IR 05000259/1990020
| ML20058Q143 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry  |
| Issue date: | 08/13/1990 |
| From: | Jape F, Peebles T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20058Q122 | List: |
| References | |
| 50-259-90-20, 50-260-90-20, 50-296-90-20, NUDOCS 9008210116 | |
| Download: ML20058Q143 (39) | |
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pn CNg, ; UNITO STATES -
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NUCLEAR REGULATORY COMMISSION REol0N11 n
g- ys 101 MARIETTA STREET. ;
- *t ATLANTA, oEORoI A 30323
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Report Nos.: 50-259/90-20,;50-260/90-20' and 50-296/90-20
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Licensee: Tennessee Valley Authodity - _
6N 38A Lookout Place 1101 Market Street Chattanooga, TN 374.02-2801 ,
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Docket Nos.: 50-259,'50-260and50-296 ' License Nos. :
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. Facility Name: Browns Ferry 1, 2, and 3 Inspection Conducted: J ne 25-29 and July 9-13, 1990 Insp.' tors: ift.u f4) 0 a?O~
F. Jape, Team 'LeadeV hn
/ Date S1'gned Team Members: R. Moore i E. Christnot K. Ivey W. Bearden- .
Approved by:
T. Peebles, Chief 7~/h [h Date Signed l Operations Branch j Division of Reactor Safety 'l l
SUMMARY I Scope: -
This announced inspection was conducted in the areas: of corrective = action program implementation ' and quality verification. activities. Performance of .
the previous.one year period'in Operations, Surveillance; Maintenance, D' sign .
Engineering, and Quality Assurance was examined to assess the effectiveness of-licensees activities in these areas. Additional inspection scope included ]j review of licensee implementation of the - revised. Nuclear tQuality' Assurance ~
Plan .and-. licensee response to previous NRC' inspection : findings related to the - ,
corrective action program and quality verification activities, q
Results:
'The licensee has demonstrated an adequate capability for the _idenUfication i and correction of problems during the- previous one year . period- via quality j v' erification and corrective action program. activities. The CAQR program;was q effective in the identification and resolution of . problems and management. was t actively involved in the corrective action program. The quality organization's '
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overview of corrective action performance by the plant organization did not >
effectively focus on verification of all aspects of performance. Several deficiencies were identified regarding trending and site quality overview p aspects of the corrective action progra The licensee was responsive to correct noted deficiencies, and initiated, or !
verified actions which addressed these areas. Management involvement in the i corrective action program contributed to its effectiveness. Deficiencies !
specific to the Engineering area included the delay in reducing the drawing !
deficiency backlog and inadequate program controls for the conditional release of non-conforming item The licensee effectively planned and monitored the transition to the new Nuclear Quality Assurance Plan. The new plan places increased responsibility for quality performance and verification of nuclear safety activities with the line organizatio Corrective . ion program deficiencies identified in the previous NRC inspec-tion hs :en evaluated by the licensee, and most of the deficiencies have been reso ve l'
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REPORT' DETAILS-f Persons Contacted
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Licensee Employees I
- J. Beasley, Monitoring Supervisor:
- P. Carrier, Manager, Site-Licensing-
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F. Froscello, Q.C. Manager
- Herre11, Plant Operation Manager
- Jones, Assistant Site-Quality Manager-
- Kazanas, Vice President,' Nuclear Assurance and Services-
- Lawrence, M005 Engineering Manager
- McKinney, Manager Technical-Support i
- Miller, QA Eval /QA 4
- Morris, Corrective Actions
- L. Myers, Plant Manager
- R. Parker, Manager Quality Program,. Nuclear Quality Assurance
- P. Salas, Supervisor, Compliance and Licensing
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- B. Shadrick, Maintenance *
J. Sparks, FCN/DCN Closure' Manager
- Thompson, Technical Support /BFNP
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T. Temple, Section Supervisor /NE Mechanical .:
- * Turner, Site Quality Manager .
