IR 05000255/1995014

Insp Rept 50-255/95-14 on 951207-960126.Violations Noted. Major Areas Inspected:Operations,Engineering,Maint & Plant Support

ML18065A493
Person / Time
Site:	Palisades
Issue date:	02/06/1996
From:	Kropp W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML18065A488	List: IR 05000255/1995014 ML18065A487 ML18065A492
References
50-255-95-14, NUDOCS 9602150226
Download: ML18065A493 (17)

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FACILITY

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Palisades -Nuclear Generating.*Pl_ant

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Palisades Nuclear_ Generating ~lant 27780 Blue Star Memorial Highwa Covert, MI 49043-9530 DATES December 7, 1995, through January 26, 1996 INSPECTORS M. Parker, Senior Resident Inspector P. Prescott, Resident Inspector.

N. Jackiw, Project Engineer-_**.

J. Nei~ler,-DRS Inspector***

R. Lerch, DRS Inspector

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APPROVED BY

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Reactor roJects Branch 3

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AREAS INSPECTED A routine, unannounced inspection of operations, engineering, maintenance, and plant support was performe Safety assessment and quality verification activities were routinely evaluated.

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9602150226 960206 PDR ADOCK 05000255 G

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. * EXECUTIVE SUMMARY. ' _...

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~f ~!.IONS (Section L 0) *. *

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i~i~:itr The inspectors performed an assessment -of aper.at ion al perfonna~~~-* ;i-ss~~~~:~,~\\),~~:,,:;: * * ",,_ ':- ".,_,_~;,...

prev1ously discussed in inspection reports that have occurred sfoce... the *:*':

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_Diagnostic Evaluation Team (DET) inspection of March 199 The following

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• *perf~rinance issues were assessed:*

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September 1994 *-Dilution Event (Inspectfon Report *(IR)94-016) ::<'.~;.~*:.r~/';*:s:_:-!~:~+:**~:,."::::~.:;:*v;

• *. December 2 994 March 1995

_September 1995 November 1995

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Pefel!lber 1995 *

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January 1996 Failure to Identify Degraded AFW System (IR 94~o2u<* *: *-"'* _.,.

Breach of Containment (IR 95-004)

Safety lnj~ction Tank Event (IR-95-011)

Failure to Secure Dilution (IR 95-013)

Excessive Startup Rate ((Section 1~2 of this IR).

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• r Disabled Safety.lnjecti.on 'Logic (Section 1.4 of.Jh_is I~f':

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• ::*... Ev~n though the above events were not individually s~fety signific:ant, ---in:.the _,<._::

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.aggregate the events represent an inspector concern.that an adverse trend jn performance could be developing. Although, the licensee's response to these*

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_*;,._performance issues overall was excellent, the inspectors expressed_ Jhis.'.. _

.. adverse trend concern to licensee management for further assessment* by the *

~lant'S line organizatio * *i*... '~.

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The Jnspectors reviewed the licensee's tracking pto~esi ~i ope~~f~i.*

wor_kar.ound Over a 11, the process was found.adequate (Section : 1. 4.) *

The list did not have general distr'1but1on*to licensee management *and. *. *'..._,_

therefore management oversight of operator workarounds ~as weak.. **

The material condition of the plant was adequate and has not improved significantly in the last yea The following material condition issues have emerged in the last three inspection reports:

Loss of level indication on the condensate storage tank and the domestic water tank (Section 1.1).

• An electrical fault in a cable in~talled several years ago resulted in the 2400 volt power system autom~tically transferring from its normal source, the safeguards transformer 1-1, to the backup source, the station power transformer 1-2 (Section 3.3).

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Various hardware issues pertaining to Appendix R fire impairments

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. A power reduction. was performed 1 n order* ~to* -f~ti'l.ifate: repaf~*-i'ng~.;~'tJ;:;.,~!W~~'.,1~~}!-l~;;:~,;-:;;i~i~\\~ri

. _swi ~chyard motor operated di sc.onnects ( I.. R "'~.sop>_..,;.,;:. _.

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Operations identified degraded *flexible connections between ~he main... i;: __ ;:**

generator and isophase bus (IR 95011).

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. Two cooling tower fans lost fan blades which caused the tripping.. of two

• 6ther cooling fans and damage t~ so~e deluge piping Also the Vibration

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trip for one cooling fan did not actuate (IR 950II).

. MAINTENANCE (Section 2.0).

• Mar:iagement oversight of the pl ant's safety program was.weak as evident !>Y : *'_:*...

~.:management not being aware that for-approximately one year,. safety~*!Deet'ings "*.-... ;.... ' - ;':.:

• .. ';:were not being held by the various departments on **a*regular bas*is.<:.-Jhis.*1.~ck... ** *' *

' of management, oversight was significant since* poor worker safety practfc.e~ *

• >continued w.i th two more events occurring during *-tM s **inspection period:***-;~;,,:*

.*(Section 2.1.I). Several examples* of poor worker safety practices-were:.

• • * i_dentifi_ed by the. inspectors in inspection report 50-255/9501 *

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. ENGINE.ERIN& (Section 3.0).

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, Management' s 'Qvers i ght of the Appendix R improvement was weak in th.at there ** "*.. * *

was no method for management to ascertain the accumulative impact of fire* *. **

.. impairments on plant operations (Section 3.2).. _,.*..

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,.* -_-:Th;**-~~~a~:~e.~t oversig~t,.,ai~~ss~ent.and*:.t~oubl*~~~oo~~ng for the faul~ed,.cabie th'at. resulted in the automatic transfer of the vital electrical busses to a *

backup source was excellen PLANT SUPPORT (Section 4.0).

Poor radiation worker practices due to adequate management oversight continued, as evident by two instances of workers exceeding radiation work permit dose limits. (Section 4.I)

Summary Of Open Items Violations:

Two violations were identified in Sections I.I and Non-Cited Violation: identified in Section In~pector Follow-yp Item: identified in-section.,.

