IR 05000259/1989050
| ML18033B077 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 12/06/1989 |
| From: | Carpenter D, Little W, Patterson C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II), Office of Nuclear Reactor Regulation |
| To: | |
| Shared Package | |
| ML18033B076 | List: |
| References | |
| 50-259-89-50, 50-260-89-50, 50-296-89-50, NUDOCS 8912180221 | |
| Download: ML18033B077 (33) | |
Text
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cs UNITED STATES NUCLEAR REGULATORY COMMISSION REGION 11 101 MARIETTASTREET, N.W.
ATLANTA,GEORGIA 30323 Report Nos.:
50-259/89-50, 50-260/89-50, and 50-296/89-50 Licensee:
Tennessee Valley Authority 6N 38A Lookout Place 1101 Market Street Chattanooga, TN 37402-2801 Docket Nos.:
50-259, 50-260, and 50-296 License Nos.:
DPR-33, DPR-52, and DPR-68 Facility NameI Browns Ferry Units 1, 2, and
Inspection at Browns Ferry Site near Decatur, Alabama Inspection Conducted:
October 16 - November 15, 1989 Inspector arp
>ter, s te anager rson, estart oor donator at gne at cygne Accompanied by:
E. Christnot, Resident Inspector W. Bearden, Resident Inspector K. Ivey, Resident Inspector e
Approved by:
e, ection Inspection Programs, TVA Projects Division hse, SUMMARY a
e sgne Scope:
This routine resident inspection included reportable occurrences and action on previous inspection findings.
Results:
This inspection report is primarily a closeout of open items and licensee event reports.
Sixteen LERs, one IFI, and nine VIOs were closed.
The plant licensing staff continues to make good progress in closing out old issues and preparing closure packages for the NRC.
The backlog of old items where the corrective action or physical work has been completed has nearly been eliminated.
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There are no cited violations or deviations in this inspection report.
One licensee identified violation concerning failure to take correction action was identified, NCV 259, 260, 296/89-50-01 (paragraph 2. 1).
REPORT DETAILS 1.
Persons Contacted Licensee Employees:
- 0. Zeringue, Site Director
- G. Campbell, Plant Manager
- M. Herrell, Plant Operations Manager R. Smith, Project Engineer
- J. Hutton, Operations Superintendent A. Sorrell, Maintenance Superintendent G. Turner, Site equality Assurance Manager P. Carier, Site Licensing Manager
- P. Salas, Compliance Supervisor J.
Corey, Site Radiological Control Superintendent R. Tuttle, Site Security Manager Other licensee employees or contractors contacted included licensed reactor operators, auxiliary operators, craftsmen, technicians, and public safety officers; and quality assurance, design, and engineering personnel.
NRC Employees
- D. Carpenter, Site Manager
- C. Patterson, Restart Coordinator
- E. Christnot, Resident Inspector
- W. Bearden, Resident Inspector
- K. Ivey, Resident Inspector
- Attended exit interview Acronyms used throughout this report are listed in the last paragraph.
2.
Reportable Occurrences (92700)
a ~
(CLOSED)
(UNIT
ONLY)
LER 259/85-47, Improper Standby Liquid Control Heat Trace Tape.
This January 1985 item identified that the Unit 1 standby liquid control pump suction lines were indicating lower temperature than the heat trace tape heater control setpoint of 80 degrees F.
The licensee determined during their investigation that the heat trace tape was drawing a current greater than the rating of the transformer.
The heat tracing is used to prevent precipitation of the sodium pentaborate.
Due to the ATWS Rule,
CFR 50.62, Requirements for Reduction of Risks from ATWS Events for Light-Water-Cooled Nuclear Power Plants, the licensee initiated ECN
E-2-P7065, which instituted changes to the SLC system.
These changes included:
Use of Boron-10 enrichment which resulted in a
change in concentration and a
lower volume of solution and therefore, reduced the injection time and maintenance of the solution.
By increasing the Boron-10 enrichment, compliance with the ATWS rule was achieved with one pump operation.
TVA design information gives a minimum abnormal area temperature of 50 degrees F where the SLC Storage Tank is located.
The SPS must be maintained 10 degrees F above its saturation temperature to prevent precipitation of the sodium pentaborate.
Therefore, a saturation temperature of 40 degrees F, corresponding to a
maximum concentration of 9.2 weight percent was established.
With this new concentration limit, disconnecting the heat tracing and changing the temperature alarm setpoints will not degrade the safe operation of the SLC because the sodium pentaborate concenvration should not exceed the newly established maximum concentration.
As a
backup, the new temperature setpoint of 50 degrees F, decreasing, would start the SLC storage tank heater and would alarm to alert the control room to abnormal solution temperatures.
The following TS amendments reflecting these changes were approved September 2,
1988:
Unit 1 - Amendment 154 to License Number DRP - 33 Unit 2 - Amendment 150 to License Number DRP - 52 Unit 3 - Amendment 152 to License Number DRP - 68 The inspector reviewed the licensee's corrective measures and determined them to be acceptable.
Even though ECN -
P7065 is a
modification due to the ATWS rule, the closing of this LER does not mean acceptance of the licensee compliance with the overall rule.
The compliance with the ATWS rule will be covered in a
separate inspection.
The licensee supplied information to the inspector that addressed only the Unit 2 SLCS.
The LER is closed for Unit 2 only.
b.
(CLOSED)
LER 260/88-15, Missed Chemistry Sample Due to Personnel Error Results In A Violation of Technical Specifications.