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Other licensee employees contacted during this -inspection 1: included craftsmen, engineers, operators, mechanics, security . force members, technicians, and administrative personne ,
NRC Resident Inspectors
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- C Patterson, Senior Resident Inspector-
- Little, Section' Chief
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- Attended exit interview i Acronyms and initialisms used'throughout this report are' listed-in the .l last paragrap j Site Quality Organization Corrective Action Program. Involvement Problems, or conditions adverse to quality, at BFN ~were addressed by two methodologie In general, problems of-safety lor operability' significance '
were processed in the CAQR program which was administratively controlled-by the site quality organization. Problems of ~1 esser-' significance or meeting specific reportability criteria, such as LERs, were_ processed by; programs administered by the specific plant organization. For example MRs-were controlled by maintenance, RIRs by Health Physics, and LERs by _
Licensin The corrective action program was ' controlled by SDSP . 3.13, Corrective Action, Revision This procedure provided specific guidance- t for processing _ of CAQRs and designated which administrative control
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procedures i .e. , ' procedures for MRs, RIRs, LERs, were procedures -for processing the lower level identified problems or CAQ Therefore, identified CAQs at BFN were essentially divided into two subsets; (1) CAQs *
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considered significant and processed via the CAQR program. controls in SDS .13 and (2) CAQs of a lower significance level which were. processed via
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CAQ/ACP Prior to May 1990, the corrective action program at BFN conservatively'
used the CAQR process as the primary mechanism for the identification and resolution of problems. Review of CAQs processed during the previous year ,
verified. that the CAQR process, although somewhat cumbersome and lengthy for minor CAQs, was effective in resolving identified problems. The CAQR process involved a comprehensive review and evaluation process which may not have been appropriate for problems of lower significance or' those problems such as LERs which already received a comprehensive review.'.
Revision 7 to SDSP 3.13 emphasized plant involvement .in the corrective action pr: cess by more effective; use of the CAQ/ACP This was accomplished by raising the threshold for initiation of CAQR Also, plant responsibility for' corrective action verification of hardware CAQRs was increased. The changes . incorporated by this revision do: not represent a corrective action program overhaul. Therefore, performance '
in the previous one year period provided the basis for this assessment of the present corrective action program at BF The site quality organization administratively controlled-the CAQR program and reviewed plant perforruance with respect to the CAQR and CAQ/ACP corrective action programs. Management's involvement in the corrective action program was primarily' evident in the CAQR program. The effective-ness of the. BFN corrective action -program was f based on - review of L performance as reflected in open and closed CAQRs, documentation of SQ overview activities and findings, and documented plant communica+1ons and trending information. Based on the information of.this review, the CAQR program was effective in the identification and resolution of problems and- -
l management was actively involved in the corrective action program. The
. quality organization's overview of corrective action performance by the I
plant organiza: ions did not effectively focus on verification of. all aspects of performance, i The Corrective Action' procedure, SDSP 3.13, provided adequate guidance for program implementation. The level of reviews and evaluations required-were appropriate for the level of problems processed as CAQR An apparent weakness in the procedure was the criteria for CAQR initiatio The knowledge. level of plant commitments and design basis required to evaluate an identified problem for initiation into either the CAQR or a CAQ/ACP program appeared to exceed the knowledge level reasonably expected from the line'. level personnel initiating a CAQ. Review of CAQRs initiated in the previous year demonstrated a tendency =of plant personnel to use the CAQR process, therefore, there was no evidence of- a CAQ receiving an inadequate level of revie Inherent in the emphasis towards the increased.use of the CAQ/ACPs is the loss of.this conservatis , !
