IR 05000245/1982004

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IE Insp Repts 50-245/82-04 & 50-336/82-06 on 820328-0508. Noncompliance Noted:Entry Into Operational Modes 2 & 1 W/O Meeting All Required Limiting Conditions for Operation
ML20055B688
Person / Time
Site: Millstone  Dominion icon.png
Issue date: 05/25/1982
From: Elsasser T, Lipinski D, Shedlosky J
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20055B683 List:
References
50-245-82-04, 50-245-82-4, 50-336-82-06, 50-336-82-6, TAC-48919, NUDOCS 8207220634
Download: ML20055B688 (15)


Text

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. . U.S. NUCLEAR REGbLATORY COMMISSION Region I 50-245/82-04 Report No. 50-336/82-06 ~50-245 Docket No. 50-336 DPR-21 License No. DPR-65 Priority Category C ___ Licensee: Northeast Nuclear Energy Company P.O. Box 270 Hartford, Connecticut 06101 Facility Name: Millstone Nuclear Power Station, Units 1 & 2 Inspection at: Waterford, Connecticut 06385 Inspection conducted: March 28 thru May 8, 1982 Inspectors: [[ 5~/[o/g p r . T. Sh'ediosky,[ Resident Inspector date signed b ffh 5-M-?Z D. R. Lipinski, Resident Inspector date signed date signed - he e b Approved by: / ' T. C.G2tasser, Chief date signed Reactor Projects Section 1B, Division of Project & Resident Programs Inspection Summary: Unit 1: Routine facility safety inspections, March 28 thru May 8,1982 (Report Number 50-245/82-04) including: evaluations of plant operations, equipment t alignments and readiness, radiation protection, physical security, fire protection, plant operating records, maintenance and modifications, surveillance testing and calibrations, and reporting to the NRC. The inspection involved 164 hours of onsite, regular, and backshift inspection effort by twa resident inspectors.

8207220634 820707 PDR ADOCK 05000245 G PDR

. . Results: No Violations were identified.

Unit 2: Routine facility safety inspections, March 28 thru May 8,1982 (RepoIt Number 50-336/82-06) including: evaluations of plant operations, equipment alignments and readiness, radiation protection, physical security, fire protection, plant operating records, maintenance and modifications, surveil-lance testing and calibrations, and reporting to the NRC. The inspection involved 120 hours of onsite, regular, and backshift effort by two resident inspectors.

Results: One violation was identified: Entry into Operational Modes Two and One without meeting all Limiting Conditions for Operation required in those modes (Details paragraph 4).

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_ __ .. _. .. _. . . DCS Identification Numbers NRC Inspection No. 50-245/82-04 50-336/82-06 Number Report Paragraph 50336-820404

50336-820404

50336-820405

50336-820407

50245-820413

50336-820417

50336-820418 4&8 50245-820315

50245-820318

50245-820322

50336-820304

! 50336-820310

. 50336-820318

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. . DETAILS 1.

Persons Contacted The below listed technical and supervisory level personnel were among those contacted: A. Cheatham, Radiological Services Supervisor J. Crockett, Unit 3 Superintendent F. Dacimo, Quality Services Supervisor E. C. Farrell, Station Services Superintendent B. Granados, Health Physics Supervisor H. Haynes, Unit 2 Instrumentation and Control Supervisor R. J. Herbert, Unit 1 Superintendent J. Kangley, Chemistry Supervisor J. Keenan, Unit 2 Engineering Supervisor J. J. Kelley, Unit 2 Superintendent E. J. Mroczka, Station Superintendent V. Papadopoli, Quality Assurance Supervisor R. Place, Unit 2 Engineering Supervisor R. Palmieri, Unit 1 Engineering Supervisor W. Romberg, Unit 1 Operations Supervisor S. Scace, Unit 2 Operations Supervisor F. Teeple, Unit 1 Instrumentation and Control Supervisor W. Varney, Unit 1 Maintenance Supervisor P. Weekley, Security Supervisor 2.

Status of Unresolved and Open Items New Items: Unit 1 None Unit 2 50-336/82-06-01, Entry into an Operational Mode without meeting all Limiting Conditions For Operation required in that mode (Paragraph 4).

Old Items: Unit 1 50-245/79-20-03, (Closed), Unit 1 Instrumentation and Controls (I&C) Department training records were reviewed.