TS Surveillance requirement 4.10.C.2.b, requires that a
sample of the fuel pool water be analyzed for conductivity and chlorine content at least once every eight hours when the fuel pool cleanup system is inoperable.
On November 28, 1988, no sample was taken until three hours after the TS required sample time.
The root cause of this was personnel error.
Although personnel were notified in writing at a shift turnover meeting that sampling was required the analysis was not performed.
The responsible person was counseled and received disciplinary action for this error.
This item is close c.
(CLOSED)
LER 260/88-16, Revision 1, Unplanned Manual Start of ESF Due to Personnel Error.
This item involves an inadvertent manual start of the 2D RHR Pump on December 9,
1988 during performance of 2-SI-4.2.8-45A(I).
Procedure step 7.4.20 called for depressing the local manual stop button for the pump, but the AUO inadvertently depressed the start button.
The UO immediately realized the error and tripped the pump from the control room in approximately five seconds.
A subsequent investigation determined that no hardware damage was sustained due to this error.
The licensee determined the cause of this event to be personnel error on the part of the AUO.
A contributing factor was that the start and stop buttons were not individually labeled as required by plant electrical drawings.
As a result of these determinations, the licensee had committed to the following corrective actions:
This event was to be reviewed by licensed personnel as part of their required reading.
Correctly label the start and stop buttons for the RHR pumps.
Review the labeling on local start/stop buttons for pumps and open/close buttons for valves in RHR, CS, HPCI, EECW and RHRSW systems, and correct any identified deficiencies prior to the restart of each respective unit.
The inspector has reviewed the implementation of these commitments with the following results:
Licensed personnel have completed their required reading of this event as of February 23, 1989.
Labeling of the Unit
RHR pump local control stations was completed on January 6,
1989 per Labeling Request Form 2-74-010589-01.
The review of labeling on all start/stop and open/close buttons, for the above referenced systems, necessary to support restart of Unit
has been completed, and all identified deficiencies have been corrected per Label Request Forms 0-067-081189-04, 1-074-081189-12, 2-074-081189-11, and 2-075-081189-03.
The overall results of this review are that all licensee actions on this LER necessary to support restart of Unit 2 are complete and acceptable.
This LER is closed for Unit 2 only.
d.
(CLOSED)
LER 259/88-35, Revision
5 Revision 1,
Procedural Inadequacy Causes Unplanned Initiation of Control Room Emergency Ventilatio 'I On October 28, 1988, an unanticipated start of CREV train "B", an ESF actuation, occurred while returning the CREV system to standby readiness following the performance of an SI.
The cause of this event was that two SIs were performed simultaneously resulting in the failure to reset the CREV initiation signal latching relay.
The root cause was determined to be inadequate procedures in that neither SI contained steps to prevent concurrent activities that affected CREV or its logic.
Revision 0 was submitted on November 18, 1988.
Revision 1 of the LER was submitted on September 27, 1989, to document a
missed commitment from revision 0 which was discovered and corrected by the licensee.
The inspector reviewed both revisions of the LER, the licensee's closure package, and revised procedures and verified that all corrective actions had been completed.
The corrective actions included revising applicable SIs to include steps to specify that the performance of other instructions affecting CREV or its logic concurrently is prohibited to include steps to reset the CREV seal-in logic prior to placing the local handswitch in automatic, and issuing a scheduling and work control procedure to include work impact evaluations.
No deficiencies were identified.
This item is closed.
(CLOSED)
259/LER 88-41, Failure to Comply With Technical Specifications Caused By Personnel Error.
On October 28, 1988, the licensee identified that chemistry personnel had failed to perform compensatory sampling as required by TS 3.2.D.
This action was required because the
.,RCW effluent radiation monitors were out of service while the RCW system was in operation.
The cause of the missed sampling was determined to be personnel error with other work in progress at the same time contributing to the error.
Activity samples taken before and after the event were below the lower limit of detection.
The licensee
'ounseled the individuals involved and revised chemistry laboratory instructions to include specific requirements for tracking compensatory sampling.
The NRC inspector reviewed the LER, dated November 25, 1989, the licensee's closure package for this item, and the revised Chemistry Laboratory Instruction Letters.
The inspector noted that the chemistry lab shift turnover checklist was revised to include an SOS signature to verify that all compensatory sampling and analysis is completed and reviewed.
The inspector also noted that the countroom shift turnover included a requirement for the offgoing analyst to list all inoperable monitors requiring sampling and flow checks including the required times for the next shift.
The inspector verified that the commitments in the LER were completed and identified no discrepancies.
This item is closed.
(CLOSED)
LER 259/88-49, Inadequate Procedure Causes Two Unplanned ESF Actuation This item included two unplanned ESF actuations which occurred on December 17, 1988, due to an inadequate SI.
Both actuations occurred during the performance of O-SI-4.9.A. 1.b-1,
"Diesel Generator A Emergency Load Acceptance Test."
One actuation involved the auto start of the 2D RHR pump because the procedure step to inhibit the start was incorrectly placed after the step to simulate an abnormal condition for the DG test.
The second actuation involved a procedural omission in that the A1 and B3 RHRSW pumps automaticely initiated when CS pump 1A received a simulated manual initiation signal in accordance with the SI.
The RHRSW pump initiations were in accordance with system design but were not noted in the SI as anticipated occurrences.
The licensee's corrective actions included revising procedures governing the preparation and review of test instructions to include cautions on ESF actuations.