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INSPECTION DETAILS*.* * <",

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• NRC Inspection Procedures 71707 and 71714 were used in

inspection of ongoing plant operation * ***

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I.I. Loss of Condensate Storage Tank Level Indication

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. In_ the* previous inspection report, 50-255/950I3,- the -inspectors performed --a~}/:::*

review of the licensee's cold weather protective measure In that review,

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. the inspectors had noted past problems of loss of level indication* on o_ne of :,_:

two level indicators to the condensate storage tank, T-2 and domestic.water*

tank, T-7 due to cold weather freezing of the associated transmitter., *The inspectors expressed concern that level indication for T-2 could be inoperable when needed during performance of certain emergency operating procedu~es~ * *.. *

Inspection report 50-255/95002 originally identified the problem-with level

indication due to freezing on T-The problem was discussed with operations personnel on November 27, 1995, and reiterated again to licensee management at

. the exit meeting on December 6, I996 for inspection report 50-255/950I On..

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_ De~ember 9, "I995 one of two level transmitters, LIA-2_02I, for T-2 faiJed.hig *,*.due to cold weather freezin Level indication to T-7 was also lost. *-_failure to take adequate corrective measures to prevent recurrence of the loss of l~vel indication of T-2.is considered a violation of IO CFR 50 Appendix 8,.*.

Cr.iterion XVI (Violation 50-255/950I4-0l)

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. 1.2. Excessive Startyo Rate Following Turbine Trip

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On December 2, 1995, following a turbine trip, a.high startup rate* (SUR) was observed while withdrawing control rods to maintain primary coolant system..

(PCS) temperatur *

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On December 1, 1995, the licensee initiated a plant s~utdown to accomplish* a short* maintenance outage. The outage was scheduled to replace the main..

generator i sophase bus duct fl ex connect ions and to perform necessary repa i_rs to the control rod drive mechanism (CROM} cooling fan: As the repai~s were expected to be accomplished over a short period of time, the licensee intended to maintain the reactor in a hot standby conditio..,

On December 2, 1995, at 5:37 a.m. with the reactor at approximately 14 percent power, the operators tripped the main turbine. Initial response following the turbine trip was as expecte The shift proceeded to reduce reactor power to less' than 1 percent power and maintain PCS temperature (T~.> above 525° ln*order to effectively control decay heat removal following the turbine trip, operators ramped reactor power to within the bypass valve capacity (4% of full steam flow). This action was necessary to prevent controlling decay heat on atmospheric dump va 1 ve ;,;:.

Reactor power was ramped down by inunediately inserting control rod The initial response to the power reduction and opening of bypass valves resulted in a decrease in T.v.*

The operator response following the decrease in

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. temperatures was. to **withdraw control rods to. decrease the rate ~f.de'c.ay" he.at -

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. removal and cooldow During the control rod withdraw the SUR reached

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approximately. 0. 7 - 0.8 decades per minute (dpm).. * This SUR exceeded :; : *<.: *> *. :;; - ::-..:~*J 0 _,_.-: ~a.dnfi.'!i.s_tr~tive limits provided. in ~OP-_6, 0 Reac~or. C9ntr~l Syst~m~ ~.;,;'.'hi~~_;__,;,~:;:.~~~~;:~~;;:L,;;;Jl'.f:;.z~

• ., * states the SUR shall be mainta1ned less than 0.5 dpm at all t~:nes. 'The high - *

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.SUR was brought to the operating shifts* attention by ci_;i outag.:* uianagement. -** ;,;.:c*:-' **... *:*:

observe Upon identification of the high SUR, operations inanediately*

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... Review of the event noted that_ the main turbine was tripped at a higher_power..

level than expected, compounding the need for timely operator response* *.,, -. * **--*.

• Alth_pug~ the turbine was tripped at a value higher than normal, the trip was*_

within ~dministrative limits specified in procedures.. The decision*to trip *

the turbine at this power level was based upon concerns with feedwater flow instabilities and perceived reliability concerns with electrical load indiC:ations below 50 megawatt The inspector's review of the ope.rator's actions noted that the reactor operator was attempting to control T.v. with control rod However, at this point in time with reactor at approximately 10~

1 percent power, the control rods had little or no effect on T~.*

T.~ was befog controlled by decay heat removal through the bypass valve.

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Ih reviewing the event, the inspectors identified several contributing

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Training Weaknesses

Operator-actions were inappropriate, as control rods were not the appropriate mechanism for contro 11 i ng PCS temperature at this power

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level. The PCS cooldown was being controlled by the bypass valv_e. * In addition~ the operator did not maintain oversight of his* actions, i.*e:*

• failed to monitor response to c.ontr*o1 rod withdrawa *

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Inadeqyate Commynicatjons Appropriate feedback, and repeatback communications between the operators would have allowed intervention and oversight to be more effectively utilize *

Inadequate Oversight Shift management was not fully cognizant of operator action Management in the control room during the evolution was not in a position to provide timely feedback. This was compounded by inadequate communications and feedback between operating crew

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Plant management took aggressive action, to address these weaknesse The inspectors reviewed the licensees actions to improve training, communications, and management oversight. During the most recent plant shutdown on January 17, 1996, the operators took appropriate ~ction to control the down power evolution, including control of decay heat removal and the cooldow The licensee took additional measures to ensure that the crew was properly

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simulator,prior to assuming shift activities. This 1 icensee-*identified *an~t'-*;* *:,.. * :*:* _.*~.' _

.. corrected *procedural violation is being treated as a Non-Cited Violation,* ~::>.*.

