IR 05000254/1990006

Insp Repts 50-254/90-06 & 50-265/90-06 on 900318-0428. Violations Noted.Major Areas Inspected:Plant Operations,Esf Sys,Radiological Controls,Maint & Surveillance,Emergency Preparedness,Security & Engineering/Technical Support

ML20043A832
Person / Time
Site:	Quad Cities
Issue date:	05/15/1990
From:	Hinds J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20043A828	List: IR 05000254/1990006 ML20043A827 ML20043A830
References
50-254-90-06, 50-254-90-6, 50-265-90-06, 50-265-90-6, NUDOCS 9005230172
Download: ML20043A832 (16)

Text

-

- _,.

.

-

.

,

,

~,

U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Reports No. 50-254/9W6(DRP);50-265/90006(DRP)

Docket Hos. 50-254, 50-265 Licenses No. DPR-29; DPR-30 Licensee:

Comonwealth Edison Company Post Office Box 767 Chicago, IL 60690 Facility Name: Quad Cities Nuclear Power Station,. Units 1 and 2

.

Inspection At: Quad Cities Site, Cordova, IL Inspection Conducted: March 18 through April 28, 1990

'

Inspectors:

R. L. Higgins J. M. Shine R. 8ocanegra T. M. Ross F. Brush

,/

.,

/

~.

Approved

J

. Hinds, MAY 15 igg

.eactor Projects Section IB Date Inspection Summary Ins ection on March 18 through April 28, 1990 (Reports No. 50-254/90006(DRP);

5 - 5579UUDBTDTe))-

Areas Inspected:

Routine, unannounced safety inspection by the resident'

and regional inspectors of licensee actions on-previously identified items; plant operations; Engineered Safety Feature. Systems; radiological-controls;--

maintenance and surveillance;' emergency preparedness;' security; engineering / '

technical support; and safety assessment / quality verification.. The Nuclear-

_

Reactor Regulation (NRR) Project Manager conducted a special announced inspection to follow up on the effectiveness ofl licensee actions.to correct the concerns and detailed findings identified by a previous special NRR

- i team inspection (TI 2515/092) regarding. development c.id implementation of Emergency Operating Procedures (EOP) at

-

Reports 50-254/88-200 and 50-265/88-200)Q.uad Cities (see previous' Inspection:

~Results: Of the twelve areas-inspected, no violations"were identified in ten A violation of;13 eFR 50, Appendix B requirements that resulted S the.

a rea s.

wrong pipe being cut and capped was identified (Paragraph 6). Additione!iy,

' one violation was identified (failure to post an-NOV per 10 CFR.19.11 -

Paragraph 2)', however, in'accordance with 10 CFR 2,- Appendix C,Section V. A,'

a Notice of Violation was not issued.

The licensee addressed NRC concerns-regarding reactor essel head cracks discovered during the Unit 2 outage.

.

The f

6.-

900523017-~

1. 310 PDR ADOCK

w

.

.. ~..

...............

-.....

_ _ _ _

,

,

,

--

...

t

,,-

-

,

,

,

N

\\

licensee submitted an amended exemption request _to 10 CFR 50.48 as-a result of a Corporate audit finding on combustible loading in the: plant. Almost all of the' outstanding concerns identified in.the.NRR E0p Inspection Report Executive

- Summary were closed..However, a limited number remain open primarily due to-inadequate oversight by site management, and the failure of site management

'and personnel to follow procedures.

.

i

'Y

%

<

2.

.

_

.

'

I+

.

,

,. -

,

.

.

.

.

of TAILS

=1.

Personnel Contacted

• 1. R. Bax'. Station Manager

1. G. Spedl, Production Superintendent

• J. Swales, Assistant Superintendent _for Operations

'

• J. Wethington, Quality Assurance Superintendent

• T. Barber, Regulatory Assurance

1. D. Boyles, E0P Coordinator

1. R. Stols, Nuclear Licent.ing

• R. Robey, Technical Superintendent

1. T. Tuhs, Regulatory Assurance

• D. Gibson, Regulatory Asst rance

• T. Tamlyn, Site Project Manager

• Denotes those present at the exit interview on April 27, 1990.

1. Denotes those present at the E0P: Followup Inspection exit meeting-on November 22 1989

,

^

The inspectors also contacted and interv %wed_other. licensee and contractor personnel during the course of this inspection.-

2.

Action on Previous items (92701 and 92702)_

On December 4, 1989, Resident Inspector's report 50-254/89022 was' issued

,

whichcontainedtwoNoticesofViolation(NOVs)ofNRCrequirements.

i Details of violation 254/89022-01e, found in paragraph.4, "Raffological-

!

