IR 05000219/1989023
| ML19325E080 | |
| Person / Time | |
|---|---|
| Site: | Oyster Creek |
| Issue date: | 10/17/1989 |
| From: | Cowgill C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML19325E079 | List: |
| References | |
| 50-219-89-23, NUDOCS 8911010152 | |
| Download: ML19325E080 (9) | |
Text
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' ' ' i i. Lew, Resident Inspector, ' , , % y q,
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~ ' ! ' n . ' '\\-( , I, , ' L = Areas: Inspected:. Resident inspectors reviewad the fcircumstanceu niid corrective ,s . g . M ' p' l actiorIEassociatOJ with the selection of, nontsaf4ty CC control power to -safety 7A j 'E
[M mYke-x 'reletodibreakers' onLunit substation M2. Plant 'opernions contir.ued for an
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The second - QM
- involved'the fiilure to properly identify and promptly correct a r.ondition l., ; >yN t, adver se to, quality.. This is an apparent violation;of of 10_ CFR 50 Append'x B, Mpv Criterion XVI end the site Operatior,ai Quality Assurance Plan.1
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O J codsultant were (in' 9rogress at the completion of the inspection.
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1.0.' Overview'..............................
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-s 12.0; Summary'of Events (93702).'...................... t ' . I , , W' 2.1 Oyster Creek ' Configuration. _.. -1 .............. 2.2 ' Di s cove ry............
i ............. , , " 2.3-. Immediate Correc+1ve Action......... . .......3 . @ 3;0l NRC' Review.(93702)~..... ,..........,.... a 4' ' ' . . ,. v < , . ;P L3..t. Plant. Visual. Inspections................'....
Q.t ' 3.2 LProcedural C,ontrol....'................. '4 " , W6 3.3. Assurance of Quality.
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................... , t . , . g,F A4. 0 Conclusions (93702)(.......................
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'25.0 Exit Interview (30703) '.......................- 7 ll
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.m 'g . e i. L DETAILS ' , , ? ' , ' ;g 1.0f0v.arview I [h[y[0 f On September 15, 1989; it was brought to the attention of an Operations " ' Department middle manager that the Unit Substation (USS) 182 breaker ' . control power / selector switch may havs been in the wrong position. At
F Oyster Creek', breaker contro1' power is supplied from the direct currtn. (DC).
' y distribution systems.
Early on September 16, 1989, this was discussed with the Plant Operations Director and was evaluated as 6n item that must , be resolved! prior to plant startup.
Through ter, ting and visual observa-r 1 7f
tion, it was concluded 'the' switch was selected to non-safety DC distribu- '# tion. system "A" vice the safety related DC'dit*rfbution system "B".
The ' //4f ' j'switchwasinthewrongposition' , , , t t . , ny The licensee correctly repositioned the switch and verified through the '- L use of electrical drawings that similar switches associated ilth other i , . y f'. ! electric breakers were cor;rectly positioned.
" . . Approxima' ely two wonths eahlier, a senior licensed operator had become T's .' t 1 aware the: switch was. selected te the "A".CC system.
This was brought to l ' < a f i L "the attentloh' of; the: Gr.,up Shif t Supervisor (GSS) and 'an Operations ' ) al'i l/c.
Department middio manager.
Their review of the. station procedures con -
7? in trolling.the'sineup of DC distribution systitms did not conclusively . determine tne. required switch position.
7 e pro:edure only.specified that fh' the " preferred" position was selection to the "B" DC systna; This concern ' lwas not! documented in-the site corrective action systens,.and effective p :, ci correctiveraction was not initiated.
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. . , i ! j"i ' USS 182 is.a!460 volt, safety related electric bus supplying power' to j , V/, 4 Coro Spray Dooster pumps B and C, and Containment Spray pumps C and D.
Dperst' ion of the plant vii.n .ie control power selected to a non-safety DC ," cpR distributio's tystem is outside the design and licensing basis of tne Q> plant.