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.:.'f,/~?~~~,_s:~~!.'~ ~with.. s!~~ion V~ I: 8.1 of. the_ N~C-.~~-~~~5~~~~-: "r.~~c~CJ. ~-*..::.. ;,;-,~£::~{~-:~*i{;;~Ji_!:~,~~~~~~:,,R;.*~;}411@ Safe*~;- Injection Svstem Disabled

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... _.,,On_,,,January 19? 1996, the Safety Injection System (SIS) logic was found_.. ::..,,._~--.-* *. *.. *_,.,_.,

. *<.,* ':*,t*/di~:abled by l 1censee management during a review of contr.ol room l~gs. -.~Review.. i:;l::,,_;_~:*f;>.;*~.?i;\\

of~~hift Supervisor (SS) logs identified that the low. pressurizer p~essure. * *. :~

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'function of the SIS logic was disabled intentionally *through a wo_rk order_:*

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.. _prqcess with the SS approva The SIS logic was disabled on Janu~ry.18,,1996

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at 8:46 p:m. with the primary coolant system (PCS) temperature at 364° Te~hnical Specification (TS) 3.17.2 requires the SIS logic (initiation, actuation, and low pressure block auto reset) to be operable with a minimum of

• one *of two channels operable with PCS temperature at or above 300° Pl ant procedures {GOP-9, Plant Cooldown from Hot Standby/Shutdown and SOP-3, Safety *

Injection and Shutdown Cooling System) require the SIS to be operable with PCS temperature above Cold Shutdown conditions (210° F).

In addition, the work

.procedure, ESS-E-24, Disable/Enable the Safety Injection System Actuation on

. Low~.. P.r:essur1zer Pressure, required the plant to.be in cold shutdown conditiQnS.*.

to.'-'ac;compliSh procedure activities. Further review of shutdown *coolirig logs.<_ *.

• i.d~nt-ified *that PCS temperature remained above-300° F :until 11:35 p~m;Jm * ",; *-....

January 18, 199 Cold Shutdown condition were not established until January

<19~\\.1~996, at i7:20 Therefore, the SIS logic was. disabled for... *->** >,..,.-...:* ' **

appr~ximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> until PCS temperature dropped below 300° F,*and :*

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• appr:-9ximately 23 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br /> until temperature dropped below 210° The time the*

. SIS*'logic was disabled was within the TS Action Statement for inoperable SIS lodic~ Therefore,* there was, fortuitously, no violation of T.~

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... ---_-__ \\ -~~*~*-->*-.. ~... "* --*~*~ -... **.. :~,i Further review into.the disablement of the SIS logic noted that only the1ow pressurizer pressure function of SIS was disabled and that containment high pr_e~sU.re function was operab 1 e.. The intent of the work order was to disable the~_low pressurizer pressure function.of SIS below 210° F to prevent

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inadvertent or spurious operation of SIS.. SOP-3 and GOP-9 do not allow *:the SIS logic to be disabled unless plant is.in.cold or refueling shutdown**

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conditions. Although disablement of the low pressurizer pressure function of SIS*'above 300° Fis not allowed by T.S. 3.17.2, it is considered to be of minor safety significance, as the SIS block function had been previously been activated and the low temperature over pressure (LTOP) function was operabl The LTOP function is required to be operable per T.S. 3.1.8.2 below 430° F to avoid pressures which might lead to failure of the reactor vesse The failure to maintain the low pressurizer pressure function of SIS operable above 210° F is considered a procedural violation for failing to follow pr'oce.~_ures (Violation 50-255/9501_4-02). Operator Workarounds The inspectors performed a review of how the licensee tracked operator workaround The licensee's system appeared adequat However, some concerns were'note The operator workaround list was in revision. The Operations Support Supervisor (OSS) maintained a list of deficiencies. The inspectors

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. : noted a current'copy of this list was not available in the tont'ro,-;rc>>om>;:::_:.-_,.::,_*_*;...

- _ - Direct feedback from auxiliary operators was not evident. The _OSS re¢eive~ _.

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_concerns through daily discussions with onshift operations management *. One -:_.>:

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.. Hem the -inspectors considered a workaround, which was 1 isted -on the~',degrad_ed __,~-------~~>_,_:~;~\\:;f;~~i'.

,.*,< -.;:a*nl:f *inoperable equipment control room turnover *sheet, but -not-~on '.the'"'l_is~:_:,~~"~,(-~,;;,~:?/~-/~s?;~-:-~tf; generated by the OSS, was the gland seal regulator P-0514. -The regul_ator.-

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required manual adjustment during a change in turbine load, as" this could-,_ *.

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affect condenser vacuum. After discussions between the inspectors and the__

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, --.OSS, the-item was added to the lis < _.-

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The inspectors-identified that the oss 1 i st maintained a separate *grouping: for :5*->~ ">:~-:~~-;>)

control room deficiencies. However, the OSS list d_id not clearly i_dentify *..

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true operator workaround When the inspectors r~viewed the list, there ~ere :~ * ~--*-*

over 130 item The items did not fit the accepted industry definitions for*

an operator workaround. Also, the list did not have general distribution to licensee managemen *

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Strengths of the licensee system was management identification of emergent issues. The OSS oversight helped to better ensure operations priorities were adequately addressed by maintenance in scheduling items to be worked.. Also, during the daily management meeting, items that were scheduled on the oss list

• on 'a six week basis were tracked by management to see how we 11 -i tem.s _stay _on _

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. Action on Previous Insoection Findings

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A review of the following previously opened unr~solved and inspection followup items was performed per Inspection PrQcedure 9290 ~

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.,i 1. 5.1 (Closed) Inspection Foll ow~up Item 50-255/94014-.M.i. Performance Of *

Operations Management Was Weak In The Planning And Direction Of Pl ant _* -

Evolutions, Process Controls And Job Assignment *

Much of the licensee management actions that addressed IFI 50-255/9~014-08 and_

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09 were determined pertinent to this issue. There were additional licensee

actions attributed to this item. Sensitivity to weaknesses in the various programs was heightened by management encouragement in the condition report -

proces Many of the collateral duties of the shift supervisors were removed, enabling them to improve oversight of shift evolutions. Procedure reviews were performed by shift personnel to enhance the quality of procedure revision The 12 week rolling schedule allowed better anticipation of upcoming work activities. The daily oversight of the operations support supervisor improved control over prioritizing emergent operations issue This item is close.5.2 (Closed) Inspection Follow-up Item 50-255/94014-08: Overall Performance Of _Onshift Supervision Providing Adequate Oversight And Directio Much of the licensee management actions that addressed IFI 50-255/94014-09 were determined pertinent to this issu An additional action that would be