Controls" of the report, describes a radiation and contamination area L

thct was not marked with the appropriate radiation control' warning. signs in violation of Radiation Protection. Standards procedures.

10 CFR 19.11-requires each licensee to post any. NOV involving-radiological working l

conditions within two working days after receiving the. document.-

On March.29, 1990,.the resident inspectors contacted the< licensee when l

a routine. inspection of site bulletin :. boards. failed. to show a posted l

copy of NOV 254/89022 in apparent violation of 10 CFR :19.11. requirements.

l The licensee confirmed that the NOV was not posted as required due to L

an oversight. The licensee promptly posted the NOV and has ordered.

additional bulletin boards to increase the visibility of posted

'

documents.- Coninonwealth Edison Company (CECO) Corporate Licensing has taken responsibility for setting up a proqram to clarify reporting requirements at all Ceco nuclear. plants.. The' job description for a position within the site Regulatory Assurance group will be modified to

-

include responsibility for posting requirements.

The violation is_not-I being cited because the criteria:specified in 10 CFR 2 Appendix C, Section V.A of. the Enforcement Policy. for an isolated violation where -

corrective action has been initiated were satisfied-(NCV 254/90006-01).

.,

One violat' ion was identified in this area.

- !

1

,

,

__

%

%

'

'

.

,

.

.

3.

plantOperations(71707)and(93702)

The inspectors. observed control room operations, reviewed applicable logs and conducted discussions with control room operators during the

' inspection period. The inspectors verified the operability of selected emergency systems, reviewed tagout records, and verified proper' return to service of affected components.

Tours of Unit I and Unit 2 reactor buildings and the turbine building were conducted to observe plant equipment: condition, including potential' fire hazards, fluid leaks, and excessive vibrattuns and to verify that mairtenance requests had been initiated for equipment in.need of maintenence.

The inspectors, by observation and ' direct-. interview, verified that the physical sebrity plan was being implemented in accordance with the station security plan. This included verification that the appropriate number of security personnel were on site; access contt01 barriers were operational; protected areas were well maintained;'and vital area barriers were well maintained.

The inspectors verified.that the licensee's radiological-protection nrogram was implemented in accordance'with' facility policies and programs, and was in compliance with regulatory requirements.

The inspectors reviewed a sampling of new procedures and changes to procedures that were implemented during the inspection period. The.

review consisted of a verification for accuracy, correctness, and

,

compliance with regulatory requirements.

These reviews and observations were conducted to verify that facility operations were in conformance with the requirements established under Technical Specifications,10 CFR, and administrative procedures.

Various operational occurrences were also reviewed as-follows:-

a.

On March 26, 1990, activities performed on the refueling floor by fuel handling personnel included the u.ncoupling and re-location of new and exposed control rod (CR) blades within the core (which contained no fuel.at the time) and spent fuel-pool. Temporary procedure 6139 " Replacement / Swap of Control Rod Bladd', which was written to govern this activity for this outage and to be reviewed

<

and made permanent after the outage, was being utilized at the time.

I While performing this pr redure on CR 46-31, proper uncoupling of

-

the CR blade from the CR drive was not achieved. The hoist operator was unaware of this.

He then-p'roceeded to raise the CR blade up and off of the drive and moved it to its proper' destination indicated by the special nuclear material transfer-list.. Communications between the refuel bridge operators and'the' unit nuclear station operator (HS0);inthecontrolroomwereestablishedandmaintainedat'all times, per procedure. Approximately two shifts-later the fuel handlers attempted to place a new CR blade into position 46-31, when it was discovered that the CR drive was et position 00 and not

,

'

position 48 as anticipated, and required for procedural uncoupling.

,

_ _ _ _ _ - - - - _. _ _ _ - _ - - - _

a

_

_

_

. _ _ _ _ _

.

.

.'

'

.

.

.

Apparently the CR drive was extended when the CR blade was lifted out of the core two. shifts earlier, and became uncoupled from the drive when the drive became fully extended at position 00. Since the core was defueled and the CR drive system was out of service at the time, the CR drive was left at position 00 until it could be withdrawn, prior to the installation of the new blade. The temporary procedure did not require the NSO to monitor the roo position indication from the control roun (which is required by CR blade unlatching procedures when there'is fuel in the core) during this phase, which should have shown a change in the CR drive position and indicated to the operator that the CR blade and CR drive were still coupled.

The inspector queried the fuel handling operating engineer, the assistant superintendent of operations, and fuel handling foreman as to why a new temperary procedure was required to perform an operation that appeared to be a routine refueling outage et.tivity, considering that the unit was in its tenth cycle refueliig outage.

The licensee personnel explained that due to events that occurred during the recent Unit I refueling outage a fuel handling r/erview program and an increased focus on procedural adherence had been instituted.