Records contained data required by the current departmental procedure. This item is close. - _--- _ k

. . Combined Units 1 & 2 245/79-20-01 and 336/79-16-01, (Closed). The requalification program for licensed operators was reviewed. The program presently provides for remedial action and a performance review for any operator failing.the entire licensing exam or any part of the licensing exam.

Previously, provisions were made only for persons failing the entire exam. This item is closed.

245/79-20-02 and 336/79-16-02, (Closed). TheHealthPhysics(H.P.) Depart-ment Training Program presently contains provision for annual procedure reviews by station H.P. technicians and procedure review prior to watch-standing for contractor H.P. technicians. This item is closed.

245/79-20-04and336/79-16-03,(Closed). The Chemistry Department Training Program was reviewed. The program includes an annual written examination as , ' a measure of technical competence. The program also formalizes the responses to be taken upon exam failure: relief from duties in the area of failure and a remedial study program leading to re-examination. This item is closed.

245/79-20-05 and 336/79-16-04, (Closed). The initial training and requalifi-cation training programs for Plant Equipment Operators (PE0) were reviewed for both units.

The current programs require certification of task accomplish-ment by supervisory personnel at a level of Supervisory Control Operator or senior. Previously, PE0's could, on some occasions, certify the training of other PE0's. This item is closed.

245/81-03-02 and 336/81-02-02, (Closed). This item had been opened pending a change to Environmental Technical Specifications (ETS) deleting marine exposure panels from the environmental monitoring programs. The subject change has been approved and incorporated in the ETS. This item is closed.

! 3.

Review of Plant Operation - Plant Inspection (Units 1 and 2) , The inspectors reviewed plant operations through direct inspection and observa-tion of Units 1 and 2 throughout the reporting period.

Unit 1 operated at full power through the inspection period with the exception of a reactor trip on April 13 and power reductions on April 2-3, April 9-10, April 19, and April 24-25 to localize and correct main condenser tube leakage.

Unit 2 operated at full power through the period with exception of reactor trips on April 4, April 5, and April 17, and a reduction to hot standby on April 7 due to a condensate system leak, a.

Instrumentation Control room process instruments were observed for correlation between channels and for conformance with Technical Specification requirements.

No unacceptable conditions were identified.

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. . b.

Annunciator Alarms The inspector observed various alarm conditions which had been received and acknowledged. These conditions were discussed with shift personnel who were knowledgeable of the alarms and actions requi red.

During plant inspections, the inspector observed the condition of equipment associated with various alams. No unacceptable conditions were identified.

c.

Shift Manning The operating shifts were observed to be staffed to meet the operating requirements of Technical Specifications, Section 6, both to the number and type of licenses. Control room and shift manning was observed to be in conformance with Technical Specifications and site administrative procedures.

d.

Radiation Protection Controls Radiation protection control areas were inspected. Radiation Work Permits in use were reviewed and compliance with those documents as to protective clothing and required monitoring instruments was inspected.

Proper posting of radiation and high radiation areas was reviewed in addition to verifying requirements for wearing of appropri-ate personal monitoring devices. There were no unacceptable con-ditions identified.

e.

Plant Housekeeping Controls Storage of material and components was observed with respect to prevention of fire and safety hazards.

Plant housekeeping was evaluated with respect to controlling the spread of surface and airborne contamination. There were no unacceptable conditions identified.

f.

Fire Protection / Prevention The inspector examined the condition of selected pieces of fire fighting equipment.

Combustible materials were being controlled and were not found near vital areas.

Selected cable penetrations were examined and fire barriers were found intact. Cable trays were clear of debris. There were no unacceptable conditions identified, g.

Control of Equipment

During plant inspections, selected equipment under safety-tag control ~ was examined. Equipment conditions were consistent with information in plant control logs.

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Instrument Channels Instrument channel checks recorded on routine logs were reviewed.

An independent comparison was made of selected instruments. No unacceptable conditions were identified.

i. Equipment Lineups The inspector examined the breaker position on switchgear and motor control centers in accessible portions cf the plant. Equipment conditions, including valve lineups, were reviewed for conformance with Technical Specifications and operating requirements. No unacceptable conditions were identified, j.