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"s*pecific to this item was* the *onshift organization* -restructure -that*:put-thre'e*.. *::.. ~<:,:,*;~*~~-;, ;

• senior reactor operators per shift.. This change included a redefi,niJjon of. ~._: __ : * ~:::....

the specific roles. This item is closed. *

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. Management Established Low Or Incomplete Standards And Expectation$ For

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Operators..-

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~-_~..,.~,,-:The licensee took several act;ons *to correct this *ma~agement defic~ency~*,:.:;~*;"~:{.~<>> :;*

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.. fitanagement _expectations were established and reinf~rced during _a.series of

--'-., -.*.:)*egul arly scheduled meetings and *diScussions. >;=Examples of these,~ ::: <

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.. CQ.!f111Unications included the daily operations mor_~_ing _meetings, weekly_*_-.-:... :.,. -,,..-..

operations manager staff meeting, monthly shift supervisor meetings, *and

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quarterly standdown meetings. A consultant evaluated and assessed individuals

• and developed personnel development plans. The primary focus of this effort

. was the development of skills associated with co11111unicating standards and

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The supervisory training improved operator knowledge* of performance standard Jwo operation crews visited different nuclear sites to compare operations po11,cies and practices with those of Palisades. Also, management simulator

~observations were discussed with the particular crew. This item i~ close '.r*~~-~*;.:/

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• LS.4 CClosedl Inspection Follow~up Item CIF.ll S0-25S/94014-18:

Inadequate

,"*

Protective Tagging Of E_quipment *..,

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Although 1 ice.nsee management has not c~rrected all *problems asso~-iated. *with

. the tagout process, much.progress has been made on the specific weaknesses.

. : 'identified by. the DET..At the time of the.DET,. the basic program was* :*...

de'fieient. Management, through.several different meth'ods clarified

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~xpectations and responsibilities of personnel involv~d in the tagout proces Training revised lesson plans and student~ were asked for input to improve the

. lesson plans. Tagouts were now performed by a dedicated group; onshif personnel *no longer have that functio _:Adm.inht~at~ve procedure 4~,10.. "".:'_"-_:

"Personnel Protective Tagging" was revised to better organize, delineate

.:

responsibilities, and make the process more restrictive. This item is close.5.5 (Closed) Inspection Follow-up Item 50-255/94014-19:

During 1993 Refueling Outage {RFO) Individuals Qualified To Operate The Spent Fuel Handling Machines Did Not Receive Formal Proficiency Evaluations Prior To Handling Fue Training was presented to the licensed operators during operator requalification training. This training included a review of SOP-28~ "Fuel Handling System" procedure and incorporated revision An overview of the spent fuel handling {SFH) equipment and a demonstration using the SFH machine of a typical fuel move was performed. A test was administered to each operator involved with the 1995 RFO to evaluate their knowledge of the fuel *

handling procedure. This item is closed.

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• ; '. 1.5. 6 CCl o-sedl * 1nspecti on Foll ow~yo *item 50-255/94014~20 :** :,-Onsh1 ft* Op~rat1 ~ni.@:ti2;t?~~{tik:~:,: ~

Super~ision Received Limited Root Cause And Event l~vestigatiori~. ~--,,_;~-:;;~~.--~-*. ~::~:Z:~~~ '-l~;~.:: *-

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. --, In May 1994, '-the operations department established the* new position--.:of :self'"-'~-=-*~~~~>'>.'-*~:~.:;~-~'-:

assessment program coordinator, reporting directly to the shift.operati_ons.. :*,.: *.. *:--.._* -..'

superintendent. *The self assessment program coordinator received in...'.depth-* ** -- -:::.-.::*

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root cause and event investigation training.. This position was -chartered with.. _ :_. _-

~

-* :overall res'ponsibility for coordinating, :maintaining; *and strengthening*~:the'<~:(-~'f:<":,~*;')-J;>~

- operations department's self assessment progra An __ independent review _.-,

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_'- ::ca°fiabil ity *was established for-department deviation/e'vent reports~* ~*-sh_iff::=:*'~*')t':~f;_"~:.r~: ~-,:~"~:~'">

. _._supervis9r'_s administrative collateral duties related to deviatjol"!/eveot_ -_

_, reports were eliminated. This item is close *-

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1.5.7 CClosedl Inspection Follow-up Item 50-255/94014-21:

Operators Receive Limited Training And Written Guidance On NRC Notification Requirement,

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,. The license*e-developed lesson plan LOCT-04.940, *10 CFR 72 & 50.9(b)

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Reportability Requirements," and was first presented to licensed operators of th~ licensed operator requalification class of 94 This item is closed. :*

-L~*.a C(Josedl Inspection fol l~-~~yp-ltem 50~255t94oi4~22: - M~nag~~e~t*-A~i.i"o~ :.:;.. -:_ :'-*_:-;

~~r_ Was _Weak To Fully *Resolve Problems With The Technical Spec_ificatforis;~<"

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And The Impact On Operability Evaluations. - -

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~ic~~s-ee' management actions that addr~~s~d IFI 50~2-5St94014-21-;~~ -23**;:~~~~*--:-: c:,..

-determi~ed pertinent to this issue.. This item is close,*

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1.5.9. CClo.sedl Inspection Follow-Up Item 50-255/940}4...:23-:

Licensing'~-Supp9rt

. ** *Of Operations In The.Area Of NRC Reportability-was Weak..__*-~-:*_::-.,,,;>;":-"-:-:*

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The_ process for reportability determinations was integrated into the -* ----

.condition"feporting (CR) proces The guidance to operations and other.

. _.