It was due to these initiatives that it became necessary to amend past practice of this activity (CR blade replacement) which was essentially performed without specific procedural guidance.

The licensee viewed utilization of the temporary procedure as a positive step to achieve management's expectations for the conduct of personnel and operations during refueling activities. The inspector concluded that.although management attention and control over refueling operations appears to be improving, the-temporary procedure written to address CR blade swap / replacements should include a step requiring NSO verification (when a drive. ppropriate) that the CR blade is moving independent from the The temporary procedure was expeditiously amended to address the inspector's concerns, b.

On April 24, 1990, the licensee discovered water spills throughout the reactor building.

The source of the leaks was determined to be fuel pool water flowing from the reactor building ventilation ducts, caused by-inadvertant overfilling of the Unit 2 fuel pool.

At the time of the incident the reactor water clean up system was out of service and t a licensee was operating the CRD system to perform various teus. The licensee was operating under a procedure which allows the CR0 pump to take a suction from the fuel pool through the Unit 2 fuel pool reject line. The condensata storage tank (CST) was isolated (85 valve shut) to prevent the.'D ;mmp from taking a suction on the CST.

In this configuration,-the 46 spm CRD pump discharge forms a loop, i.e. suction is taken from the fuel pool and discharged back to the fuei pool through. the CRDs, thereby maintaining a constant fuel pool-level.

Meanwhile, the licensee was performing a hotwell condenser tube leak inspection and had flooded the condenser. The condenser level

,

,

_

-

- --

_

_

_

.

,

,

.

'

..<

.

.

control valve (LCV) had been manually isolated, per procedure, to

[

perform the test. After the tube leak test had been completed, the

.

LCV manual isolation valves were opened to allow condensate to be rejected to the CST. However, since the CST 85 valve was shut and

'

the pool reject line open, a flow path from the condenser to the Unit-2 fuel pool was established..Within a matter of minutes the'

,'

controlroomreceivedaUnit2skimersurgetank(SST)highlevel j

alarm, Unit 1 SST high level alarm, Unit 1 fuel pool high level s

alarm, and then a Unit'2 fuel pool high level alarm..

Concurrently, the licensee was also in the process of filling the.

i Unit 2 "B" RHR loop.

When the high -level alarms started coming in.-

t the licensee stopped the filling process, believing this to be the q

cause of the flooding. -The licensee also started rejecting fuel

pool water to the Unit 1 CST using the Unit I fue1 pool system.

The licensee soon realized that the closed 85 valve was the' culprit, opened it, and the fuel pool level started recovering.

'

The root cause appears to be that the licensee had too many

[

inter-related operatione going on at the same time. The CRD j

operation conflicted %1th the condenser tube leak inspection l

pn cedure and additionally, the CRD procedure showed ste,ns to line

"

up de CRD pump to the fuel. pool, but omitted instructions on

,

returning the lireup back to normal.. Procedure changes have been'

.

Initiated to co' rect these weaknesses, but'the licensee has not-addressed the concern regarding management of multiple operations.

This is an unresolved item (Unresolved Item 254/90006-02).

L One Unresolved Item and no violations or' deviations were identified in this area.

4.

Engineered Safety Features System (71710)

'

During plant tours of Units 1 and 2, the inspectors walked down some of-t the accessible portions-of the.High Pressure Coolant Injection (HPCI),

'

Reactor Core Isolation Cooling (RCIC), Core Spray (CS), Residual Heat i

Removal (RHR), RHR Service Water, Standby Liquid Control (SLC), and.

Standby Gas Treatment (SGT) Systems. The-inspectors also walked down

the Emergency Diesel Generators (EDG) and the Station Batteries.

'

110 violations or deviations were' identified in this area.

I

'

,

5.

_ Radiological Controls (71707)(93702)

'i i

Portions of the reactor buibing became contaminated on allLlevels as a

result of the fuel pool ove-fill incident (Section 3.a.) on April 14, 1990.

Reactor building access was controlled while Rad Protection roped off contaminated areas and began clean up. Contaminated areas generally,

ranged from:1K to 2K removable, with one area near the' reactor building-

')

closed cooling-water heat exchangers (Unit 2) showing areas ranging from

SK to 60K per.100 square cm. The licensee' completed the cleanup and-returned all areas to pre-contamination levels.

,

la No violations or' deviations were identified in this area'.

'

s

'

.

s

..

.

'

'

.

.

.

6.