Reactor Trips - April 4 (Unit 2) At 1215 on April 4, 1982, Millstone Unit 2 experienced a reactor trip due to a main turbine trip on low condenser vacuum. High winds and seas caused a rapid buildup of debris on the main circulating water (MCW) inlet travelling screens. Two of 4 MCW pumps tripped on high differential pressure across the travelling screens.

Flow could not be restored in time to prevent main condenser vacuum from decreasing to 20 inches (Hg) and initiating a turbine trip. All systems functioned normally on the trip.

The reactor was made critical at 1853 on April 4.

Surveillance Procedure 24010, Revision 3, " Reactor Protection System Matrix Logic and Trip Path Relay Test" was in progress as part of the plant startup routine.

This surveillance involves sequential tripping and resetting of redundant power supply breakers to the Control Element Assembly Drive Mechanisms (CEADM).

Breakers TCB1 and TCBS were tripped and reset in turn. Contacts for 1 of 3 phases failed to latch shut, however, due to a failure of a spring in the latch mechanism.

Since the breaker mechanism had reset, the indication for breaker TCBS showed, " Closed." When breakers TCB-3 and TCB-7 were later opened, power was interrupted to one phase of half the CEADM and a partial CEA insertion occurred at 1930 from 0.0001% reactor power. Following repairs and retesting, the reactor was again made critical at 0020 on April 5.

The inspector has no further questions about these trips.

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Reactor Trip - April 5 (Unit 2) At 1558 on April 5,1982, Millstone Unit 2 tripped from approximately 5% power on low level in Number 1 Steam Generator.

During manual steam generator level control, the operator failed to anticipate the increased steam demand during a level swell while placing the turbine on line. All systems functioned satisfactorily on the ensuing transient. The inspector has no further question. . 1.

Forced Shutdown to Mode ~2 - April 7 (Unit 2) At 0440 on April 7,1982, Millstone Unit 2 sustained a 500 gpm condensate system leak while operating at full power. A reactor shutdown was begun and the Main Steam Isolation Valves were shut at 0836. The reactor was maintained critical in Mode 2 at 0.05% power.

Investigation revealed that sections of the manway cover gasket for condensate /feedwater heater "3A" had carried away.

Less severe degradation was observed on other heater manway gaskets. While the manufacturer of the failed material confinned the pressure and temperature rating of the material, the manway gaskets for heaters 2, 3, and 4 were replaced with a high temperature material. No other equipment damage nor personnel injury occurred.

Plant systems responded satisfactorily during this transient. The inspector has no further questions in this matter.

m.

Inadvertent Actuation of Anticipated Transient Without Scram / Alternate Rod Insertion (ATWS/ARI) Logic - April 13 (Unit 1) At 1902 on April 13, Millstone Unit I was manually scrammed from full power following an inadvertent actuation of the ATWS/ARI logic.

This actuation caused an immediate trip of both reactor recirculation pump motor generator field breakers.

The plant was manually scrammed as Technical Specification 3.6.H.4 prohibits reactor operation with-out forced circulation. The ATWS/ARI was inadvertently initiated when both channels in Division I were simultaneously de-energized by plant operators while conducting ground isolation on the 125 volt DC electrical systems. Plant procedures were not sufficiently detailed to warn operators that simultar.aously energizing or de-energizing both ~ channels in either ATWS/ARI division would likely result in an actuation of the associated trips.

A change to ATWS System operating procedure has been made to call

operator attention to the characteristics of the system.

l Other plant systems responded satisfactorily during the ensuing transient. The inspector has no further questions about this matter.

n.

Reactor Trip - April 17 (Unit 2) At 1706 on April 17, 1982, Millstone Unit 2 sustained a trip from full power due to low level in Number 1 Steam Generator (S/G).

l A 1/2 inch copper air line parted at a soldered elbow joint causing the instrument air header in the turbine building to rapidly depres-surize. Because of an orifice in the turbine building header supply, pressure was maintained in the balance of the instrument air system.

No annunciation of the loss of instrument air was received.

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. . Upon loss of instrument air, the Feedwater Regulating Valves (FRV) " lock-up" in their existing position, feedwater pump turbine speed is maintained constant, and the level control valves for the feedwater heaters fail shut diverting heater drains to the condenser.

At Millstone 2, turbine extraction steam cascades through the heater chains to a drain collecting tank. Two high pressure heater drain pumps inject into the condensate heaters near the feed pump suction.

