirculation pump shaft seal package. While

attempting to isolate the loop, seal pressure, temperature, and

leak rate were not decreasing quickly enough to ensure continued

unit operation. To increase the pump shaft seal’s cool down rate

and reduce leakage, shift supervision directed actions which were

inconsistent with both Clinton procedures and vendor
recommendations for isolating the seal package. After this

procedural noncompliance, seal leakage increased to greater than

5.0 gallons-per-minute, the technical specification (TS)

allowable leakage rate. The shift crew entered the emergency

plan, declared a Notice of Unusual Event, and made appropriate

notifications. 

The plant was now in a TS limiting condition for operation (LCO)

which required reducing the leakage within four hours or shutting

the plant down. Based on the four-hour limitation, additional

procedural steps were not followed in another attempt to reduce

the leakage to less than the TS limit to allow for continued unit

operation. These activities exacerbated the seal condition

resulting in a seal failure and leakage exceeding the installed

instrumentation’s ability to accurately monitor the leakage. The

crew, although recognizing the seal failure, did not recognize

the instrumentation’s limitations. It was not until a relief

Shift Technical Advisor arrived that leakage rates were properly

calculated. Even though shift management was aware that these

actions would further degrade the seals and was aware that a

previous seal failure had resulted in leakage in excess of the

criteria for declaring an Alert under the emergency plan, an

Alert was not declared following all of the obvious indications

that a seal failure had occurred.

After the seal package failed, shift supervision continued to

delay commencing the reactor shutdown, maximizing the operating

time and fully expecting the leakage to drop below the TS limit

so that single loop operation could be maintained. Finally, four

hours after the seal package failed (two hours after the LCO

expired), with a leakage rate still greater than twice the TS

limit, a briefing was held for the planned orderly shutdown of

the unit. Plant shutdown continued to be inappropriately

protracted with plant operation continuing to within 46 minutes

of the 12-hour shutdown requirement being exceeded. 

Throughout the event, operators’ actions were complicated by

preexisting equipment deficiencies. The originally installed

leakage rate instrumentation has been a continuing problem at

Clinton. A modification installed to provide similar information

had its indication capped at 8 gallons-per-minute, well below the

actual leakage achieved during the September 5 event. While

providing leakage rates, the modification did not support

continued leakage rate information or emergency classification

assessments when most needed. Safety relief valves, cycled 85

times in the April event discussed earlier, were leaking and

contributed to operators diverting their attention from the plant

shutdown to enter an Emergency Operating Procedure to reduce

suppression pool level.

Even after the unit was placed in a shutdown condition, the

operations department still appeared to be driven by schedule

pressures rather than conservative operating practices. For

example, while placing the feedwater system in a cleanup mode,

the operations department determined there was a need to expedite

the cleanup rate and again operated equipment/components outside

of procedural controls. This procedural non-compliance resulted

in the spinning of the feedwater pump without oil to the bearings

which could have caused serious damage to the pump. 
Following the event, our observations indicated that the Clinton

staff believed that the actions taken during the event were

appropriate. The failures to follow procedures, inadequate

procedures, operator performance issues, and inadequate

management involvement were not promptly identified nor

understood. It was not until the NRC had extensively intervened,

through a number of calls with senior plant management over a

period of several days that action was taken to initiate a

thorough and comprehensive assessment. This commitment was

formalized in our Confirmatory Action Letter dated

September 11, 1996. The initial assessment, while drawing

appropriate overall conclusions, did not provide a solid basis

for some of the conclusions. For example, while the initial

assessment concluded that procedures were not followed, the

detailed report indicated that procedural steps were followed, or

a procedure deficiency existed, when in fact the problem was that

procedural steps were not followed. Following subsequent

discussions with the NRC, the Clinton staff's revised assessment

corrected these issues.

In summary, our assessment of the recirculation pump seal package

failure event identified three significant concerns. First, the

operations department lacked an appropriate safety focus as

exhibited by: (1) the failure to follow procedures in an

extraordinary attempt to keep the unit in an operating condition,

and (2) the protracted unit shutdown. Secondly, the failure to

correct known material condition deficiencies that complicated

operators’ actions and responses indicated a lack of management

sensitivity and priority to the removal of barriers affecting

operator performance. Finally, the engineering department’s

support to operations was weak as exhibited by poor corrective

actions for the original leakage instrumentation problems and the

deficient compensatory modification. 