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The CAQR validation provided an example of management involvement in the corrective action process. A management review committee reviewed each m
CAQR to verify the problem was adequately defined and merited the CAQR process. An additional function of the MRC was to designate responsi- !
bility for corrective action to the appropriate plant organizatio ,
Review of MRC meeting minutes for the previous year demonstrated the Site Director and plant organization managers routinely participated in MRC functions. The MRC provided a cross organizational review' of each- CAQ *
Management involvement contributed to the CAQR program effectiveness by timely establishment of- responsibility: for resolution - of identified problems. Additionally, the MRC function provided management a real time awareness of the problems identified at the plan ,
Corrective action scheduling and tracking phases of the CAQR program were adequate. Following responsibility designation by. the MRC, corrective action determination 'and implementation dates were entered into the TROI computer tracking system. SQ monitored and trended plant performance timeliness throughout the CAQR proc'ess. .An example of SQ trending effec-tiveness was the adverse trend of untimely corrective action performance identified prior to February 1990. This trend was evident from the large number of escalation actions being initiated by SQ for corrective action
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response and closure as reflected in monthly trend reports throughout-198 Management corrective action was the initiation - of mandatory .
Saturday Morning Meetings for organization managers responsible. for !
escalated CAQR Late-CAQRs decreased substantially from 101 in February l
to 21 in April 199 The Saturday Meeting provided another example of-management's effective involvement in the corrective action progra *
l An additional mechanism to irsure resolution 'of identified problems was l the System Preoperational roeck Program - which was specific. to: Unit 2.
l This program coordinates toe completion of _DCNs, ECNs, CAQRs, etc., which l have been designated by a cross organizational review board to be l necessary for system operability to support Unit 2 restart. The system l engineers are involved .in implementation of the. SP0C .for-their ~ assigned t system of 236' open CAQRs' were designated as restart items. A l
review of open CAQRs verified the corrective action implementation dates were reasonable and were entered in the.TROI system. A review of restart ~ t CAQRs verified the completion schedules :were entered appropriately into '!
the SP0C data base. Review of open CAQRs in conjunction.with the tracking :
and scheduling activities demonstrated-adequate follow-up of identified '
problems using the CAQR proces Review of ' closed CAQRs- demonstrated effective use of the escalation process to' accomplish problem resolution. ' q A sample review of closed CAQRs -indicated the . identified CAQs' were ade-quately identified and resolved. The sample included.the following CAQRs:
BFP 900115 BFP 900163 BFP 900186 BFP 900192 BFP 900153 BFP 890306905_ '
BFP 900003 BFP 900023 BFP 900154 P-BFP 900097 .BFP 900140 BFP 900107 P i BFP 900080 BFP 880406 BFP 900014 P i BFP 890821 BFP 900174 P '
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The level of review and evaluation accomplished for each CAQR was adequate l and in compliance with program guidance. The generic . reviews and correc-l tive actions accomplished were adequate. In cases where timeliness was ,
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. inadequate, appropriate- escalation actions were initiate The CAQRs i
process was well documented and demonstrated SQ maintained an awareness of resolution status and communicated to ' plant _ management plant performance regarding timeliness. The total open' CAQRs decreased .from 451 in June l
1989 to 236 in July 199 In conjunction with the sample review which indicated CAQRs were adequately resolved, this demonstrated the CAQR i
program has been effective in correcting. identified problems,
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The quality organization has implemented a well developed CAQR trending .
program. Although some CAQ/ACPs, e.g. IIRs. and RIRs, are included as !
trended parameters, this' trend activity.did not include all CAQ/ACP Trending of the CAQ/ACP programs was the responsibility of'the applicable l administrative organizations. There were three . levels of CAQR_ trending.
l Level III trended parameters monthly by individual plant organizations l such as maintenance, engineering, or operations and provided this report ,
to the plant organization managers. The Level II monthly report ~ !