Maintenance /Surveillang (62703), (61726), and (92703)

'

p

.

a.-

Maintenance Activities Station maintenance activities of systems and components listed

,

below were observed or reviewed to ascertain that they were-conducted in.accordance with approved procedures, regulatory guides and industry codes or standards and in conformance with Technical Specifications.-

The following items were considered during this review:

The Limiting Conditions for Operation (LCOs) were met while components or systems were removed from service; approvals were obtained prior to initiating the work; activities were accomplished using approved procedures and were inspected as applicable; functional testing and/or calibrations were performed prior to returning components or systems to service; quality cor, trol records were maintained; activities were accomplished by' qualified personnel; parts and materials ~used were properly certified; radio-logical controls were implemented; and fire prevention controls-were implemented. Work-requests were reviewed to determine status R

of outstanding -jobs and-to assure that priority is assigned to

'

~

safety-related equipment maintenance which may affect system performance.

The licensee discovered on. March 25, 1990 that a: Residual Heat.

Removal (RHR) System drain line had been inadvertently cut and i

carped on February 20, 1990, by contractor workers working on a jet

pump. instrument drain line removal project. The apparent cause was J

due to failure of a contractor' foreman to locate and identify the

'

entire run of piping. The lower-run of the jet pump drain line i

was located in-the drywell basement beneath the. ground level

-,

grating, and due to ongoint outage activities. -the basement was

inaccessible at the time t1e forem6n performed the pre-work i

wal kdown. Subsequently, a contractor Quality atrol(Q.C.).

-

inspector ini.tialled the work package certifying that piping-identification was complete and correct, but failed to go down

to the basement and walkdown the lower run'of pipe. The work i

package instructions to the foreman simpiy-stated " Locate and-verify lines to be cut and capped.". It did not 3rovide instruc-t tions on en approved technique for identifying tie lines, and no

acceptance criteria'was included for the Q.C. inspector.

'

10 CFR 50 t. endix B,' Criterion V, in part requires thatLactivities affecting quality shall be prescribed by documented instructions,

'i procedures, or drawings, and shall include appropriate quantitative or qualitative acceptance criteria for determining that activities important, to safety have been accomplished.

Failure to provide L

adequate-instructions to the foreman and acceptance criteria to the i

Q.C. inspector is a violation of Criterion V. (265/90006-01)

y a

/.

7 y

'

-__ o

.I

'

.

.

,

,

This violation is of concern because the licensee had previously de-emphasized the safety significance of an NRC finding involving assen61y of safety valves (Violation 254/89022-020) based on the belief that the Q.C. hold point would have caught the improperly assen61ed valves.

,

'

The inspectors witnessed or reviewed portions of the following maintenance activities:

Unit 1 A Reactor Feed Pump Repairs Unit 2 Residual Heat Removal Service Water System 185 8 MOV Replacement Unit 2 Recirculation System Ringheader Endcap Repair Unit 2 Inboard MSIV Disassembly and Inspection Unit 2 Outage Turbine Overhaul b.

Surveillance Activities The inspectors observed surveillance' testing, including required

'

Technical Specification surveillance testing,. and verified for -

actual activities observed that testing was performed in accordance t

with adequate procedures.

The insp?ctors also verified that test instrumentation was calibrated, that Limiting Conditions for.

Operation were met, that reroval and restoration of the affected components was accomplished, and-that test results conformed with Technical Specifications and procedure requirements. Additionally, the inspectors ensured that the test results were reviewed by personnel other than the individual directing the test, and that any deficiencies identified during the testing were properly reviewed I

and resolved by appropriate management personnel.

II) While performing a surveillance (MCC-28/29-5 Auto transfer l

Logic Operability Surveillance), the licensee discovered that l-the auto-transfer time delay relay took 38.99 seconds to

'

transfer load exceeding the specified 20 +/-5 second time i

delay. The failed surveillance test put the plant in an unanalyzed condition. The time delay relay was adjusted, replaced, and tested and passed within the specified limits.

The inspectors will review this event when the licensee j

issues the LER.

'

(2) On March 25, 1990, with Unit I at ap(NS0) was performing proximately 95% power and '

in EGC, a Nuclear Station Operator control rod (CR) drive weekly. surveillance QOS 300-1 (CR Weekly

-

Exercise) when CR M-3 went from position 48 to position 44 on a single insert signal instead of position 46,-as expected.-

A withdraw signal was then applied resulting-in CP. slippage into position 42.

The unit wa's taken.off EGC and a qualified

.

nuclear engineer was notified as required by procedure.

-Elevated drive pressure was required to withdraw the rod back to position 48, indicating a possible problem with'the-drive-mechanism. Special test "CRD M-3 Special Maneuver" was written and performed to further address the operability of the CR M-3

-

r

.

'

.

.

.

drive mechanism. During the test the CR mechanism responded l

correctly to the insert signal, stopping at position 46, but

-

could not be withdrawn to position 48 with normal or slightly elevated drive pressure.