.. depar_tments--Jor reportability decisions was consolidctted into administrative-.,_*-~:. _ -

proc~dure 3.03 "Corrective Action Process".

Each CR presented to th~ Shift

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Supervisor wil 1 receive -a reportabil i-ty detenni oat ion along with an equipment operability determinatio Each new CR was also reviewed by the condition review grou Significant CRs were then reviewed by senior licensee managemen All CRs then go to licensing for an independent verification of operation's reportability judgemen Since potentially reportable situations

.faced by operations on shift were invariably captured on a CR, this should provide a ~eparate review of all reportability decisions. This item is close.5.10 (Closed) Inspection Follow-up Item 50-255/94014-24: Operations Self Assessment And The Corrective Actions To Problems Identified By These Sel.f Assessments Were Wea Licensee management expended considerable resources to address this proble Progress was found to be adequat The main effort to address these issues wai the coridition report (CR) progra Shift Supervisor collateral duties related to CR administrative processing and trending were eliminated.

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.

. operations CRs were assigned to an.operatlons self.assess.ment program*:**::.-.:.:.~-->-~~.~~-:~;~!<:".:~-~*:*

....-.coordinator. Also, management stressed a lower threshold'_for genf!r~ting'C-~s. :::*:~~'~;*,,;,::::;)~f;::::~

'

,. ; <.::,Qp~rat ~,ons.. personne 1 v_i sited other ut i l.i _t i_es. to *:c.~pa_re,._pra~t i:~e~:f_'f'f"9Pet,lJ,~~-~-:*:~;~~:~~;f~~.t~ht

'

manaqement frequently observed crews *in the simulator -to prov1de-d1rec~",;,~it-:S~f/o:;;~:j;>-:;'"?i:{~;;:.

.;.~;;;:

feedback to crew Self-check practices and questioning attitude.. was**,stressed ;;';;,,,..,.,.*<:.*.

in pre.:. job briefs, which were done on a greater frequenc An 'initial ;fr.en.d" :.:/a~c-"* "\\*.,-

.an~lysi_s was done, with assistance from a contractor specializing i!l __ causal... :... >.. ' :*....

, ' : * **fac~or analysi *

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{rfl;ough action's.' in the operation's department~nia-~t'e~--c~cti~n--plari>'ieveral,~{*/

-~:**

-..-,1.!'i ~ i a~ i v~s were developed and acted, upon Some of.t.~ese. i niti ~tives.-were.;,"~: -~.<-:;.2:--:* '* ~;::_;~*:

• operat 10ns management was trained 1n*se1 f assessment techn.1 ques, onshi ft crew *. _, * :* * ** *

.. --.-::..*

ev~luations were performed, and communication of self assessment goals to shift personnel were don This item is closed:-

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1.5.li' (Closed> Inspection Follow-up Item 255/94014-°3:3: Failure =*To *Ens-ure All Parts Were Removed Following Repairs To Charging Pump (P-55A).

• The licensee determined that this was an operational failure resulting i *. debr.is..in the c;harging system and_not-,!l.failure_of maintenance to n,aintai,n.

_.,..,, '__cleanliness *during work activities. Jhe>inspector's review of*this:matter;.~.:<.:' -,

• ' '::cone 1 uded that -continued attention. was,n.~cessary regarding foreign.*mater::i al

-~/y_,

exclu~jon (FME) during maintenance. _This t~nclusion was* based on recent FME

• issues identified in inspection.reports *50-255/94009.and 50-255/94011.:~*+ffhe.:*:?,_,_.::... * * *

• NRC*will monitor this area during rini'tine inspections. This item is *closed.>~.,

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I..5.12 CClosedl Inspection follow-yD Item 255/94014~34: Several_Material.. *,

Deficiencies Existed Due To A Lack Of Communicating* Performance*. *

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Standards And Expectations. :'."':** *

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-.-The li.censee*~.developed a su~ary*d

oc:uirii!~rit titled:..;~site-Expectati~ns**~n~"* :..... *.' ";

. S_t~n~_~rds n and disseminated th~ dOCl_l'!'en.~'.s cont~mt~_.to all site person_n~l.,:.'*

• * ~through *employee meetings, standdo~ri.*. rneeti ngs and *rout int!'. staff ineet i ngs.:---J~(. :">

• inspectors reviewed Pali sades Perfonnan_te Enhancement Plan ( PPEP). ACt ion Plarl" *,'- * '*

2.6, and confirmed the Operability Determination Process is clearly addr'ess~d *

in Administrative Procedure 3.03. This item is close.0 MAINTENANCE NRC Inspection Procedures 62703 and 61726 were used to perform an inspection of maintenance and testing activitie.1. Maintenance Activities *

• Portions of the following maintenance activities were observed or reviewed:

Reinstallation Of Right Angle Drive Gear Box For Volume Reduction System Extruder

Refurbishment Of Manual Isolation Valves For The A and B Evaporators

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Replacement. Of ST-()5228 Auxiliary *Feedwater.Turbine.Steam Supply )\\

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Drain Ya l ve *

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T_wo events that indicated poor worker safety practices and could h.ave _had

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. serious consequences occurred during this inspeCtion period. *seve'ral examples*:

• _:o * *.,-*

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. of poor worker safety practices were also identified by the inspectors in

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inspect ion report 50-255/9501,_; _:*.:*,.. /,,. ' : - <*>* <..... *., _.:.>;f.,'.. ~;,;::\\'!..'.'.-* ::~,} :/;..:;.;: ~--

o.i(oecember 2, 1995, ari instrument and control (I&c(techriiciari.:'rece*i~ed *~;;.ct: ~'.!'~*'Ei_i*::ei;~f£:;

-,.eleftrical shock and burns when the technician inadvertently came.. in_contac_t.*. *..