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- c 6;ks At.the conclusion of this inspection, the license * was in the process of
' v a;f ,c . etternnning when ana how the selector switch was incorrectly positioned to {{ >, the "A" DC system, fh> 2.9 Summary of Events 0n ( f&l(L ; ",' Oyster Creek safety related electric power distribution consists of wmt ' Rysfcar; Creek Coni'f e,prgion 2.1 s ,
IN J)[idf; < if. IL twoll160 voit b u es (IC ani 10) and t w 4 0 volt unit substations (IA2 f teld 182). Bretker contral power is suppMed from the site DC l N I h j-distribution systems.
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N - , ' ,N ) . The Oystar Cre k design originally provided for two DC distribution M systems, "A".and "B".
The option existed, in the past, to select-i g y" either DC "A" or'"B" contro1' power for safety related electrical ? buses.
Since batteries "A" anc "B are located in the same-room, it.
p% . as later decided to add another battery, "C",-which was' physically . w separated from "A" ard "B".
^ ' The' breaker control power configurations were modified accordingly.
l' This new configuration provides control power for 4160 bus '10 and 460 ,
volt USS 1A2 from DC "C".
The old electrical connections from the>e < ' buses to DC A" were replaced by connections to DC "C";. and the e electrical connections to DC "B" were removed.
So for these~two
' h:. , buses,.even though.the selector switches still exist, there is only~
one possible source of control power.
f For the remaining two buses, 4160 bus 10, and USS 182, the electrical design was left essentially intact.
Using the selector switch either 7" DC "A" or DC "B" could be selected. The primary difference between ^ batteries "A" and "B" is that battery "B" is qualified as seismic ', category I while battery "A" is not.
- The site updated Final Safety Analysis Renort indicates that safety
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loads are sunplied from DC. centers "B" ano "C".
DC center "B" supplies division "B" safety related loads and DC center "C" supplies /d1 cision "A" safety related loads. Operaticn of the plant with. safety related breaker control power selected to the "A" DC distri- ' ' bution system is outside the design and licensing basis.
2.2 Ofscoyery l ' During preparations for startup' on 9/15/89, a Group Operating E Supervisor (GOS) (cenior licensed operator) checked with operations management regarding the status of an Item which he had previously - E '9 questioned. Approximately t e months eerlier, the GOS had been giving . an oral examination to a cont.rol room operator (CRO) trainee and had - / ,
observed'the DC selector switch for USS 1B2 to be selected to the "A" station battery which he questioned.
$ <- Station procedures were referenced by the operators to identify the I required position of the switch.
Plant Technical Specifications, j Section S.7, " Auxiliary Electrical Power," is vague in its require- < , , 1... - ments and did not address the selection of DC control power for breakers. Station procedure 338, "460 Volt Electrical System" did i f.
not address the DC control power select switches.
Procedure 340.1, "125 ry ^.'. U.D.C. Distribution System "A" and "B", identified that the " pre- ! f' Jg ferred" position of the switch was to be "B" battery.
The electrical i , component lineup sheets did not include this DC selector switch.
The ! / procedures did not specify or control the required switch position.
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, 2.D . ' ' ' , , f ' [ ' The matter was further complicated because of the quality'of plant . labeling. There was no confidence in which side of the switch was l
- U the'"A" battery and which side was the "D" battery. The labelling-J
" , , was suspect being merely "Dync" tape labelling.
, The GOS discussed the concern with a Group Shift Supervisor (GSS) and an Operations Department middle. mar.ager was informed.
Since no clear . k requirement could'be. identified to reposition the switch.to the "B"
battery, and because of the potentia 1' risk of. shifting DC control
. . power while the plant was operating, it was decided to leave the " ' control power selected to the "A" battery..The concern was not'
formally documented, q i s-Early on September 16, 1989, a different operations department middle
F . manager raised the concern with the Plant Operations Director. 'It , was determined that this item had'to'be resolved prior.to plant l c startup. Tests were performed to confirm the actual position of.the switch. These tests showed the switch was selected to the "A" . 1I station battery.
The switch was repositioned to select the "B" 'I batteri.
> l 2 '. 3 Immediate Corrective Action ' t After confirming the DC control selector switch for unit substation i 182 was out of position, Plant Operations and the Independent On-Site
Safety Review Group (10SRG) took the following actions: "
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Made a 10 CFR 50.72 four-hour notific tion.