The licensee also committed to review and revise other SIs which have the potential for initiating ESFs.
The NRC inspector reviewed the LER, dated January 19, 1989, and the licensee's closure package for this item.
The inspector reviewed procedures governing the technical review and approval of procedures, the restart test program, the post modification test program, and the conduct of testing and verified that they included methods to ensure that steps which initiate ESF actuations are identified in the procedure.
The licensee identified several SIs which initiate ESF actuations without prior notifications.
The inspector reviewed a
sample of the listed procedures and verified that they had been revised to reflect ESF actuations.
No deficiencies were identified.
This item is closed.
(CLOSED)
LER 259/88-51, Failure to Neet Technical Specifications Because of Personnel Error.
On December 21, 1988, the RCW effluent radiation monitors were declared operable and chemistry personnel discontinued sampling which was being conducted in accordance with TS 3.2.D.
However, on December 22, the licensee discovered that the radiation monitor sample pumps were not operating.
The radiation monitors were then declared inoperable and sampling was reinstated.
The licensee determined the cause of the event to be personnel error in that the system was not verified to be operating locally prior to being declared operable.
The system was declared operable based on documentation and control room indication only.
The NRC inspector reviewed the LER dated January 27, 1989, and the licensee's closure package and verified that the corrective actions stated in the LER were completed.
These actions included revisions to the system operating instruction and AUO routine checks to verify that local equipment is properly aligned and operating.
The event was also made a
part of the licensed operator urgent reading assignments.
The inspector walked down the RCW effluent monitor system for Unit 2 using the revised procedures and identified no discrepancies.
This item is close (CLOSED)
LER 296/89-01, Failure to Provide Required Continuous Fire Watch on Inoperable Fire Doors Caused by Personnel Error Due to Insufficient Training.
This item involves the discovery that compensatory measures required hy TS 3. 11.E were not properly maintained between January
and February 5,
1989.
This TS requires a continuous fire watch to be posted at inoperable fire doors.
During this period of time, Fire Door 655 was inoperable because the door would stick on the floor when fully opened.
Fire Door 656 was inoperable because it would not latch properly.
Instead of posting the TS required continuous fire watch, a roving fire watch was assigned to monitor the inoperable doors+
The licensee determined the cause of this event to be personnel error in that the fire protection foreman was not sufficiently familiar with TS compensatory fire watch requirements.
Corrective actions implemented by the licensee are as follows:
The required continuous firewatch was established on February 5, 1989.
Corrective maintenance was performed on both doors and they have been restored to full operability.
All ESTs have received formal training in TS requirements for fire watches.
This training was completed prior to May 1, 1989.
The inspector reviewed the above actions and considered them to be appropriate.
This item is closed.
(CLOSED)
LER 260/89-03, Failure To Remove Jumpers From RPS Logic Placed During Performance of SI Due to Personnel Error.
Thi s event was a lso identi fied in IR 89-08 as Viol ation 260/89-08-01, whose closure is discussed in paragraph 3 of this report.
This item is also considered closed.
(CLOSED)
LER 259/89-12, Unplanned Actuation of Emergency Equipment Cooling Water Pumps and Violation of Technical Specifications Caused by an Electrical Fault.
This LER identified an unplanned ESF actuation when at 1:55 p.m.,
on May 5, 1989, a fault occurred in the isolated phase bus duct on the secondary side of the Unit 1 main transformer 1A.
The fault was automatically cleared by operation of protective relays which isolated the faulted equipment.
Because of existing plant configurations, a
loss of raw cooling water pressure and an automatic start of the A3 and D3 EECW pumps occurred.
The 500 KV system, through the main transformers, was the only qualified
offsite power supply available at the time of the event.
This fault separated Units
and 2 from the 500 KV grid and placed them in a
condition without a
qualified offsite power supply.
This constituted an Unusual Event and made safety related AC loads on Units 1 and 2 inoperable per TS definitions.
The BFNP is supplied from a 500 KV grid system as well as a
161 KV grid system.
Due to a voltage regulation concern, the 161 KV system was considered not qualified to supply safety related electrical loads.
Following the initial review of plant conditions, operations personnel manually r eenergized the Unit 1 4160 volt unit boards and common board
"A" which were deenergized by the fault.
A safety evaluation was completed for qualification of the 161 KV supply.
Based on this evaluation and implementation of its special requirements, the 161 KV offsite supply was declared qualified at 6:00 a.m.
on May 6, 1989, and the Unusual Event was terminated.
This event was caused by a lack of administrative contr ol on the operation of the bus duct cooling system and lack of preventive maintenance on the bus and bus duct system.
The lack of maintenance allowed the buildup of dirt and moisture in the bus duct and was the apparent cause of this electrical fault.
This condition was determined to be from two factors.
The first was the lack of positive internal pressure in the bus duct which normally comes from the bus duct coolers.
These coolers were removed from service in 1985 when the unit was shutdown since there was no requirement to operate them while the main generator is out of service.
The second factor was a lack of adequate preventive maintenance on the bus duct which allowed the degradation of the expansion boots and inspection window caulking to go unnoticed.
With the bus duct coolers out of service, degradation allowed the intrusion of moisture, rain water ahd dust into the bus duct.
The licensee corrective actions included:
Repair/replace, clean, inspect and test the bus duct seals.
Set up a
PM program to perform a full range of specific transformer tests every four years as a minimum as well as to perform a visual inspection of expansion boots, inspection windows and inspect for dust and/or moisture.
