Junk Plant Hope Creek: Their Employees Turning Agaisnt Them

05000354

Does this happen often? Why would a employee lie?

HOPE CREEK GENERATING STATION - NRC INVESTIGATION REPORT NO. 1-2016-003
Dear

Dear Mr. Sena:

This letter refers to an investigation initiated on November 5, 2015, by the NRC Office of Investigations (OI) and conducted at the PSEG Nuclear, LLC (PSEG) Hope Creek Generating Station (Hope Creek). The investigation was conducted to determine whether an instrument and control (I&C) technician had deliberately failed to follow site procedures resulting in a reactor scram. Based on the evidence gathered during the investigation, the NRC preliminarily determined that a (now-former) PSEG employee at Hope Creek deliberately failed to follow a procedure...

Factual Summary of NRC Office of Investigations (OI) Case No. 1-2016-003

On September 28, 2015, an instrument and control (I&C) technician completed procedure HC.IC-FT.SA-0001, “Redundant Reactivity Control System (RRCS) – Division I Channel A” and successfully tested the ‘A’ channel of the RRCS. The I&C technician then proceeded into procedure HC.IC-FT.SA-0003, “RRCS – Division I Channel B” to test the ‘B’ channel of the RRCS. While the technician was performing this procedure, the reactor tripped. To determine the cause of the reactor trip, on September 30, 2015, PSEG performed complex troubleshooting, which included reviewing the data saved from plant parameters. Based on the troubleshooting, PSEG determined that the I&C technician had made an error during the surveillance testing, causing both RRCS channels to trip and the reactor to scram.

OI interviewed a PSEG staff engineer involved in the troubleshooting. The engineer testified that he analyzed real-time printouts of reactor parameters at the time of the event to recreate the scenario on the reactor simulator. The engineer stated that, from the simulation, it was determined that the I&C technician had incorrectly selected the ‘A’ channel of RRCS and then selected the ‘B’ channel with the test input still inserted in the ‘A’ channel. This error then caused the reactor recirculation pumps to trip leading to the reactor scram. Additionally, the engineer testified that the full RRCS system was reviewed as part of the troubleshooting and no other failures were identified.

The I&C technician testified that he had received training and was fully qualified to perform surveillances of the RRCS and had performed this particular surveillance   

The employee says something else broke.

numerous times. The technician acknowledged that he had received training on procedure use and adherence and understood that if an issue occurred, to stop and resolve the issue before moving forward in the procedure. The I&C technician stated that on September 28, 2015, he and another technician had been assigned to perform the RRCS surveillance on the Division 1 ‘A’ and ‘B’ channels. The technician testified that the cause of the reactor scram was “something went wrong with RRCS,” adding that he did not make any mistakes or deviate from the procedure. The I&C technician could not provide an explanation for the contradiction between PSEG’s determination for the cause of the scram (i.e. human performance error) and the technician’s own testimony.

OI reviewed the copy of HC.IC-FT.SA-0003, used by the I&C technician on September 28, 2015. The technician had initialed the warning at the start of the applicable section of the procedure which stated “Extreme caution should be exercised with key functions on Display Monitor. Careless keyboard manipulation can cause a reactor scram. If any doubt or questions arise, THEN CONTACT Job Supervision immediately.” Contrary to this warning, the I&C technician, as proven through plant data, did not stop and contact supervision after incorrectly selecting the ‘A’ channel of RRCS. Instead, he selected the ‘B’ channel with the test inputs still inserted in the ‘A’ channel.
OI concluded based on the preponderance of evidence, that the I&C technician deliberately failed to follow this procedure.

Hope Creek Generating Station Technical Specification 6.8.1.d, “Procedures and Programs,” requires that written procedures shall be established, implemented, and maintained for surveillance and test activities of safety-related equipment. HC.IC-FT.SA-0003, “Redundant Reactivity Control System – Division 1 Channel B, C-22-N-403E, N402E ATWS Recirculation Pump Trip,” cautions that “Careless keyboard manipulation can cause a reactor scram. IF any doubt or questions arise, THEN contact Job Supervisor immediately.”

ENCLOSURE 2
APPARENT VIOLATION

Contrary to the above, on September 28, 2015, PSEG did not properly implement a procedure for a surveillance activity of safety-related equipment when the individual performing an RRCS surveillance test made an error and rather than immediately stopping and informing the job supervisor, attempted to correct the error. Specifically, when manipulating the keyboard, the individual selected the wrong channel to test. Rather than contacting the job supervisor, the individual attempted to correct for the error by selecting the proper channel with test inputs still inserted in the other channel, which ultimately led to a dual recirculation pump trip, alternate rod insertion (ARI) initiation, and a reactor scram.

About a year later, the exact same kind of event, but different instrumentation occurred at shutdown.   

Licensee Event Report 2016-005-01

DESCRIPTION OF OCCURRENCE

On November 5, 2016 at 0404 a RRCS I ARI {JC} signal was generated while excess flow check valve testing was in progress. The RRCS/ARI signal was generated due to trip signals on reactor pressure vessel dome pressure high channel "B" (expected for testing) and RPV water level low channel "A" (unexpected for testing condition). The unexpected signal was generated during the performance of isolating transmitters during preps for excess flow check valve (EFCV) testing. This signal would have been reset in accordance with procedures if followed. There were two procedures being executed in parallel by technicians to perform the excess flow check valve testing. The test procedure is written to test all EFCV's, with the EFCV's being separated into 21 groups based on channel and instrument rack relationships. Only one of the EFCV groups, group J, was to be tested. A second procedure is used to align and isolate the instrument racks for testing. Since only one group was to be tested, the evolution required partial procedure performance and coordination of both procedures to accomplish the test. In marking up the procedures for partial performance, the steps to isolate transmitters that were not to be tested were marked Not Applicable (N/A). In the process of marking up the procedure, the steps to reset any RRCS trips was also inappropriately marked N/A. As a result, the trip of the "A" channel low RPV water level was not reset prior to performing the test of the "B" channel high RPV pressure.

The cause the event was inadequate procedural guidance which resulted in a personnel error associated with partial procedure use.