-- ' , Pepositioned the DC selector switch to the "B" station battery.
' - Reviewed station procedures and electrical elementary drawings - . to identify similar selector switches. These,were visually ! verified to be correctly positioned and labelled.
l; . Verified other station DC and AC electrical transfer switches to - , be correctly positioned.
< .r l Implemented procedural changes to identify these DC control r - < L power select switches and to specify the correct position.
Briefed each subsequent oncoming thift to reinforce the design ' - l differences between the station "A" and "B" battery and ' emphasize that all safety . lated DC loads (from division "B") , lC must be supplied by the "B" station battery.
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f ' On September 22, the Site Director issued a memorandum to all site personnel anphesizing the requirements to properly document deficient l conditions.
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g, g Subsequent'to.these immediate corrective actions the licensee has I ' ' E _ 10SRG manager was charged with the responsibility of reviewing this implemented a detailed review focusing on two areas.
First, the.
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incident.for technical issues. Second, a review will be performed to
, E determine how and why the switch was mispositioned, when the problem ' . was identified and what weaknesses exi.t in identifying, documenting, l b Land correcting this condition adverse to' quality.
u f,1 The immediate corrective actions were discussed with NRC regional ' ' management personnel in a conference call on 9/1G/39.
It was , p' concluded that these immediate corrective actions were sufficient to l , c, address the immediate concern and verify that similar components were t properly positioned and controlled.
- , . . . 3.0 NRC Revyw
3.1 Plant Visual Inspectiens On September' 16, 1989, an NRC inspector visually inspected unit
subs.tations IA2 and 182. The inspector verified the DC selector . switch for unit substation 182 had been repositioned to "B" station battery, i It was identified that the labelling for USS 1A2 indicated the capability to select "B" station battery and "C" station battery.
. ' The switen was selected to the "C" station battery, which is correct.
' The insptctor questione d if station "B" battery actually supplied power to the other side of the selector switch.
Licensee review concluded the labelling was incorrect and there was no DC. power tc L USS 1A2 from "B" DC. The labelling indicating "B" battery was
removed.
, 3.2 Procedural Control ! Station Procedure 338, "460 Vol Electrical System" and 340.1, "125 VDC Distribution System A and B," were compared to electrical , drawings BR-3033 and D-3028. Station Procedure 338 did not address ( the DC control power selector switches.
Station Procedure 340.1 did address the DC control power sele :to. switch, but only in the portion l af the procedure which initially places the station battery into service. The procedure did not specify "B" battery as the required - position, only as the " preferred" position.
In the electrical com-m M>> ponent lineup sheets provided with Procedure 340.1, these DC control power selector switches were not included.
- L Plant Technical Specifications were reviewed to identify the require- ' ments for site electrical systems.
Section 3.7 specifies that 460 ' , .*
volt buses IA2 and 182 be energized, and that station batteries "B" L and "C" be available for normal service with a battery charger in ' L n l 'c f
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It was concluded that these requirements ! do not-provide detailed instruction to ensure-that these components
are available.and in service.
No reference was made to the DC control ,' power for tLe breakers on unit substations IA2 and 1B2.
It was concluded the site procedural controis for establishing and verifying ' the' correct. position of ' unit substr. tion 1B2 DC control power selector switch were inadequate. 'The required position in accordance with the design and licensing basis was not specified..No provisions were included to periodically verify' switch position.
NPC requirements in 10 CFP. 50 Appendix B Criterion V, require that 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. The Operational Quality-
< . Assurance Plan for Oyster Creek, Section 6.10.1.2, specifies that procedures shall be provided for control of equipment as necessary to maintain personnel and reactor safety, to avoid unauthorized . ' operation of equipment and to assure that the operational equipment ' is in.a re:dy status.
, , This is an apparent violation in that neither Station Procedure 338 or Station Procedure 340.1 incluaed the provisions necessary to ensure those switches were correctly positioned.
This procedural inadequacy resulted in plant operation outside of its design and , licensing basis for an extended period of time.
3.3 Assurance of Quality The inspector reviewed station requirements for id9ntifying and
' '. correcting conditions adverse to quality.