The CR was then inserted to position i

44, but again, further withdrewal attempts were ineffective.

The scope of the special test did not include the possibility that the CR could not be withdrawn, was appropriately discontinued, and operating procedure QOA 300-2 " Inability to drive a Control Rod - Control Rod Stuck" was entered. The.

,

nc+-

9verride function was utilized, per procedure, and was

,

sk.w ;ful at withdrawing the red to position 48. The'special test was revised and performed to obtain more information.on-the CR' drive-problem, but during.the performance of the test the CR drive failed to malfunction as before. Due to the inability to duplicate the CR failure to double notch or not withdraw, the licensee determined that'the CR drive was operable, theorizing that routine' intrusion of air into the drive system during static periods between CR drive exercises

'

could possibly have caused the malfunction. The licensee has established a program to trend all CR weekly exercise double

'

notch occurrences to determine if venting of the CR drive mechanisms is warranted prior to the performance of the weekly surveillances.

The inspectors witnessed'or reviewed portions of the following test activities:

Unit 1 Core Spray /LPCI Monthly Valve / Pump Operability.

Unit 1 Control Rod M-3 Special Test i

Unit 1 Traversing Incore Probe Procedure

-

Unit 2 Primary System Hydrostatic Test Unit 2 Valve Integrity Inspections Pursuant to Primary Hydrostatic L

Test l

Unit 2 Control Rod Blade Shuffles.

t l

Unit 2 Fuel Support Piece Inspections

_

Unit 1/2 Emergency Diesel Generator Monthly Surveillance

,

i One violation was identified in this area.

.

7.

Emergency Preparedness (71701) (94600)

On April 3,1990, the licensee declared an Unusual: Event due to. loss of ENS and all other commercial offsite telephone lines.

The event was.

attributed to maintenance work being performed at the site by the local phone company. Within less than four hours, phone company workers l

reported to the site and restored phone communication and the Unusual

.

L Event was terminated.

I The resident inspectors met with three local' officials that have I

emergency response responsibilities to discuss activities that occurred

'

on' March 13, 1990, when several tornadoes touched down in the area,.

including a touchdown on-site. The officials included the Cordova, Il s

Police Chief and Fire Chief and the Albany, IL Police Chief.' The

4

.

.--

..

.

'

, a

.'

'

.

.

.

officials were generally satisfied that their disaster response was adequate, but_ expressed a desire for more and better communication between themselves and the station. The resident inspectors have communicated this to station management.

8.

gcurity(71707)

During the inspection period the inspectors toured'the plant and the Central Alarm Station to assure that security programs were being properly. implemented.

The inspectors verified that security barriers were in place, security doors were operable, the security force was alert, personnel correctly displayed their identification badges and visitor access was being properly controlled, While performing a routine plant walkdown the resident inspector a.

noticed a guard posted near access to a vital area who appeared inattentive, with his eyes ' closed. The' inspector observed the guard:

for a period at a short distance to verify that' the guard was in fact inattentive. The inspector confirmed this and then reported the observation to a guard posted in the same area, who notified his supervisor and a response team was immediately dispatched.

The station security administrator was notified, who then made a one hour Emergency Notification System call due to the loss of access control to a vital-area within a vital area. Further investigation revealed that access control to the vital area was being maintained by two guards posted' at-separate locations. The inattentive guard was responsible for controlling access to the vital area only during certain occasions when the security barrier was removed to facilitate outage activities.- At the time ~the guard was inattentive, the security barrier was intact, and 'it appears that

-

access control was adequately maintained, due to the posting of ~ the second guard. The inspectors reviewed licensee root cause determination and corrective actions ~ to prevent recurrence which~

included disciplinary action _ to the guard and evaluating working conditions.at the post in' question. The licensees actions appeared to be adequate.

'

b.

On April 8,1990, site security received an anonymous phone call from within the plant that a contractor foreman' had alcohol on his breath. The contractor's' supervisor was notified and he requested a breath analyzer test after confirming that the foreman's' breath.

smelled of alcohol.

The results of the test showed an' alcohol level higher than allowed by the licensee's Fitness for Duty (FFD);

program.. The foreman's site access was promptly revoked and he was -

escorted off sits The subject was involved in coordinating the activities of fire watch workers.

The licensee made the required 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> NRC notification.

It appears that the licensee's FFD programo functioned as intended in identifying this individual. -

No violations or deviations were-identified in this area.

9.

Engineering /TechnicalSupport(93702)(37828)

.

The feedwater hydrogen addition modification for'both units is

.

continuing.

.

l d

.

.

.'

'

.

.

..

During routine refueling outage work on the Unit 2 reactor vessel, on March 28, 1990, licensee personnel.noted discolorations on the stainless steel cladding of the reactor vessel head inner surface that appeared to be crack indications.