While the examples differed, the same issues were independently

confirmed during the OSTI. A number of problems with procedure

adequacy and adherence were identified. Two cases of

preconditioning for a diesel generator surveillance and an

inadequate local leak rate test procedure were identified. The

preconditioning is of concern because this could mask materiel

condition issues affecting the operability of the diesel

generators. Problems with procedure adherence were further

exemplified by operators failing to follow the procedure for

isolating spent fuel pool cooling and thereby allowing a 1000

gallon per day leak. In addition, when an operator was asked why

they (operators) were having difficulty with a specific

procedure, he responded that they were trying to do this the

right way because the NRC was watching. This statement

demonstrates a poor attitude toward and understanding the

importance of procedure adherence.

The OSTI identified, through control room observations, a lack of

management oversight and a full appreciation for the

responsibilities held by licensed operators. At one point the

“at the controls” operator left the designated control area

without obtaining a relief. Short term relief turnovers were

weak, and variations in crew communications and formality were

observed. That these activities would occur during a major NRC
team inspection, with inspectors in the control room, indicates

to us that these problems may be more widespread. 

Engineering support to operations was weak and the engineers

exhibited a weak safety focus. Engineering and operations on

occasion conducted tests on facility systems with the reactor at

power to identify potential impacts on safety systems. For

example, cycled condensate was isolated from the residual heat

removal system to determine the potential impact. This test

resulted in the residual heat removal system being declared

inoperable. These special tests did not receive the required

safety evaluations (10 CFR 50.59) or site reviews for

acceptability. Further, engineers indicated it was acceptable

to perform actions by combining steps from disparate procedures

without further review. Conducting unreviewed, unauthorized

tests demonstrates a lack of a safety focus by engineers and

licensed operators. 

The OSTI also noted that often engineers seemed focused on

finding a way to justify system operability rather than

performing an in-depth evaluation and analysis demonstrating

system operability and compliance with the FSAR. The operability

evaluation program was poor with the process for operability

evaluations not fully described. The Clinton staff did not know

how many or what operational evaluations were in-place. Further,

the staff had no mechanism of tracking evaluations. This is of

significant concern to us because degraded plant equipment needs

to be promptly evaluated to ensure appropriate safety margins are

maintained.

Most of these significant issues described in this report

including several apparent violations with multiple examples,

were identified by the NRC, including: 12 examples of failing to

follow procedures, 8 examples of inadequate/inappropriate

procedures, 4 examples of failure to perform safety evaluations

(10 CFR 50.59), two examples of inadequate corrective actions, an

example of an operator leaving the “control” area without relief,

and an example of operations management not performing

appropriate administrative activities. The failure of the

Clinton staff to recognize the significance of the issues

identified and to promptly and appropriately respond to the them

shows a lack of appreciation for the importance of adherence to

NRC requirements. 

Based on the results from the inspections and as noted above,

several apparent violations of NRC requirements were identified

and are being considered for escalated enforcement action in

accordance with the “General Statement of Policy and Procedure

for NRC Enforcement Actions” (Enforcement Policy), NUREG-1600.

No Notice of violation is presently being issued for these

inspection findings. In addition, the number and

characterization of apparent violations described in the enclosed

inspection reports may change as a result of further NRC review.
A pre-decisional enforcement conference to discuss these apparent

violations will be scheduled. The decision to hold a predecisional enforcement conference does not mean that the NRC has

determined that a violation has occurred or that enforcement

action will be taken. The conference will be held to obtain

information to enable the NRC to make an enforcement decision,

including a common understanding of the facts and circumstances

surrounding the violations, their root causes, your opportunities

to identify the apparent violations sooner, your corrective

actions, and the significance of the issues.

In addition, this is an opportunity for you to point out any

errors in our inspection reports and for you to provide any

information concerning your perspectives on 1) the severity of

the violations; 2) the application of the factors that the NRC

considers when it determines the amount of a civil penalty that

may be assessed in accordance with Section VI.B.2 of the

Enforcement Policy; and 3) any other application of the

Enforcement Policy to this case, including the exercise of

discretion in accordance with Section VII.

You will be advised by separate correspondence of the results of

our deliberations on this manner. No response regarding these

apparent violations is required at this time.

In accordance with 10 CFR 2.790 of the NRC's 'Rules of Practice,'

a copy of this letter and its enclosures will be placed in the

NRC Public Document Room (PDR).

Sincerely,

/s/A. Bill Beach

A. Bill Beach

Regional Administrator

Docket No. 50-461