At full power, approximately 30% of feedwater flow is supplied from this path.

The loss of instrument air to the secondary system resulted in a loss of heater drain flow.

Although the FRV's were in local manual control, the Feed Pump speed could not be changed. Level fell in both S/G's with Number 1 S/G reaching its Reactor Protective System trip setpoint first.

All safety systems functioned normally on the trip. The reactor was made critical at 0635, April 18, following repairs to the instrument air system.

4.

Limiting Operational Mode Changes (Unit 2) Operational Mode Changes from 3 to 2 and 2 to 1 were made on April 18 and 19, respectively, without meeting all Limiting Conditions for Operation required for those Modes.

At 1645, April 17, the motor operator for valve 2-CH-514 charging pump suction supply from the combined boric acid pump discharge was found inoperable. As both boric acid pumps, valve 2-CH-514, and a charging pump are supplied from electrical division Z-2, this boric acid flow path was unavailable. The operations personnel examined Technical Specification 3.1.2.2., Reactivity Control Systems, and found that the Specification was met as two of three stated flow paths were operable.

The operators failed to recognize that Specification 3.5.2, Emergency Core Cooling Systems, was controlling and that Action Statement 3.5.2.a was entered when valve 2-CH-514 failed. That Specification requires two separate, independent and operable ECCS subsystems.

Each subsystem includes a charging pump with a separate and independent flow path from a boric acid tank via boric acid pump or gravity feed. Because of the failed valve 2-CH-514, the charging pump on electrical division _ Z-2 did not have an independent suction supply flow path.

A reactor startup was made on April 18 with Mode Changes occurring at . 0635, April 18, and 0518, April 19. Technical Specification 3.0.4 requires that an Operational Mode shall not be entered unless the i conditions for all Limiting Conditions for Operation are met without reliance on the provisions contained in the action requirements.

This is a Violation (50-336/82-06-01).

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) The valve 2-CH-514 was returned to service at 1815, April 20, following replacement of the motor. Prior to the motor replacement, a safety analysis . was written and approved by the onsite review committee. An operator, ! ' with no other concurrent duties, was stationed at the boric acid system and instructed to open 2-CH-514 through written procedures and temporary changes ,

to OP-2506,LOCA; OP-2509,MSL Rupture; OP-2514, Emergeacy Boration and OP-2515, Steam Generator Tube Rupture all dated April 19.

On April 20, the licensee determined that a previous design change changed the size of the 2-CH-514 operator to a smaller motor.

The circumstances surrounding this design change will be inspected along with item 50-336/82-06-01.

5.

Northeast Utilities Service Company (NUSCO) Construction Quality Assurance (Units 1 and 2) The inspector reviewed the program of QA Surveillance and Audits performed during NUSCO Betterment Construction projects at Units 1 and 2.

These activities are performed by NUSCO Construction QA. This review was conducted per the requirements stated in:

a.

The licensee's QA Topical Report, Revision 4A, submitted to the NRC April 22,1982; i b.

NUSCO QA Procedures NQA-1.07, Training and Qualification of NQA Lead Auditors and Surveyors, Revision 1, March 22,1982; c.

NQA-1.14, Conduct, Reporting and Follow-up of Audits, Revision 1, September 28, 1981; ! d.

NQA-1.15, Review and Approval of QA Program /QA Surveys of NUSCO Suppliers Revision 1, February 3, 1982; e.

NQA-1.16, Audit, Survey and Inspection Computer Program, Revision 1, February 25, 1982; , f.

NQA-1.18, Procedure to Stop Work, Revision 1, February 3,1982; g.

NQA-2.07, Preparation of Inspection Paaages, Revision 1, September 28, 1981; h.

NQA-2.08, Conduct and Reporting of NUSCO Quality Assurance Inspections, Revision 0. December 20, 1979; i. NQA-2.10, Performance, Reporting and Follow-up of Surveillance Activities, Revision 2, March 3, 1981; I j. NQA-4.03, Preparation of NUSCO Construction Quality Assurance Audit Checklists, Revision 1, March 22,1982; k.

ANSI N45.2.12 - 1977, Requirement for Auditing of Quality Assurance Programs for Nuclear Power Plants.

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- The inspector reviewed the following packages: a.

QA Audit A-40713, NUSCO Generation Construction QC Program, April 19, 1982.

b.