Evaluate, establish, and implement an acceptable method to operate the bus duct cooling system while the generators are out of service.
The inspector walked down the isolated phase bus duct system.
It was noted that all three cooling system fan blowers were operating, the ducting systems appeared to be intact, and new expansion boots were installed on the Unit 3 transformers.
The inspector determined the corrective measures were appropriate.
This item is closed for Units 1, 2 and (CLOSED)
LER 260/89-15, Revision 1,
Reverse Rotation of 2C RHR Pump Cooler Fan Motor.
This event was also identified in IR 89-20 as Yiolation 260/89-20-01, whose closure is discussed in paragraph 3 of this report.
This item is also considered closed.
(CLOSED)
LER 260/89-17, Unplanned ESF Actuation Caused by a Spurious I RM Spi ke.
This item involved the completion of initiation logic for a Unit 2 full scram on June 7,
1989, caused by the receipt of a hi-hi signal by IRNs C,
G, and H.
These upscale spikes were caused by a TIG welding machine in use in the vicinity of the IRN preamplifier panels.
When in the inert gas welding mode, this machine generates a high frequency signal which, when sensed by the IRNs, causes a
hi-hi.spike.
As reported by the licensee in this LER, three half scrams in December, 1988 were also attributed to high frequency signals from TIG welding machines.
These occurrences resulted in a
memo dated January 27, 1989 (RIMS R40890125956)
from the Plant Manager to the Modifications Manager.
This memo required the auto start function of all TIG machines in designated areas of Unit 2 to be disabled, thereby precluding the generation of high frequency signals.
The licensee's investigation of this later event revealed that, in spite of the Plant Manager's instructions, the high frequency signal generation capability of these machines had not been disabled.
The following actions have been taken to preclude future recurrence:
TIG welding machines have had their high frequency generators disabled by removing the "spark" switch from the control panel and internally securing the function in the "off" position.
These actions preclude reenabling the function without disassembling the machine and reinstalling the switch.
A memo dated June 29, 1989 (RINS R79890629971)
has been issued to all modifications managers summarizing the details of this event and emphasizing the importance of implementing management instructions.
The inspector reviewed the above corrective actions and considers them adequate to prevent further recurrence.
This LER is closed.
The licensee identified that they had failed to adequately implement identified corrective actions following the 1988 event which would have prevented this event from happening.
This is considered a
violation of 10 CFR 50, Appendix B, Criterion XYI, Corrective Action, and is identified as NCV 259, 260, 296/89-50-01, Failure to Take Corrective Action to Prevent IRM Spikes.
This licensee identified violation is not being cited because criteria specified in Section V.G.l of the NRC Enforcement Policy were satisfie m.
(CLOSED)
LER 259/89-21, Failure To Establish Correct Fire Watch Due To Personnel Error Results In Condition Prohibited By TS.
This item involves the discovery that compensatory measures required by TS 3. 11.G were not properly implemented between August
and August 7, 1989.
This TS requires a continuous fire watch to be posted at inoperable fire doors if operable fire detection is not present on either side of the door.
During this period of time Fire Doors 643 and 644, which do not have fire detection on either side, were blocked open to facilitate heat 'removal from the Unit 2 480 V
Shutdown Board Rooms.
The duty EST foreman erroneously determined that an existing hourly fire watch patrol provided the appropriate compensatory measure for these doors.
The licensee determined the cause of this event to be personnel error in that the EST foreman did not complete a proper review of Form FPP-2 Attachment F,
as required by procedure FPP-2,
"Fire Protection-Attachments."
Corrective actions implemented by the licensee are as follows:
The required continuous fire watch was established at 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br /> on August 7, 1989.
The duty EST foreman was counseled on procedural requirements pertaining to fire watches.
A memorandum was issued to require EST foreman to consult the duty Fire Protection Engineer when determining appropriate compensatory measures.
Fire protection personnel reviewed this event to emphasize the importance of following procedures.
A list of fire doors required by TS and their associated fire detection instrumentation was compiled and incorporated into procedure FPP-1, "Fire Protection Plan," Table 9.1.1.
This item is similar to LER 296/89-01 closed in this paragraph.
A violation would normally be issued for a repeat offense, but a
similar item occurred on August 8, 1989 which was identified as NRC violation 89-33-04.
This LER is another example of that violation.
This LER is closed.
n.
(CLOSED)
LER 260/89-24, Contract Engineer Entered High Radiation Area Without Proper Dose Monitoring Equipment Due to Personnel Error.
This item was previously identified as NCV 259, 260, 296/89-33-01 for which no response was required.
The licensee's action for this item was acceptable.
This item is close ~
(CLOSED)
LER 260/89-25, Removal of Fire Hose CM Due to Personnel Error Results In Condition Prohibited By TS.
This item involves the observation, September 19, 1989, that the CM for inoperable hose stations 2-26-877 and 2-26-878 was not in place.
For inoperable hose stations, TS 3.11.E requires the installation of a gated wye on the nearest operable hose station, with sufficient hose length to cover the required area.
The above two hose stations, were placed in an inoperable condition on June 28, 1989, after an upstream isolation valve was closed to isolate a pin hole leak in the HPFP supply line, and the required gated wye was installed, per Attachment F Permit Number 89-553, at operable hose station 2-26-281.
On August 17, 1989, hose station 2-26-281, along with several other operable hose stations, was utilized to provide the required CM made necessary by a Unit 1 Reactor Building Fire Protection System outage, per Attachment F Permit Number 89-644.