,

Liquidpenetranttesting(PT)andultrasonicexamination(UT)revealeda 30-inch-long crack and 22 other cracks of various dimensions concentrated in a circumferential zone near the flange-to-dome weld. Additional pT and UT of the crack zone (360 degrees) found approximately 11 more crack

'

indications.

The cracks were removed by ;rinding and revealed that the deepest crack had penetrated the' stainless steel cladding into the base-

material to a depth of less than one-fourth inch.

Five boat samples of cracks were also taken and sent to Argonne National Laboratory for metallurgical testing. On April 19, 1990...the licensee met with repre-sentativesofNuclearReactorRegulation(NRR)todiscussengineering reviews, results of snalysis and testing, and planned. corrective action.

+

'

After the meeting, NRR did not express objections to the licensee's

'

assessment of the problem and planned corrective action.

NRR is following this issue.

No violations or deviations were identified in this ' area, 10.

Safety Assessment / Quality Verification (40500)(35502)

During the inspection period the inspectors met frequently with members

,

of the licensee's Quality Assurance staff to discuss the licensee's

'

Quality Assurance program.

During the. inspection period the inspectors attended the Onsite Review Committee meeting held to assess Unit 2

-

prior to startup.

The licensee initiated deviation report 04-01-90-033 documenting an

,

out of service period of greater than 7-days for _the high range noble-gas main chimney monitor, which is. required by: Technical Specification 3.2.H.2 and Table 3.2-6 action F.

The inspector examined the compensatory measures required end the reportability of the issue, for which the licensee's actions' appeared adequate,

,

11. LERReview(90712)(92700)

a.

(Closed)LER 254/90004, Revision 00i Unit One Reactor Scram From a

)

Generator Trip Due to Failure of the Negative. Sequence Relay. On!

'

March 10, 1990, Unit One scrammed from approximately-98% power due to a turbine-generator load mismatch.

The cause of the event was a failed negative sequence time overcurrent relay. The fault was most'

>

probably caused by multiple lightning strikes present during the time of the scram. All expected ESF actuations occurred as expected

'

after the scram and the unit was brought to a safe shutdown-

!

condition.

The licensee replaced a circuit board and bench tested the relay and verified that it operated properly.

This LER is closed, b.

(Closed) LER 254/90006, Revision 00: Tornado Touched Down On Site.

One contractor was injured during the tornado touchdown which is

.

11'

.

_

.

.

'

-

,

.

.

discussed in detail in inspection report 254/90002; 265/90002.

The

!

root cause of the injury was the worker's inability to hear warnings over the site pager and bullhorns because of heavy hail striking the

outside of the mobile home trailer office. The licensee evaluated its response to the event, but a comprehensive evaluation of how-

-

site personnel are notified is not yet complete (0 pen Item

.

50-254/90006-03).

The licensee has repaired the damaged security t

fence and rad waste ventilation duct. This LER is closed.

j c.-

(Closed)LER 254/90007, Revision 00: -ESF Actuation Due to Management Deficiency Involving Work Instructions. An electrical.

foreman requested, the operating department to place out-of-service (005) certain relays associated with the 2A reactor building ventilation rad monitor. With the concurrence of the electrical

-

planner, the shift control' room engineer modified the work package and the out-of-service request due to other ongoing plant operations. However, the changes were never communicated to the-

.

electrical foreman that initially. requested the out-of-service.

The electrical foreman subsequently failed to recognize that the scope of the the work package had been modified, and lifted a lead which initiated the SBGT-system.

Corrective actions taken include new work package preparation procedures, which are in the approval phase, and administrative procedure revisions to require

out-of-service consideration when preparing work instructions.

This LER is closed.

,

d.

(Closed)LER 254/90008 Revision-00: Outside Design Basis of Plant Because Fire Loading Exceeded Exemption Requests Due to' Management Deficiency. As a result of a Corporate audit finding, the licensee on March 21, 1990, discovered that several fire zones had exceeded fixed combustible loading stated in exemption requests to 10 CFR L

50.48. A courtesy Emergency Notification System (ENS) phone call l

was made because the specific reporting criteria could not be

determined. On March 28, 1990, a one-hour ENS phone notification

'

was made when it was ascertained that the plant was outside the.

• design basis due to combustible' loading. The licensee initiated fire watches and has submitted revised 10 CFR 50.48 exemption'

.

requests. This event-is being followed by NRR. This LER is closed.

t e.

(Closed)LER 265/90005, Revision 00: Group 11 Isolation Resulting from Personnel Error. An ESF actuation occurred while.the

,

Instrument Maintenance department was performing the "High Drywell

'

Pressure Scram Functional Test". This event was caused by poor

communication and lack of work instructions. The licensee has l-taken appropriate corrective actions including procedure revisions.