Surveillance Report 79-155 Millstone Unit 2, Charging Pump-C Replacement.

c.

Surveillance Report 79-176 Millstone Unit 2, Anchor Bolt Program.

d.

In Process Verifications V-1, 4 and 18 concerning NRC Bulletins' Anchor Bolt Program, Seismic Verification Program, and Contractor Welding Programs, respectively.

In addition, computerized QA Audit Schedules and lists of audit findings were reviewed.

There were no unacceptable conditions identified.

6.

Requalification Training Program Annual Review - Unit 1 a.

Scope: A review of the requalification training program for licensed operators was conducted. The review involved: verification of the program's conformance to the reouirements of 10CFR55 and NUREG 0737, " Clarification of TMI Action Plan Items"; review of personnel training records, formal lesson. plans, and training schedules; interviews with selected operator-licensed and senior-licensed personnel; and, attendance at three requalification lectures, s b.

Details: 1.

Lectures Attended --- Fuel Design and Performance --- Heat Transfer, Thermodynamics and Fluids (one day of a five-day program) --- Mitigating the Consequences of Core Damage (one and one-half days of a five-day program) 2.

Documents and Records Reviewed --- Personnel training records of 39 licensed operators.

--- Training schedules for 1981 and 1982.

--- Administrative Control Procedures (ACP) 8.09 Series covering topics of record retention, operator training, and requalification.

c.

Findings: 1.

The training program outlined in the ACP 8.09 Series continues to meet requirements of 10CFR55 and NUREG 0737, 2.

Lessons attended were well prepared, well taught, directed to the correct level, and well supported by study materials and lesson plans.

3.

Training and examinations scheduled were actually conducted based on interviews with license holders.

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The completed 1981 requalification examinations have apparently been stolen. The licensee has conducted an investigation into the matter and has notified the Office of Nuclear Reactor Regulation.

Examination results by topic are available, however, and have been used in selecting topics for the 1982 requalification training program.

5.

Record maintenance for the 1982 requalification program was very informal.

Documentation of program completion for the 39 persons for whom records were reviewed was completed only with great di fficul ty. A personnel change in the training department has led to an improvement in record keeping for the 1982 requalification cycle currently in progress. This may be the subject of future NRC inspections.

7.

Review of Plant Operations - Logs and Records - (Units 1 & 2) During the inspection period, the inspector reviewed operating logs and records covering the inspection time period against Technical Specifications and Administrative Procedure Requirements.

Included in the review were: ' Shift Supervisor's Log - daily during control room , surveillance Plant Incident Reports - 3/28/82 through 5/8/82 Jumper and Lifted Leads Log all active entries - Maintenance Requests and Job Orders - all active entries Construction Work Permits - a'l active entries Safety Tag Log - ail active entries Plant Recorder Traces - daily during control room surveillance Plant Process Computer Printed daily during control room - Output surveillance Night Orders - daily during control room surveillance The logs and records were reviewed to verify that entries are properly made; entries involving abnormal conditions provide sufficient detail to comunicate equipment status, deficiencies, corrective action restoration and testing; records are being reviewed by management; operating orders do not conflict with the Technical Specifications; logs and incident reports j detail no violations of Technical Specification or reporting requirements; i and logs and records are maintained in accordance with Technical Specification j and Administrative Control Procedure requirements.

l There were no unacceptable conditions identified.

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. 8.

Licensee Event Reports (LERs) The inspector reviewed the following LERs to verify that the details of the event were clearly reported including the accuracy of the description of cause and adequacy of corrective action..The inspector determined whether further infomation was required, and whether.

generic implications were involved. The inspector also verified that the reporting requirements of Technical Specifications and Station Administrative and Operating Procedures had been met, that appropriate corrective action had been taken, that the event was reviewed by the Plant Operations Review Committee, and that the continued operation of the facility was conducted within the Technical Specification limits.

Unit 1 82-07 Setpoint drift of 1 of 4 Isolation Condenser high steam flow pressure switches.

82-08 Inoperable Main Steam Line Drain Valve, Inboard Stop Valve for "B" Torus Spray line, and Inboard Stop Valve for "B" Drywell Spray line due to moisture in motor-operator breakers.

Info. ltr. dtd.

Setpoint drift of 4 of 4 ATWS/ARI system reactor April 30,1982 level switches.