~--'*.;,~

with an energized 480 volt AC terminal strip. The l&C technician was in the

. process of troubleshooting problems with a generator bearing vibration probe for the main generato The terminal strip was located in a main generator

_excitor housing cabinet. A pre-job brief was perfonned and the technician was

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• . *aware that a tagout isolation of all power sources for the excitor was not yet complet Power was still available to 480 volt AC excitor heater circuit Control room approval was obtained to start the task. The work order involved only visually inspecting and taking measurements.. After taking the out~ *.*~housing cabinet panel off the excitor; ~the technician found that the -physical

• of!entatiori of the vibration probe' s te*rminal strips *prevented any * :;.: ::\\..._ '. *

. troubleshooting measurements. **Normally,~ once worki_ng conditions were* /:*

.* :o:'".. *. *,

identified as different than expected, work would cease.. But then, the

• technictan thought there was a determinated instrument.cable. *.While. *. ~ :... * *._.. **- *

.attempting to locate the identification"tag for the suspect wire, the.,.-_:-

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technician came in ~ontact with an enet~ized 480 volt AC heater circ~it. Poor

, self-check practices were identified as* the causal factor for this_*in~ident.-:

In*_another incident, although there were other contributing facto.rs~* the*iast.--..

• • **

safety barrier failed when maintenance workers _did not verify the*_tagout *:

boundary was adequat On December 18, 1995 a mechanical maintenance (MM)

technician was trying to. rig piping.to remove.MV-CRW 744, an evaporator concentrate discharge valve. A metal identification tag on a nylon strap*

contacted heat tracing, which had not been properly de..:.energized, causin*g a spar No one was injure Inaccurate_ ;Vendor diagrams 1 ed to the ~rong _

breakers being tagged ou However~ a step, generally n~t included in a tagout, designated that the MM personnel to consult the electricians prior to starting work to verify that the circuits were actually de-energized.* This step was not complete *

Licensee corrective actions have been proposed, but have not been complete In addition, licensee management was unaware, that for approximately a year, the maintenance groups had stopped the practice of conducting monthly safety meetings.

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• - -:,2.2 * Syrveillance-Actiyities

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Portions of the following surveillance ~ctivities "wer~ observed or reviewed:_:.*

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.::./?~~i~ _-_- -Helium:te-~k Test.For Condenser:Vacliu~~~~ks. -,.:::,.. *~*-'*.**_.. --.. :";,:~:i:~~~:-~~~i.~<}::-2~'.:~~~;iS;~{i:;j~;~~<-~*'-

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Special Test for Troubleshooting Palisades.Plant Computer

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• SpeCial Test For P-BC Auxiliary Feedwater._Pump -To Verify Mini.mum

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.Start Time

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M0-7A-2 Emergency Diesel Generator.1-2 Monthly Test Action on Previous Inspection Findings

. A review of the following previously opened unresolved and inspection ~ol)owup

• items was performed per Inspection Procedure 9290.3.1 (Closed) Inspection Follow-yp Item 50-255/94014-31: Oversight Of *

Maintenance Activities By Supervisors And Managers Through Observing In-*

Process Work Was Consistently Lo >.* -: >_

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.:In Response to this item, the license* implemented a monitoring and.field '* - *

• .observation program to observe site employees performing assigned _activities. '

• :Observations by. department managers and*other participants were *performed one-.

• or two times per month and were documented in Observation Field Notes. A *

monthly or bimonthly meeting was held to discuss the identified observation _Revision 2 to the Monitoring and Field Observation. Program Pol icy' includes*.,- ~

_ greater emphasis on the manager and supervisory coaching of workers* *in.. t.he * *

field: The revision also combines all the management monitoring meetings into one forum and designates the Program Coordinator.as the *focal point for~-:-~

preparing and leading the periodic review meeting Based on interviews" w_ith

.licensee personnel, the inspector confirmed that the program is being. * ~.* * _

• • implemented by the plant. This item is closed. -

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2.3.2 (Closed) Inspection Follow-up Item 50-255/94014~37: The ~r~vent~ti~~

Maintenance Program Was Wea The position of planning support supervisor (PSS) was created. The PSS was responsible for administering the PM program. Also, each department had a coordinator responsible for updating and revising the PM tasks for that particular department, as required. The system engineer was responsible for development of the PM program for the assigned system.-

On a routine basis, the PSS received a list of overdue PM A documented justification from the system engineer was required for a PM that exceeded a grace period due dat Any,PM that was also an operability concern, operations reviewe The review was *also performed by the responsible department supervisor. This item is

• closed.

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• ...?.3.3 CCl osed Inspection Foll ow-up Item 50-255/94014-38: ~o_nc~rn.Rel a~ed J~:; ;'\\:"~*r<::*_:..*.. ~'>'- :;*

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- The Effectiveness Of Work Control Process In The Areas Of Tracking* 'And

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Reporting. *

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.. * :*-.* -(*T~~g;l i.censee.- ha-s. taken *a number of steps* to address* *.thi ~ conce~n~:-~.~*;A:~~*~l~~Y:,~{~ti;=,;;;. -=~fr:~~;~~{~~~'.,:;;,

• - Ma1ntenance Planning and Scheduling Department was establishe~ in September*-

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..'.-199_4~ to focus on control of maintenance work request.> and work orders'/~ In -.~~

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.. ad4ition, a 13 week rolling schedule was implemented to enhance maintenance... *

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_ 'scheauling and planning. Palisades Administrative Procedure 5.0l was revised.. :

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• .* to~"r~duce the number of work types' and standardize 'the categodiatfo"ri' of the '{~,::~,_"-:'*;-;*"C:O:;l<'.:>

. _ *..,*::.\\Work~*:types *. The inspectors confirmed that.the abov.e actions had.been. takeri.*.<>S~t:~<;~\\~"'*~,

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• IhiS'"*item is **close * *-

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2.3.4 (Closed) Inspection Follow-yp Item 255/94014-51: There W~s Often Poor Oversight Over Contractors' Work Including Ineffective Technical Reviews

• of Work Product To improve performance in this area, the licensee developed and issued a guidance document to establish responsibilities and training requirements for the service coordinator on control of contractors and non-CPCO organizations..