incorporated the Level III trends into a monthly overall plant report to the plant manager. The quarterly Level 1 -trend report incorporated all TVA Level II reports to identify corporate trends. The Level III'and-II 1 trend reports primarily. trended internally and externally identified deficiencies against each organizations providing a perspective of each organizations performance as reflected by. reported deficiencies. Level II trend report parameters provided a focussed picture of CAQR program l performance. The Level-I trend reports provided a comparison between TVA sites which focussed more' on common causes o,f: deficiencies such e personnel error, procedural error, and equipment ort . design failur Review of the Level III and II trend reports for 1989 and 1990 4'
demonstrated SQ-has effectively monitored plant performan_ce. Although the corrective action procedure did not provide specific guidance for th identification of adverse trends or establishment -of performance control limits, control limits were established and adverse trends were identified-and communicated to managemen ,
In addition to trending discussed above, overview of corrective . action l performance. by SQ was provided by audits and monitoring report review l Corrective action program audits BFA 90017 dated May 16, 1990, and.BFA
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i 890001 dated November 1989, provided cross-sectional . reviews of corrective action activities. An example of the depth of the corrective i action audit and the follow-up was demonstrated -by a finding : from the e L
1989 audit which identified examples of improperly -invalidated CAQR Corrective action included an expanded review sample of 163 CAQR invalidations over the previous 3 quarters. The relatively low percentage of improperly invalidated CAQRs was corrected and the MRC was then ;
j required to approve all invalidations. The 1990_ audit identified examples
- of inadequate processing of Test Deficiencies. Corrective actions were not yet proposed for this findin The corrective action audits contributed to SQ's overview of the corrective action progra . .
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- SQ accomplished additional corrective action overview functions via
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monitoring report reviews, Monitoring - reviews were real ~ time' focussed '
reviews of specific program aspect Monitoring report QBF-M-90-1080 dated February 20, 1990, reviewed IIRs to verify deficiencies identified during incident investigations were addressed as CAQRs'where. appropriat Monitoring reports QBF-S-90-1007 dated January 12,.1990,- reviewed CAQ/ACPs to verify they met SDSP 3.~13 requirements for corrective action program This report identified 4 CAQ/ACPs which did not meet the trending requirement Corrective action initiated was to perform monitoring reviews of these four CAQ/ACPs to identify adverse trends as an interim measure until the corporate standard procedure.for trending was. approve .
Monitoring' reports QBF-M-90-1326, 1318, 1324, and 1317 reviewed the deficient CAQ/ACPs for adverse trends. Monitoring reports QBF-M-90-1428 - ;
and 1173 reviewed CAQ/ACPS for~ contractor MRs and COTS to verify CAQRs were initiated ~where appropriat <
i SQ overview of .the corrective action programs- accomplished by trending, audits and. monitoring reports was adequate to verify performance for :
the previous one year period. The focus of this cverview will not be .
adequate to verify performance as the plant organizations assume greater I responsibility for corrective action functions. For example, the initial q CAQR versus CAQ/ACP determinations by the line organizations has becom '
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more significant in determination _of the level of review and evaluation in item receives. Overview of this functions should include - all CAQ/ACPs rather than the three previously monitore ~
The licensee responsiveness -
to this issue was demonstrated by their timely initiation of a'comprehen-sive review of CAQ/ACP determinations . following discussion ~ with the inspecto Secondly, although responsibility for corrective Laction verification of hardware CAQRs was given -to- thel plant organizations in . ,
May 199(., SQ did not initiate or schedule overview activity to assess
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l plant performance ragarding this verification functio SQ overview l
. activity should provrde additional focus on the following corrective l action program performance aspects:
(a.) Initial CAQ/ACP versus CAQR, determinations _ byt the line '
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(b.) Corrective action verification function performance by plant !
organization This issue will be identified as IFI 50-259,260,296/90-20-02, Site Quality Corrective Action Program overvie Additionally, although SQ trending of the CAQR program is thorough, it does not encompass all the corrective action programs i.e .CAQ/ACPS and <
CAQRs. As the use of the CAQ/ACPs is increased'.an effective review of L corrective - action . performance at BFN will include l the integration of- 3 trends of all CAQ programs. This issue was addressed in paragraph 4Eas
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inspection followup item, 50-259,260,'296/90-20-01'.