Unit 2 82-05 Isolation of I of 2 power operated primary relief valves due to valve leakage.

82-06 Failure of 5 containment isolation valves and the personnel access hatch to pass type B & C containment leak rate tests.

82-07 Inoperable Turbine Driven Auxiliary Feed Pump due to internal pump wear.

82-09 Operation without the required number of independent Emergency Core Cooling subsystems.

See paragraph 4 for details.

9.

Review of Periodic and Special Reports Upon receipt, periodic and special reports submitted by the licensee pursuant to Technical Specification 6.9.1 and 6.9.2 and Environmental Technical Specification 5.6.1 were reviewed by the inspector. This review included the following considerations: the report includes the information required to be reported by NRC requirements; test results and/or supporting information are consistent with design predic-tions and performance specifications; planned corrective action is adequate for resolution of identified problems; detemination of whether any information in the report should be classified as an abnormal occurrence; and the validity of reported information. Within the scope of the above, the following periodic reports were reviewed by the inspector: -

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Review of Periodic and Special Reports (Cont'd ) j Monthly Operating Report Units 1 and 2, March 1982.

--- Radiological Environmental Operating Report,1981.

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Inspector Witnessing of Surveillance ~ Tests The inspector witnessed the performance of surveillance testing of selected components to verify that: the surveillance test procedure was properly approved and in use; test instrumentation required by the procedure was calibrated and in use; technical specifications were satisfied prior to removal of the system from service; the test was performed by qualified personnel; the procedure was adequately detailed to assure performance of a satisfactory surveillance; and test results , satisfied the procedural acceptance criteria or were properly dis- . r positioned. The inspector witnessed the perfonnance of:

Unit 1 ' "A.P.R.M.

Calibration" per SP 404C, Revision 1, on March 30, 1982.

--- ' " Reactor Building Closed Cooling Water Vibration & Hydraulic --- Test" per SP 1060.11, Revision 4, on April 8,1982.

" Reactor Building Closed Cooling Water Pump & Discharge Check - --- Valve Readiness Test" per SP1087, Revision 0, on April 8,1982.

" Reactor Feedwater Pump Readiness Test" per SP1084, Revision 0, --- on April 28, 1982. * "Feedwater Pump Vibration & Hydraulic Test" per SP1060.3, --- Revision 1, on April 28, 1982. * l

  • Feedwater pumps at Millstone 1 are,a portion of the Feed Water Conlant Injection (FWCI) portion of the plant Emergency Core Cooling System.

Unit 2 ,

I " Functional Test of Auto Aux Feedwater Initiation Logic" per --- SP2402M, Revision 3, on April 26, 1982.

" Reactor Protective System (RPS) Bistable Trip Test" per --- SP2402G, Revision 3, on May 4, 1982, i ! _ _ _... _ _ _ _ __ _ _. _. - .. .. ... -.. . .. __. _

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Plant Maintenance and Modifications During the inspection period, the inspector frequently observed various maintenance and problem investigation activities.

The inspector reviewed these activities to verify: compliance with applicable codes and standards; required QA/QC' involvement; proper use of safety tags; proper equipment alignment and use of jumpers; personnel qualifications; radiological controls for worker protection; fire protection; retest requirements; and reportability as required by Technical Specifications.

In a similar manner, the implementation of design changes and modifications were reviewed, including the associated 10 CFR 50.59 safety evaluation. Compliance with requirements to update procedures and drawings were verified and post modification acceptance testing was evaluated. The following activities were included in this review: , Unit 1 Reactor Building Closed Cooling Water System leak localization.

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Unit 2 Charging Pump A cylinder and plunger repairs and repacking.

--- I Service water pump A installation following refurbishment.

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12.

Review of Radioactive Material Shipments - (Unit 1) The inspector reviewed the activities concerning the shipment of radio-active waste to the Barnwell, S.C., burial site. Those activities included receipt inspections of the shipping cask and liner, solidifica-tion of material, radiation surveys and the completion of administrative and quality control requirements prior to shipment. These inspections concerned: Dewatered Purification Media March 29, 1982 --- L.S. A. Drums (Laundry) April 1,1982 --- 13.

Exit Interview At periodic intervals during the course of the inspection, meetings were held with senior facility management to discuss the inspection scope and findings. }}