This resulted in hose station 2-26-281 simultaneously providing CMs for two separate Attachment F Permits.
Sometime between August
and 28, 1989, the sign associated with Permit 89-553 was removed by unknown personnel.
On August 28 the need for the 89-644 CM ended.
As the 89-553 sign was no longer present, the gated wye and additional hose was removed from Hose Station 2-26-81, resulting in the TS violation.
The licensee's investigation of this event determined the cause to be personnel error on the part of the unknown person who removed the 89-553 permit sign.
A contributing cause is that there were no procedural requirements in place for periodic verification of fire protection CMs.
Upon discovery, imnediate corrective action was to reinstall the required wye and hose.
To prevent recurrence, Procedures FPP-1 and FPP-2 have been revised to provide for periodic verification that required CMs remain in place.
In addition, fire protection personnel were required to review this event as part of required reading.
The inspector reviewed the licensee's actions and procedure revisions and considers them acceptable.
This item is closed.
p ~
(CLOSED)
LER 260/89-26, Personnel Error During DG Air Compressor Maintenance Results In Failure to Meet TS Requirements.
This item involves the failure to maintain the required number of Unit 2 CS and RHR pumps operable between August 10 and 11, 1989 for a period of 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />.
This condition came about when the "B" DG was declared inoperable due to the inability to meet minimum air star t system pressure requirements caused by an air leak on the high pressure head of the right bank air compressor.
The licensee's investigation determined the root cause to be personnel error.
Earlier in the day, the compressor had undergone corrective maintenance to repair a
leaking reed valve.
During reassembly, the head was incorrectly installed and debris was allowed to remain in the head bolt holes.
This prevented proper torquing of the head bolts, resulting in the air lea In order to preclude future similar errors, the personnel involved
~
were individually counseled and all appropriate maintenance personnel received documented training in the cause of this event.
In addition, procedure MMG-45 has been revised to provide more explicit installation and PMT instructions for the replacement of the air compressor high pressure head.
The inspector reviewed the licensee's actions and procedural enhancements and considers them acceptable.
This item is closed.
3.
Action on Previous Inspection Findings (92701, 92702)
a ~
(CLOSED) IFI 259, 260, 296/87-46-05, Correction of Emergency Plan Manual Deficiencies.
This item was that the EPN contained outdated procedures.
As a
result of these deficiencies and other necessary upgrades, the EPN was deleted.
The manual procedures were incor porated into site procedures within chemistry, fire protection and operations.
The licensee has a separate radiological emergency plan with associated emergency plan implementing procedures.
Each of the eight EPM procedures were superseded or deleted as follows:
Deleted Re laced b
EPM-1 EPN-2 EPN-3 EPM-4 EPM-5 EPM-6 EPN-7 EPM-8 Fire Protection Plan Spill Prevention Control and Counter Measures Deleted - covered by existing REP O-AOI-100-3, Flood Above Elevation 565 O-AOI-100-6, Release of Hazardous Chemicals or Gases Abnormal Operating Instruction 1, 2-AOI-100-2 and 3-AOI-100-2, Control Room Abandonment Abnormal Operating Instruction O-AOI-100-4, Breach of Wheeler Dam Abnormal Operating Instruction O-AOI-100-5, Earthquake Abnormal Operating Instruction The inspector reviewed the new procedures and concluded the outdated information was removed from the new procedures.
The EPM was originally required by N(AM Part II, Section 1.1, Revision 1.
This part of the NgAN has been superseded by an ONP Standard, STD - 10. 1.54, Revision 0, "Interim, Plant Operating Instructions."
This procedure was reviewed and contains a section titled "Abnormal and Emergency Operating Instructions."
Since most of the EPM procedures were replaced by AOIs, the procedures were essentially renamed and updated.
The actions taken to resolve this issue were adequate.
This item is close (CLOSED) VIO 259, 260, 296/83-53-04, Failure to Respond to gA Audit Findings Within Required Timeframe and (CLOSED)
VIO 259, 260, 296/85-03-01, Failure to Promptly Correct Conditions Adverse to guality - Audit Responses.
These violations were identified during two separate NRC Special gA Team Inspections conducted during November
-
December 1983 and January 1985 at TVA's Chattanooga and Knoxville Offices to evaluate the adequacy of licensee's management and gA controls related to licensed activities.
In the first violation the NRC inspector identified four examples where responses to gA audits were not submitted by the audited organization within
days as required by ANSI N45.2.12,
"Requirements for Auditing of guality Assurance Programs for Nuclear Power Plants,"
which is endorsed by the licensee's gA Program as defined in TVA-TR75-1A.
The inspector reviewed the licensee's responses to the first violation dated February 15, 1984 and April 25, 1984.
In those responses the licensee attributed the violation to lack of management emphasis within the gA and audited organizations to promptly define actions required to achieve corrective action.
The licensee further stated that various corrective actions were in place to preclude recurrence.
This included specific procedural requirements to provide formal responses to audit deviations within 30 days.
However, during the second team inspection a
NRC inspector noted that although improvements had occurred in this area, additional management attention was still needed.
That inspector reviewed gA audit reports issued since the first inspection and identified at least three new examples where audited organizations were still not responding to audit findings within the required timeframe.
Since these new examples were not all inclusive and other audit findings remained unresolved, a
second violation was issued for failure to establish management controls to assure that CAgs were promptly corrected.
During an enforcement conference associated with the second violation and other continuing problems, NRC and TVA representatives held discussions concerning TVA's apparent inability to promptly resolve problems identified during gA auditing activities.