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In coaclusion,:the CAQR program was effective in the identification and
resolution of problems in the previous one-year period. The-CAQR process-encompassed those identified problems of -safety or operability ~ signifi--
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cance. The corrective action program is currently evolving to establish '
greater corrective action responsibility on'the plant' organizations. The quality organization overview of the corrective action program was- '
adequate in the previous- year but requires additional focus on: verifying
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satisf actory performance as the program evolves. Management' involvement ,
in the corrective action program'was primarilyu evident with respect. to the CAQR program and was a major contributor to-the-effectiveness of- this ,
progra I l Nuclear Quality Assurance Plan
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l TVA has revised its _QA topical report -to. encompass several changes and - !'
improvements. The new plan was submitted to.the NRC in_ March 1989 and was l- subsequently approved by the NRC in January 1990. A six month-period was l permitted to prepare for implementation of the 'new plan, called NQAP.
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Therefore the plan was implemented by June 30,:199 The new plan prescribed the program for- assuring ' qual _ity in the- design modification, operation and maintenance- of the plant. .The : previous QA program requirements were essentially retained and newly added items are: The QA requirements' have been consolidated and the "how to. do" details were delete ; The philosopby within the new plan is .that quality assurance' for
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nuclear safety is the responsibility of all-employees, especially the line organizations. This meanslthat QA willL no longer perform-in a'
line function, but would have 'a strong . role as an overseer _ = of -
activitie The quality. assurance organization now has the option to use a graded approach to accomplish their activities. This means_that techniques
other than 100 percent in-line verification may beiutilized so that resources- can be concentrated -on problem areas, or ~ activities significant to nuclear safet To accomplish an orderly transition ~from the old NQAM-to the new NQAP, TVA !
prepared an implementation plan. This plan was reviewed by,the inspector and found to be thorough and complete. Assignments -were made and all . .
procedures requiring a . revision were identifie This was done in March-1990. In early June 1990, Site Quality conducted an audit 'using ~a team of site and corporate personnel to verify the readiness for the: June .30, <
1990, effective date. The audit results were reported to the manager NQA on June 15, 1990. The audit team determined that full compliance with'the NQAP was achievable by June 30, 1990, Five discrepancies were identified by the audit team and actions to resolve each item was provided. _ These are described below:
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' Responsible line management is unaware of the transition - of - the ,
Topical Report to the NQA Pla j Controlled copies of the NQA Plan were relativ'ely unavailabl , The elements of the NQA ' Plan for trending: are not specifically ,
addressed in site Administrative Control Programs,
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j The elements of-the NQA Plan concerning." Graded Verification" are n'o ~
implemented in BFN site procedure l
' f the site procedures previously- identified and . requiring revision to implement' the NQA Plan, six have not been revised, j The actions to facilitate implementation are described below::
' Personnel from SQ have met with plant personnel to provide' input for-a site-wide dispatch. This dispatch will : inform site. personnelJof the = NQA Plan implementation and changes resulting from the-implementation. This was done on June'22,~1990, An attempt will be. made by SQ to increase the numberiof controlled copies of.the NQA Plan. However,.BFN does not believe:this must be
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done before implementation of the NQA Pla .
! While the elements of the' NQA Plan pertaining to trending l .re' not !
specifically addressed in site procedures,. Quality Monit'.,cing ha .
monitored all ACP programs, and BFN believes _ that the. quality indicators being trended are adequat I Even though the elements of the NQA Plan concerning Graded .. ,
Verification are not implemented, BFN is currently not grading items which would require a graded verification. :Since> BFN 'is not currently exercising the option to grade, this. area is not considered necessary for the NQA Pla During the identification of the required. changes, thd =line manager responsible -for initiating: the . change < was-. identified = SQL will-contact the line organization and communicate the: urgency < of these -
revision '
j In conclusion, the NQAP is now; in ~effect and- the transition Jhas been - 1 successfu TVA's performance under the new -NQAPL will be examined to' !
determine if the change results in: a satisfactory -level of ' nuclear safety'.