!

This LER is closed.

,

.

12.

Emergency Operating Procedures (EOP) Inspection Followup (TI 2515/92)

a.

Background From July 18 through July 29, 1988, a special safety team from the

>

Office of Nuclear Reactor Regulation (NRR) conducted an inspection of the development and implementation of Eraergency Operating

. ;

L e

,.

-

,

.

.

,

s t

Procedures (EOP) at the Quad Cities Nuclear Power Station (QCNPS),

Units 1 and 2.

This inspection was just one of many NRR E0P team ins)ections conducted at each Boiling Water Reactor (BWR) facility

!

wit 1 a Mark I Containment throughout the United States. Temporary Instruction (TI) 2515/92 provided the guidance for these inspections

-

to ensure completeness and uniformity.

Results from the NRR E0P team inspection at QCNPS (inspection report numbers 50-254/88-200 and50-265/88-200) were transmitted to Conmonwealth Edison Company (CECO) by letter dated December 5,-1988. The Executive Summary and i

inspection reports enclosed in that letter identified many

.

significant concerns and listed a large number of detailed findings.

CECO was requested by the December 5, 1983 letter to formally transmit their proposed corrective action plans to the NRC. By letter dated February 24, 1989 CECO responded to the NRC's request

'

with the details and schedule of their proposed corrective actions

!

regarding the concerns identified by the NRR EOP inspection team.

'

Additionally, at the request of the NRR Project Manager (PM,' 'or

QCNPS, Ceco provided a status update of their progress by letter

!

dated September 14, 1989. According 'to this last letter, only a few of the corrective actions proposed by CECO were not fully complete.

b.

Inspection l

During October 30 through Nove,ber 2,1989, and November 21 through-22, 1989, the NRR PM for QCNPS conducted a followup inspection to determine the effectiveness of CECO's corrective actions to resolve the concerns and findings identified by the NRR E0P team inspection.

The purpose of this followup inspection was to verify closure of all outstanding concerns by reviewing applicable procedures, documents, and records; and conducting interviews of appropriate site manage-

!

ment and responsible personnel (i.e. operators, E0P Coordinator, trainingstaff,etc.). The findings from this followup inspection are detailed below in much the same format used in the NRR E0P l

team's Executive Sunnary and adopted by CECO in subsequent letters.

'

Although all of the concerns identified in the Executive Summary l

were inspected, only those considered to be unresolved or open are 1-described below. -Ceco has resolved or dispositioned most of the NRR-

-

E0P team's original concerns and findings regarding the E0Ps at QCNPS, however there still remains several-significant open items which will require additional corrective actions on their part.

It a

should be noted, that this E0P followup inspection does not obviate further NRC inspection activities which may relook at CECO's corrective actions in greater technical detail.

This inspection was intended to:

(1) verify that CEC 0's corrective action plans scopedalltheNRRE0Pteamconcernsandfindings,(2)assessthe

,

reasonableness of CEC 0's technical and programmatic approaches to--

'

resolve these concerns and findings, and (3) confirm implementation of CECO's corrective actions.'

'

.

l

!

,

.

., '

.

.

.

c.

Detailed Inspection Findings CECO's corrective action plans to resolve the concerns described in the Executive Summary of inspection. reports 50-254/88-200 and 50-265/88-200 were essentially C7mplete by the time of this followup-inspection. Although implementation of a few corrective actions, remained outstanding. Ceco had achieved sufficient progress to support a followup inspection of their effectiveness in resolving the applicable NRC-concerns.

By the end of the E0P followup inspection, it was determined that Ceco had resolved or adequately addressed each of the E0P team inspection concerns except those detailed as follows:

(1) NRC Concern (1)bi - The licensee failed to develop and-implement an adequate verification and validation program for the E0Ps.

The verification and validation program performed did not programinatically address the necessary attributes and was performed in an informal manner which severely limited the effectiveness of the effort.

,

,

Finding-Aformalverificationandvalidation(V8V) process for revising QGA procedures was developed ~and institute:i per, Quad Cities Administrative Procedure (QAP) 1100-13 " Control of Emergency Operating Procedures", Revision 1, issued August 1988.

(At QCNPS, the E0Ps are known as the Quad-Cities General

l Abnormal Procedures (QGA)). -This administrative' procedure l

did incorporate the' essential. elements of NUREG-0899 for controlling the V&V process. However, Ceco failed to follow i

many of the explicit and fur.damental directions of-QAP 1100-13

'

I during the V&V procese fo.' the revised QGAs of April 1989.

Although a satisfacto.