The NRC staff stated their position that the basic problem was that TVA had not established specific guidance and measures which assured that such problems would be escalated to higher management attention whenever corrective action could not be resolved between lower levels of the line management and the gA staff.
During that meeting TVA management stated that corrective actions wer'e in progress to resolve the specific audit findings and that management controls would be improved to assure the adequacy and timeliness of corrective action The inspector reviewed the licensee's response to the second violation dated April 24, 1985.
In that response the licensee attributed the violation to the same causes as the first violation.
Additionally, the licensee attributed the violation to failure of management to properly assign responsibility and accountability in this area and to failure to escalate problems to higher levels of management when required.
Subsequent to these team inspections, the licensee has developed and implemented a
new standardized Corrective Action Program which the licensee states will result in directing management priorities at reducing the number of CAgs and establish prompt response to audit deviations.
The gA manual and plant procedures have been revised for the propose of ensuring prompt attention to corrective action and provide escalation of those items that are not completed within the required time frame.
This is zo be accomplished by tracking and trending of open CAgRs and providing reports to be reviewed at the appropriate managerial levels.
Escalation to higher levels of management is performed whenever required to obtain the proper amount of attention to overdue corrective action.
Another change is that audit findings are now documented as CA(Rs rather than tracked separately as audit items.
Audit items identified prior to the use of CA(Rs for that purpose are tracked on TROI with corrective action established for each example.
The inspector performed a
review of late corrective action and extension of corrective action, which is documented in Inspection Report 89-49.
During that review the inspector noted thai any overdue corrective actions received proper approval for extension of completion of corrective action or the issue was escalated to higher levels of management inorder to obtain the attention required to resolve the issue.
Based on this and another recent review of corrective action which is documented in Inspection Report 89-48, paragraphs 3.h and 3.i, the determination was made that the licensee currently has in place a
workable program to insure that planned corrective action occurs within required time frames or that escalation to higher levels of management occurs.
Based on discussions held with members of the licensee gA organization and these reviews of outstanding late corrective action, the inspector determined that correct amount of attention is now being given to tracking and trending CAORs.
The inspector reviewed the status of selected CAgRs identifing audit findings associated with several recent completed licensee gA audits.
The results of that review is the determination that the audit findings receive the same consideration as other licensee identified conditions adverse to quality, i.e.
late approval or submission of corrective action plan or completion of scheduled corrective action items are escalated to higher management unless approval for extension of due date is authorize With the exception of the concern relating to significant backlog of corrective action items, as identified in Inspection Report 89-49, the NRC inspector determined that the licensee has made a
considerable improvement in the area of management/tracking of l}A audit findings.
These items are closed.
(CLOSED)
VIO 259, 260, 296/86-43-04, Adequacy of Engineering Evaluations Documented on Dispositioned CAgs.
This violation was identified during a
NRC special team inspection conducted at TYA's Knoxville Office of Engineering to evaluate the adequacy of the licensee's performance in identifing conditions adverse to quality (CAg), corrective action, and determining generic applicability of CAgs.
The inspector identified three examples where dispositions of conditions adverse to quality were not sufficient.
The licensee had failed to properly determine the root cause of the events and the documentation did not show that generic evaluations contained enough information to allow the other licensee facilities to properly address the problems.
The inspector reviewed the licensee's response to the violation dated July 10, 1987.
In that response the licensee attributed the violation to the failure to provide adequate and sufficient problem descriptions and detailed information in the assessment of the potential generic condition as recorded on the PGCE memorandum so that other TVA facilities could properly assess the generic implications.
The licensee committed to developing a standardized root cause analysis procedure and to conduct training throughout the Office of Nuclear Power before its implementation.
The inspector examined documentation provided by the licensee to verify root cause analysis training.
Site personnel in quality assurance, licensing, engineering, and management positions were required to attend one of a series of
hour workshops which covered the new corporate root cause determination program.
Licensee personnel are not to perform root cause analysis until qualification is documented by the responsible organization supervisor.
The inspector reviewed PMI-15.9,
"Plant Incident Report,"
and SDSP-3.7,
"Corrective Action," and noted that these licensee procedures provided adequate quidance and information to allow someone with the proper combination of training and experience to perform root cause determinations.
The licensee has established a
MRC, whose composition and responsibilities have been delineated in SDSP-3.7,
"Corrective Action."
Effective use of the MRC should result in an improvement in the proper evaluation of CAgRs at Browns Ferry.
The inspector determined that adequate licensee corrective actions have occurred such that future failures of this type should be prevented.
This item is close (CLOSED)
VIO 259, 260, 296/88-32-01, Failure to Follow Pr ocedures While Tagging Out Components for Maintenance and While Performing a
Surveillance Test.
This item included two examples of failure to follow procedures by licensee personnel.
One example involved tagging out the wrong component and failure to perform independent verification by reactor operators during the implementation of a hold order.
The second example involved skipping steps during the performance of an SI resulting in an ESF actuation.
The.licensee concluded that both examples were the result of personnel failure to follow procedures or inattention to procedures.
The inspector reviewed the licensee's response to the violation and the closure package for this item and concluded that these errors were the direct result of personnel error.
The inspector also noted that the individuals involved were counseled on the need to pay attention and follow procedures.
No deficiencies were identified.
This item is closed.
Also, in their response to the violation, the licensee noted that there had been several recent examples of weakness in SIs and stated that TVA had initiated a detailed evaluation of the SI program.