Th(J nspectors reviewed the licensee's Performance Enhancement Action Plan

Objectives 1.6 and 3.1 and determined that this plan addressed* the concern

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'*.*.--:re.lated to poor oversight of c*ontractors' work. The NRC will continue to

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monitor the liCensee's activities in this area. This item is closed.-

. - '). 0. ENGINEERING

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NRC Inspection Procedure 37551 was used to perform an inspection of engineering activitie * -

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,.. *** Ray-Chem Splice~

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The licensee identified a question regarding environmental qualification of Ray'.'"Chem splices used on safety-related Rosemount transmitters and :initiated C-PAL-95-0681. A heat shrink shim sleeve used in the splices with crimp type butt connections was originally provided by Raychem, but a review of *the*

documentation found that the splice was qualified for use with.045n diameter wire, not the.037" diameter wire on the Rosemount transmitters. A written acceptability determination was prepared by the licensee which concluded that, based on comparison with similar, qualified, splices by Rosemount and Raychem, the splice design used was environmentally qualifie This qualification relies on the outer jackets and the outer splice cover to prevent moisture from reaching the conductor The inspectors reviewed this determination and concluded that the written determination did not adequately demonstrate the acceptability of relying on the outer covers because the Rosemount report indicated that the outer jacket was cracked in one case, and

• the qualifications of the field ~able jackets were not fully addresse For *

e~~mple, although the licensee has ~tated that "the field cable is fully qu~lified," qualification reports often do not take credit for the cable jacket for qualification. Jackets are typically said to be only provided for mechanical protection of the conductor insulation, e.g., during cable pulling.

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:---* * *:~,-,The. cable jacket may be damaged dur*ing install at ion, but this does :*not_ *.~.. :;"~*><*'f~' -~i~>h*.;~_~*'.:. -

• . -_typically affect qualification of the actual conductors as long as the jacket_::::~'"-*~

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pro_tects them from damag An additional concern would be for.maisture 'to.',*'\\:~*~:*:-.*~_".::-:.;~'.-:

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::en_t~r. J;he end of the cable and wick, or fl ow, a_l ong.the conductor~* ~.o the* ::._,:.::/*;:~:~~:~\\:ft*r-isf-'.:.::

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• -"'*:-."'~spl iCe: -*Only-*a small amount of moisture could **cause* deviations* **1n***the '.:.low '.*;dX~Wl':f*{Y,:*.'"'-J~z:;;::"

.,,,vogage t; ;.11smitter signals. This issue is an insp:!ctor follow up _.;tern

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, pending further discussions with the 1 icensee~ (50-255/95014-03) * *--

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.:*~* -'~:~-3 ~-:{ ::. Appendix -R Fire Impairments

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~:Th~--;C1ns'pectors performed a review of outstanding Ap'p'endix R impafnnent ;issues'~{:~J-:..,~~-:

.. i' DurJng this review, several weaknesses were identified in the licensee's *. _,-

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num~er of deficiencies attributed to. the list, the.inspectors were concerned that.the licensee would be able to adequately assess the overall -imp'acl of the**

impairment The inspectors were also concerned that fire watches ~ould be r~mo~ed before pertinent impairments werEf:repaired. -.

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The 1 icensee subsequently developed a comprehensive 1 i st to address the concern Upon closer review, the inspectors identified an issue that was not documented on the list. The item concerned LER 95-13. This item concerned fuses in the potential transformer (PT) circuit for the emergency diesel generator 1-1 which were not properly coordinated. *Another deficiency -of this list was that not all impairments (i.e., leaking valve or fire main piping)

that would not necessarily require a fire watch were included on the CR fire tour list. Also, continuous fire watch areas were not on the lis Another concern the inspectors identified to the licensee were the number of impairments in the cable spreading roo The licensee had no mechanism in place to assess the significance of a number of impairments in one area. *'

The inspectors also had a concern with the compensatory measures taken for the main lube oil storage tank roo There was no requirement to perform a walkdown in the room, because the room ~as not safety related. This has been a longstanding issue between the licensee*and NRC over the adequacy of the

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~west wal 1, wh*ich *is sheet metal rather than ~a fire :barrier. /:*However:'~-;.-'fi~e ~-. '_:;:*;::,,;g* *'

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in this area could impact safety related equipment. -The licensee was in.the*.*.. :*.:-

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In meetings..-*with *the -1 icensee*~ * NRC expressed *concerns. of. adeq(i"attf"mahagemerit*o;~,~ :-::.;~"':***.:.

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oversight with the Appendix R program because of the number.of deficiencies

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identified. 'The licensee is presently rev1ewing all outstanding* fssues* and * -

inspector concerns to develop a more complete list in order to adequately

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• At S:37 a.m., o-n January I6, I996, the 2400 *volt *feeder breaker ~t-~om* th~--~,-*-

safeguards transformer, breaker I52-40I, tripped on protective relay

actuation. The breaker trip initiated a-fast tr~nsfer to the alternate

• source, startup power transformer I-2.. The safeguards bus, is the preferred off site power supply to the plant safety related electrical buses. *

Plant operations initiated a walkdown of electrical components to ascertain cause of the breaker I52-40I trip and.determine the effect on plant equipmen During the walkdown, smoke was obser~ed at the safeguards bus feeder cable

• conduit entering bus IC switchgear rooin_.~.