The change in processing of CAQs.is illustrated in Attachments 1 and~2 Trend Analysis Program l Criterion XVI, Corrective Action of Appendix B to 10 CFR 50 requires ~ a '
corrective action program that includes measures = to preclude repetitio ANSI N18.7, Section 4 mentions trending of day'-to-day events to indicate a
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This philosophy is- stated in sect' ion 10.2.5 of TVA's ' nuclear quality -
assurance plan.- The plan requires trend analysis to be performed on-conditions adverse to quality and-the results are to be used'by management ,
to determine quality status, identify adverse trends .and compare quality [
of performance among organizations and industry standards. The- trend
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analysis program is described . in STD-3.1.10, -Trend Analysis. The plan r
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assigns responsibility for trend analysis to Nuclear Quality Assurance and
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other site organizations. The. applicable sections .of the NQAP c and the i trend analysis procedure were reviewed by the inspector -and both = were found satisf actory. The NQAP and the corrective action procedure assigns responsibility for recognizing and reporting any condition adverse to-quality to alll plant personnel. Any person aware that something is not as
, it should: be, must promptly complete an .. occurrence report and--forward _ it to their superviso These . data are collected' from all departments- ,
collated for trending. and analysi Trend reports are prepared for all levels of. management' on a periodic btsis. Each organizational component ;
establishes limits on goals to detect. unsatist.:ctory-trends. A.CAQR mus . then be prepared for any. adverse trend of activitie This triggers a review for corrective action by the MRC within three- working day If it is determined that operability, could be : affected,. the CAQ-PRD form must . be submitted to the ~ duty plant manager immediatel Through-interviews of plant personnel and attendance at two MRC meetings, the inspector concluded that the process -is working. Each.CAQR on the MRC'
agenda was thoroughly discussed, action determined and responsibility a assigned. The meetings were attended by- plant Operations, Nuclear Engineering, QA, Site Directors' staff and other personnel; directly associated with the issues.-
To assess the effectiveness of the trending activities, a series of trend reports and performance report - were reviewed. In] order 'tt - get 'a . l sufficient sample of this activity, someL of the steports were- prepared :
under the previous QA topical report, NQAM, and some were. issued after the- '
new NQAP was effective. In addition, interviews and discussions were held with those who prepared the reports and those who receive these data. The inspector concluded that the program is fully supported by managemen Results are forwarded to top management with unf avorable trends hig lighted. The program is well documented and accepted by all departments.
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Site Quality and Corporate Quality Assurance performed a review of. BFN's corrective action process for agreement with the: trending.. program. The . .;
review dated July '7,1990, by G. G. Turner, identified .four ACPs that -
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required revision to fully implement the conditions stated in STD-3.1.1 these are:
a) Maintenance Management System .
b) Processing Drawing Discrepancies !
c) Conduct of Testing d) Engineering Evaluation Request
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This finding was discussed with appropriate personnel and . agreement was reached on the change and a completion date. Completion of this action 1 wil' be tracked as an inspector followup i tem 50-259,260,296/90-20-01, completion of action identified to satisfy STD 3.1.10', trend analysi .-
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9-l Plant Operations This area concerned the implementation of corrective actions as they relate to plant operation The' inspectors' observed control room operations and reviewed applicable logs including' the shift logs, clearance hold order book, TACF log, and Licensee Reportable Event 4 Determination Binde The inspectors also1 observed- plant-activities outside the control room. No noteworthy or significant events -
occurred during this inspection perio Within the area of plant operations conditions adverse to-quality may be dispositioned under a number of ACPs as allowed by SDSP-3.13.- However, the majority -of CAQs identified by operators are dispositioned- under 1 CAQ/ACPs such as LERs, IIRs, or WR In order to determine. the1 extent and effectiveness of SitegQualityi Organization tetivities _in this area the inspector held discussions with various members of the . Site ' Quality Orgen1zstio During those discussions the inspector was provided a compuser printout which the licensee representatives stated listed all Quality Monitoring Reports and-Special Quality Surveillances performed in _the plant operations. area- .