This issue was reviewed in NRC IR 89-43 and further review of SI program deficiencies will be conducted during the follow up of the findings of that inspection.
(CLOSED)
VIO 259, 260, 296/88-36-02, Violation of TS For Failure to Follow SDSP 3.15.
This violation involved a failure to follow procedures in that SDSP 3.15,
"Independent Verification," required that electrical lineups on electrical equipment clearance and systems alignment checklists be independently verified by individuals qualified to perform the steps being verified.
On December 16, 1988, an NRC inspector identified that electrical lineups on equipment clearance and system alignment checklists were being independently verified by AUOs who had not received the required electrical training The reason the violation occurred was that the personnel involved during the initial preparation and detailed review of SDSP 3.15 failed to identify that parallel changes were required in SDSP 14.9,
"Equipment Clearance Procedure" and PMI 12.15,
"System Status Control Procedure".
Operations personnel used these procedures to do independent verification for electrical lineups on equipment clearances and system alignment checklists.
As a result, the requirement of electrical training to independently verify electrical lineups was not me SDSP 14.9, Revision
was issued on January 20, 1989 and SDSP-3. 15 was included in the references section as an interface document and the definitions section defines a qualified operator as
"An AUO who has completed Step 2B electrical training and electrical upgrade qualification cards or operations personnel of a
higher classification are considered to be qualified operators for the clearing and tagging of components not under the jurisdiction of the wilson Load Dispatcher".
PNI 12.15, Revision
was issued on January 20, 1989 and SDSP-3.15 was included in the references section, and Sections 4.8.4.9 and 4.8.4.13 instruct the originator to "Insure that independent verification criteria for each item deviated is performed in accordance with SDSP-3.15."
The requirements of these three procedures are now consistent in regard to the independent verification requirements.
The licensee provided a
copy of this violation and the licensees response, as required reading for all operations personnel involved in the preparation of operations procedures, reminding them of the need for careful review of parallel procedure revisions.
The inspector has reviewed the current procedures, SDSP 3.15, SDSP 14.9, and PNI 12.15 and determined that the parallel procedures are consistent.
Informal interviews with randomly selected AUOs indicated that they understand the qualification requirements for independent verification of electrical lineups and system alignment checklists.
The licensee's actions have appropriately addressed this violation.
This item is closed.
(CLOSED)
VIO 260/89-08-01, Failure to Follow Procedure By Not Removing Jumper Installed During IRN Surveillance.
This item involved the discovery that, on February 3, 1989, the SRN scram function was not operational for approximately two hours.
This condition was discovered during functional testing of the Unit 2 SRN rod blocks/scrams.
That licensee's subsequent investigation revealed that two temporary jumpers had been installed in the RPS logic during performance of IRN rod block/scram functional testing earlier the same day.
Procedure 2-SI-4.2.C-3.2FT, step 7. 14.6, required the removal of the jumpers near the end of the IRN test, but the step was marked N/A and not performed.
This caused the SRN scram function to remain disabled and was not discovered until performance of the SRN test, approximately two hours later.
The licensee has determined the cause of this event to be personnel error.
The steps placing and removing the jumpers had been added to the procedure in a
recent revision.
Also, the jumpers were installed during one shift and were to be removed on the next shift.
Due to a
lack of attention to procedural detail by the IN technicians on the later shift, the jumpers were not removed as require The following corrective actions have been completed:
Maintenance personnel have reviewed the event as part of required reading with emphasis on attention to procedural detail.
Procedure validation for 2-SI-4.2.C-3.2FT was completed on August 24, 1989 and the resulting comments have been incorporated.
The inspector reviewed the above actions and determined them to be appropriate.
This item is closed.
g.
(CLOSED) VIO 259, 260, 296/89-11-01, Failure to Satisfy TS 3.2.A.
This item involves the failure to comply with TS Table 3.2.A, Note G
which specifies compensatory actions to be taken when the minimum number of instrument channels are not operable.
The specified compensatory action requires isolating the reactor building and initiating SBGTS.
Radiation monitor 1-RM-90-142 had been declared inoperable for troubleshooting and repair, and the above compensatory actions were implemented until the monitor was reinstalled.
however, the compensatory actions were not maintained throughout the period of time that PMT was being performed, resulting in the TS violation.
The licensee has attributed this event to personnel error.
The original MR covered only troubleshooting activities, and IM personnel failed to return the MR for revision and further review prior to initiating repairs.
Therefore, the SOS was unaware of the PMT being performed.
Corrective actions implemented by the licensee are as follows:
IM and operations personnel were required to review this event as part of their required reading to emphasize the need for thorough and precise communication.
IM personnel were counseled in the importance of adherence to procedures.
SDSP 7.9,
"Integrated Schedule and Work Control,"
has been revised to required SOS and STA signatures on impact evaluation sheets for any maintenance or modifications on TS required equipment.
PMI 15.10,
"Tracking of LCOs,"
has been revised to require acknowledgement by each shift of the completion or continuation of compensatory action The inspector reviewed the above actions and procedure revisions and determined them to be appropriate.
This item is closed.
(CLOSED) VIO 296/89-11-05, Failure to Satisfy TS 4.6.B.l.c.
'I This item involves the failure to perform TS required compensatory sampling of the reactor coolant water conductivity for Unit 3 at eight hour intervals, while local conductivity monitor 3-CIT-43-011 was inoperable.
This compensatory sampling was required when the local monitor was removed from service for repair and calibration.