Station Procedure 104, ' " Control of Nonconformances and Corrective Action," has the following provisions: All personnel assigned to work at Oyster Creek are responsible
for communicating identified deficiencies to the GSS and their i supervisor.
' , All supervisory personnel are responsible for ensuring devia-
tions which they may become aware of are documented in n accordance with this procedure, The GSS is responsible for evaluating the effect of identified s
daviations on the safe operation of the plant, initiating whatever cor:ective action is considered necessary and making reports and notifications required by procedure, , r a i i
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-)# } I- , Procedure 104 defines a condition a'dverse to quality as an.all ' ' inclusive term used.in reference to any of the following; failures, i malfunctions, deficiencies, effective items and nonconformances. -It i ~ . includes events / situations which may' require further review, reporting
or corrective action.
A significant condition adverse.to quality is i - L one which, if uncorrected, could have a serious effect"on safety or ! operability.
S.tation' Procedure 104, paragraph 5.1, requires personnel-who become ' aware of a condition adverst, to quality to document it using the w appropriate means described or report it to their supervisor.
Para- '
graph.5.6 specifies'a deviation report should be prepared for events ' where corrective action to prevent recurrence may be needed, signi- , ( ficant conditiors adverse to quality.may exist, and notification of .- or reporting to regulatory agencies may be required. As'an example of conditions requiring a deviation report, Station Procedure 104,
Appendix I, lists operation of a safety related system contrary to i that as described in the FSAR.
g b ', , , , Station Procedure 104 implements the requirements of 10 CFR 50 , Appendix B, Criterion XVI and the site Operational Quality Assurance , Plan requiring measures to be established which ensure that condi-tions adverse to quality are promptly identified and corrected. The cause of significant conditions adverse to quality shall be deter-mined and appropriate action taken to prevent recurrence. The l identification, cause and actions taken to correct significant
conditions adverse to quality shall be documented and reported to the t appropriate levels o6 management.
For t.pproximately two months, senior licensed operators and site o middle management personnel were aware of a potential condition adverse to quality and did not document it in the site's corrective < action systems. This failure to properly identify and correct a L significant condition adverso to quality is an apparent violation b of 10 CFR 50, Appendix B, Criterion XVI, and the site Operational , , Quality Assurance Plan, Section 8.1.1.
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I t The identification and avaluation of this event was discussed with one of the involved operators. The operator thought that some u verification of the accuracy of the labelling should be performed p prior to actually concluding that the switch was mispositioned, j Given that the labelling was correct, the operator recognized that J selection of the DC control power to the "A" battery was not tppro-L'V priate.
The operator indicateo reluctance te write the deviation report in accordance with Procedure 104 because the existence of a deficient condition had not been established.
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, , F The inspector: concluded the requirements of Procedure 104 to document b deficient conditions or potential deficient conditions are not fully implemented by all site personnel.
In this case an actual deficient condition went unevaluated, and Lhe plant was operated outside_the o _ design and licensing basis for an extended period of time. This ' ' , condition.could have impaired the operability and reliability of safety related equipment.- o
4.0 Conclusions- '
The requirement of the updated FSAR that station battery "B" supply safety related equipment was not reflected in station procedures. This absence of specific requirements for the position of the switch, resulted in it being selected to battery "A" for an extended period of time.
"These t weaknesses allowed the plant'to operate outside the design and licensing i ... basis."
When this condition was brought to the attention of senior licensed . operators and site middle management, station requirements to. document, review,'and specify corrective action were not taken for an extended period of time'. The operators and site manager elected to pursue resolu-tion of the question in an informal manner.
This shows weakness in the t' implementation of corrective action system measures and incomplete under-standing of the requirements by station personnel.
T f Insdequate station system operating procedures, combined with ineffective , implementation of site corrective action system measures permitted reactor
operation with site safety equipment outside the design and licensing L basis.
5.0 Exit Interview l.,' A summary of the results of the inspection activities performed during . ! ' this report period were reviewed with senior licensee management at the end of this inspection.
The licensee stated that, of the subjects discussed at the exit interview, no proprietary information was included.
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