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Subsequent investigation-by the licensee revealed a ground in the *cable

-*between.breaker I52-40I -_and _safety *bus *ID breaker I52-203. *:*The-grQund was --*.: *., located in the portion of cable underneath the turbine building.. Jhe licen~ee initial plans were to pull back the damaged cable.and replace the cable with

• new cable. The new cable would be routed in.the same conduit or use alternate ro~t i ~g between the breaker and the saf eiy.-buse The 1 i censee was ai so --

continuing the investigation of the root cause of the cable *failure."*

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The licensee pulled_ back the damaged cable from the conduit between breaker I52-40I and the IC switchgear roo VJsible inspection found insulati.on burned on two of the three conductors.:.,-;_~-The burns were separated: fo * the conduit by approximately I6 fee The licensee cut out the damaged portions of _the conductors for laboratory testing and root cause analysis. The -

licensee also included several apparently undamaged sections of the cables for analysis to determine the cause of cable deterioration in the underground conduc The licensee has pulled in new I5 kV cable to replace the damaged cable between breaker I52-40I and the IC switchgea Instead of using the existing conduit under the turbine building, the licensee opted to run the cable through the turbine building at the 790 level using the existing network of cable tray The inspectors walked down the new cable installation. Generally the installation was considered acceptable for non class IE cable. The licensee's civil/structural was reviewing areas where additional cable support may be require The cable was subjected to a high potential test of 2I kV subsequent to installation.

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• ~'.*,~-~,-.. -:_--t~e' i~'sp-~cto;s'" review 6i :logs,* ch~rts and in:ter~*1ews '~ith f1~en~1;~:-p~f'~Jn-~;l('s;:'.:~:.:'~~~>ti~::2( 'l

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_.Support Activities, with an emphasis on oversight of radiatiof! -~o,r:ker:.. '...,, :,_.. * '*.-_

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- :.. The. ii te was "projected to accfue 450 *perso*n ~rerii "and *over l lOO PC Is fo'i* the'*:-.":,;.;.:-';'*.'--:,:-""::,,..

---.. **.:~:year._-. Inspection Reports 50-255/95011 (DRP) and 95008(DRP) had_ prev_iC?u~ly

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• described inspector observations of poor radworker practice During this* *

inspection period, the following two-occurrences, identified by.the licensee_

resulted in the ED 1 imits being exceeded. *

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. - ll."containment Check Valve* Test Procedy-re During performance of Q0-11 "Containment Check Valve Test Procedure," an auxiliary operator (AO) exceeded the.ED limit for the radiation work permit

--* * (RWP) for the task. The ED limit was ~he allowable radiation dose for a.

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. __,::~ingle entry.into the auxilhry-_buildi_n~f;'4 _._._:

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• -The inspectors discussed t~e event with the operations, hea 1th physics. *:* *' *

'_;management and the AO *involved. -"The inspectors detennined that *,the *Aos took a

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.dose survey of the area and checked the EDs on a periodic basis.-

However, an *

AO accumulated dose at a higher rate than expecte The AO picked ~P five.

.,~ mrem more than the 40 mrem limit. This was due to safely securing from the.

task ~efore leaving the work area.. Although not, considered a_hi,gh _radiatio!'

area;' some 1 ocal hot spots impacted 'the-*dose for the _task. : *.

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. Packing Adjystment to CV-1059 The projected dose. for a *packing* adjust"1ent to CV-1059, pres_suriz~r "~pra/:*-.

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• valve, was estimated at 0.150 person~rem. The actual dose for this job was 0.355 person..,:rem. Several problems led to the failure of this job from an ALARA perspective. A pre-job brief was held; however, when the Shift Supervisor (SS) was contacted to initiate work, the SS pointed out the work order could not be perfonned as written; the plant was not in the proper operating mod The plan was revised to include a significant amount of time

• at the valve, with no valve stroking from the control roo The SS was concerned that stroking of the valve may cause a pressure perturbation. A review of the radiation work permit (RWP) and attached ALARA review indicated that no ALARA reevaluation was perfonned.* Neither the ALARA planning representative or shift outage manager knew that the plan was changed until the workers had already made an entry in containment and the RWP was placed on hold due to exceeding the projected dose estimate. *The licensee's actions to evaluate this issue will be reviewed during a* future NRC inspection;

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_ Th~,}in,sp~ctors contacted vari.ous 1 icensee operations, mainten_~nce,* __., __.. _:

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_. * _;-.eng_1.neerrng, 'and plant support personnel throughou~ the inspect1.C?,n.p~~io_~-~~~~**0',~!t+j\\g~:~~l~~. ** './<, ***":**se~ior *p_er~onnel *.are 1 isted below>*~,:,-~*,,.,<"*.*.. _._._.,\\'-*,.. **.-.*- ': *c~':'?~:~~:~~?:~f:~~,~~~~;-~~l~;~~10i~~~~~~t..

At the conclusion of the inspection on January 26, 1996, the inspectors :met :*.:'>*:~- <.*,;;;:*,*

_; wit,h 1 icensee -representatives (denoted by *) and su11111arized.the scope and-"

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\\fi~~~ings of the inspection activities *. The 1 icensee did not identify.. any of->

, th4f documents or processes reviewed.by the inspectors are proprietary. __. ____. _ ".. _....,,.

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_. *R_. A. Fenech, Vice President, Nucle~r Operations _

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'T. ~J. Pa 1 ini sano, Pl ant Genera 1 Manager

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• K. P. Powers, Nuclear Services General Manager

• G.* B. Szczotka, Nuclear Performance Assessment Manager

~H_i-*_L. Linsinbigler, Design Engineering Manager*:.-

• D~;:::W. *smedley, Licensing Manager

• D~-- W. Rogers, Operations Manager

~*s: Y. Wawro, Planning & Scheduling Manager

• R~~B. Kasper, Maintenance & Construction Manager

. ~-*K*.: M. Haas,.Training Manager

. *cit R. Ritt, Administration Manager

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';_.::*R{-1J. Gerling, 'Nuclear Fuels Manager

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• *M. G. Genrich, Acting System Engineering Manager

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'..;;t:~-~~D*(~~. Malone, Shift Operat;ons Superv;sor. --

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. *D.- *J. Malone, Chemical & Radiation Protection Services Manager : :_

.*J._ P. Pomaranski, Deputy Maintenance & Construction Manager*

• R~-A. Viricent, Licensing:Sup~rvisor

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• *R.-;*E. Mccaleb, NPAD Site Assessment' Supervisor

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