Procedure SDSP 7.9, "Integrated Schedule and Mork Control," did not require an IE to be performed on this type of instrument prior to allowing work to begin.
In addition, IN personnel did not utilize Attachment 1 of INSI-3014, which requires the use of stickers or markings in the control room when instrument accuracy is questionable or the instrument is removed from service.
As a result of these inadequacies, the ASOS was not aware that the monitor would be rendered inoperable during troubleshooting and recali bration, thus, the required eight hour sampling'as not performed for approximately 23 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br />.
The licensee determined the root causes to be the inadequacy in SDSP 7.9 which did not require the performance of the IE, and the failure of IN personnel to utilize the above referenced form.
Had these actions been properly performed, all appropriate personnel would have been aware of the requirement for compensatory sampling.
To preclude future recurrence, procedure SDSP 7.9 has been revised to specifically require that IEs be performed for chemical instrumentation equipment covered by TS, and IN technicians have been instructed in the importance of completing the necessary forms to notify the ASOS when equipment is to be made inoperable.
The inspector reviewed the above actions and determined them to be appropr iate.
This item is closed.
(CLOSED)
VIO 260/89-20-01, Failure to Neet TS Requirements for Operable RHR Pumps.
This item involves the failure to maintain at least two RHR pumps operable, as required by TS 3.5.8.9, during the period of Nay 10 - 25, 1989.
During this period, both RHR Loop II pumps (B and D) were inoperable due to a scheduled maintenance outage and Loop I pump C was inoperable due to its associated pump area cooler fan motor rotation being reversed.
This left Loop I pump A as the only operable RHR pump.
The licensee's investigation of this event determined the root cause to be a
combination of personnel errors and conflicting phase rotation mar kings on the fan housing and the motors.
Cable 2ES1195-I, the power feed to the fan motor, had been replaced per work plan 2123-89.
Although the modifications engineer and the independent verifier both signed the step in the workplan verifying proper rotation, neither actually observed the rotation and the fan
0
was, in fact, rotating backward.
Additionally, while a paper sticker on the fan housing shows the correct rotation, a brass tag on the motor indicated the incorrect rotation.
The following corrective measures have been implemented to correct this item and preclude future recurrence:
The leads to the 2C RHR room cooler fan were swapped to achieve proper rotation and tested to verify that correct rotation exists.
The other three RHR room cooler fans and two core spray room cooler fans were tested for proper rotation and found acceptable.
Procedure 2-TI-134 has been instituted to provide guidance in verifying proper rotation of room cooler fans by measuring air fl ow.
Procedure ENI-33 has been revised to include provisions for verifying proper phase rotation and replacing any incorrect rotation indicators.
Procedure SDSP-17.2 has been revised to include qualification requirements for personnel directing post modification testing.
The personnel involved have been counseled in the importance of strict compliance with procedural requirements, and the independent verifier has received additional documented training in the requirements of SDSP 3.15,
"Independent Verificati on. "
The inspector reviewed the above licensee actions and procedure revisions and considers them to be acceptable.
This item is closed.
4.
Exir. Interview (30703)
The inspection scope and findings were summarized on November 15, 1989 with those persons indicated in paragraph
above.
The inspectors described the areas inspected and discussed in detail the inspection finding listed below.
The licensee did not identify as proprietary any of the material provided to or reviewed by the inspectors during this inspection.
Dissenting comments were not received from the licensee.
Item 259, 260, 296/89-50-01 Descri tion NCV, Failure to Take Corrective Action to Prevent IRN Spikes, paragraph Acronyms AOI ASOS ATWS AUO BFNP CAQR CFR CM CREV CS DG ECN EECW EMI EPM ESF EST HPCI HPFP IE IM IMSI IR IRM KV LER LCOs MR MRC NCV NQAM NRC ONP PM PMI PGCE PMT QA RCW REP RHR RHRSW RPS SBGT SDSP SI SLC SOS SPS SRM
Abnormal Operating Instruction Assistant Shift Operations Super visor Anticipated Transients Without Scram Auxiliary Unit Operator Browns Ferry Nuclear Plant Condition Adverse to Quality Report Code of Federal Regulations Compensatory Measure Control Room Emergency Ventilation Core Spray Diesel Generator Engineering Change Notice Emergency Equipment Cooling Water Electrical Maintenance Instruction Emergency Procedures Manual Engineered Safety Feature Emergency Services Technician High Pressure Core In,iection High Pressure Fire Protection System Impact Evaluation Instrument Maintenance Instrument Maintenance Special Iristruction Inspection Report Intermediate Range Monitor Ki 1 ovolt Licensee Event Report Limiting Condition for Operations Maintenance Request Management Review Coranittee Non Cited Violation Nuclear Quality Assurance Manual Nuclear Regulatory Commission Office of Nuclear Power Preventive Maintenance Plant Manager Instruction Potential Generic Condition Evaluation Post Maintenance Test Quality Assurance Raw Cooling Water Radiological Emergency Plan Residual Heat Removal Residual Heat Removal Service Water Reactor Protection System Standby Gas Treatment System Site Director's Standard Practice Surveillance Instruction Standby Liquid Control System Shift Operations Supervisor Suction Piping Solution Source Range Monitor
0
STA STD TI TIG TROI TS TVA UO URI
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IO Shift Technical Advisor Standard Technical Instruction Tungsten Inert Gas Tracking and Reporting of Open Items Technical Specification Tennessee Valley Authority Unit Operator Unresolved Item Violation