V&V process was developed it was not implemented per procedural design.

In actual practice, the

,

V&V process at QCNPS evolved into an informal ed hoc exercise l

with only a vague resemblance to QAP 1100-13. Consequently, many of the QGA changes in the April 1989 revision were not adequately verified or validated in accordance with procedural

controls or industry accepted guidelines. As such, this-

!

concern continues to remain open (IFI-01).

!

(2) NRC Concern (2)d. - The licensee provided inadequate. management oversight of the E0P development program...

Finding - Although the three specific subsections'(i.e. 1, 2, and 3) in the Executive Summary related to this concern were acceptably addressed or resolved by CECO, the overall NRC concern continues to remain uncorrected. Several procedural steps in QAP -1100-13~ directly prescribe thel conduct of certain a

critical management activities intended to provide control and oversight of the E0P developmental program and-its imple-mentation.

However,. senior site management failed to comply with most of these procedural requirements.

In fact, the pervasive absence of management participation in the implementation of QAP 1100-13 during the April 1989 E0P

14 l

1

n..

,

'

.

-

.

.

.

revision, and subsequent efforts, suggests QCNPS' management.

did not recognize or understand their administrative responsibilities.

For example, the "on-site review" required by QAP 1100-13 for many of its essential steps (e.g. procedure q

subsections C.2.b. (2), C.3.c C.3.e, and C.3.g) -in diveloping

'

and maintaining accurate E0Ps were not~ accomplished by the OnsiteReviewCommittee(OSRC).

In fact, most of the independent review functions and E0P process decisions, including QGA Comittee respons,1bilities e.g. QAP subsection C.3.f)defaultedtoasingleindividual((i.e.E0PCoordinator),

who was also directly responsible for, performing the bulk of the efforts to revise the QGAs.

In practice, rather than by procedure, the E0P Coordinator accomplished most of:the E0P developmental activities with little or no independent review or oversight by QCNPS management. Consequently, this concern remainsopen(IFI-002).

The concerns summarized in the Executive Summary were based upon specific inspection findings described in great detail within the main body of the NRR E0P team inspection report. The E0P followup inspection only planned to examine a small number of these specific

,

findings to merely verify that CECO had addressed them within their corrective actions. However, it became apparent-during this inspection that CECO had not performed a comprehensive review of the specific NRP E0P team. inspection findings, since some of these findings were not adequately resolved (e.g. findings 3.2.5(1) thru (6),and3.3.1(3)).

Albeit, most of the. specific findings were probably resolved by Ceco's corrective actions to address t.be Executive Summary concerns but, Ceco should have made a greater effort to assess each of the specific inspection findings.and disposition them accordingly. This issue is considered open (IFI-003).

i d.

Conclusions

.!

At the completion of this special E0P followupfinspection, the inspector discussed his findings with QCNPS management and staff.

Although most of the concerns and findings previously identified by the NRR E0P team are considered closed, several areas requiring corrective action were not adequately addressed and/or implemented at QCNPS.

In particular, management lacked sufficient resolve and involvement to ensure acceptable implementation of the E0P developmental process in accordance with QCNPS administrative procedure (QAP 1100-13). Consequently, the failure of QCNPS-s'

personnel and management to comply with their own programatic controls has cast significant doubt on their effectiveness in maintaining accurate and up to date QGAs. Furthermore, even though CECO addressed all the concerns identified in the executive summary.

of the NRR E0P team's inspection report for QCNPS, Ceco failed to recognize the necessity of addressing each of the detailed E0P findings contained in the report's main body.

It should be roted that CECO has already undertaken additional significant corrective action efforts in msponse to findings

.....,, -. -... - -..,,,

.-.----n.

E

'l

, *

-

,

' /:

.

'

..

..

i presented during the exit neeting... The NRRfPM has substauently discussed and reviewed some of these preliminary corrective actions'ar.d concluded that their-scope and timetable, appears' ton be appropriate.

'

,

No violations or deviations were identified in this area.

-

13. ManagementMeetings-EntranceandLExitInterviews(30703)

L

-

_

Theinspectorsmetwithlicenseefrepresentatives(denotedinParagraph1)~

throughout the inspection period and at the. conclusion:ofJthe inspectionL on-April 26 ;1990,- and summarized the scope:and_ findings of thet

,

-.

inspection activities.

~

The-inspectors also discussed the likely informational content.of, the.

inspect?on ~ report with regard-to documents. or: processes reviewed by th:

inspectors during the' inspection. LThe ; licensee-did not' identify. tany ;such.

'

documents / processes as proprietary.-

)

i

'

,

N J

'

)

!?'

s

L

!

g.

/

m

_ _ _ _,. - - - -,., -

,-

-~