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during the period January 1, '1989, until the start of this inspectio The inspector selected frem this list 36 monitoring reports and ' two special reports for revie Specific reports reviewed are as follows:
1 Report Number Subject ,
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QBF-M-90-0010 Conduct of Operations L QBF-M-90-0192 Conduct of. Operations Observation of STA Activities
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QBF-M-90-0251 QBF-M-90-0252 Observation of.STA Activities E QBF-M-90-0005 Limiting' Conditions for Oper. tion l QBF-M-90-0208 Limiting Conditions for Opeiation QBF-M-90-0216 . Limiting Conditions for Operation QBF-M-90-0217 Limiting Conditions >for Operation ,
QBF-M-90-0250 Limiting Conditions for Operation QBF-M-90-0132 Clearance / Hold-Orders QBF-M-90-0137 Clearance / Hold Orders L QBF-M-90-0157- Clearance / Hold Orders QBF-M-90-0043 Observation of Fuel Handling Activities ,
QBF-M-90-0044 Observation of Fuel-Handling Activities QBF-M-90-0045' Observation of~ Fuel Handling Activities QBF-M-90-0046 Observation of Fuel Handling: Activities QBF-M-90-0056 Observation of Fuel = Handling Activities QBF-M-90-0079 Observation of Fuel Handling-Activities-QBF-M-90-0108 Observation of Fuel' Handling Activities QBF-M-90-0109 Observation of Fuel Handling Activities
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QBF-M-90-0110 Observation of Fuel Handling Activities'- >
QBF-M-90-0111 Observation of Fuel' Handling Activities QBF-M-90-0114_ Observation of Fuel Handling. Activities j
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QBF-M-90-0115 > Observation of Fuel Handling' Activities-QBF-M-90-0117 ' Observation of Fuel Handling Activitie '
QBF-M-90-0130 Control of ~ Temporary Alterations-QBF-M-90-0163 . Control-of Temporary Alterations QBF-M-90-0194' Control .of Temporary Alterations >
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QBF-M-90-0206- Control of Temporary Alterations ,
QBF-M-90-0213 : Control'of Temporary Alterations -
QBF-M-90-0629 Fire Watches Fire Watches !
QBF-M-90-0947_
QBF-M-90-0181 Portabl_e Fire Extinguishers,' Hose Stationsi 1 QBF-M-90-0182- Portable Fire Extinguishers,_ Hose Station QBF-M-90-0286 Portable Fire Extinguishers, Hose Stations- !
QBF-M-90-1080 Various Incident. Investigation-Reports-: ,
j Reviewed tolerify' any CAQs identified
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were properly documented QBF-M-90-0278 Special Quality _ Surveillance. performed to' '
follow-up on corrective actions associat'ed'
.with Incident Investigation Report, . ,
l II-B-90-046,.where the High Pressure Fire ,
Protection System was inadvertently
l isolated on April l 26,1990,(also' covered -
under LER 259/90- %i)
QBF-M-90-0285 Special Quality Surveillance. performed.t j verify roouired ' signs posted and hose
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stations. marked as inoperative, i ve ri fi cati on ' of irequi red . compen sator :
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firehoses available as required- =[
For those reports reviewed there were.no significant CAQs identified by licensee personnel. In most cases, only minor, administrative: and Jother .!
discrepancies were identified which were corrected- as' COTS. However, it' :
is noteworthy to point out' that quality monitoring activitiesi were a noticeably redirected as the result of identified problem areas such as a fire protectio >
Control of Fluid Systems g The inspector selected for review various;IIRs which the licensee performed--
since January 1, 1989, in the plant operations area. IIRs reviewed included the following:
Relort Number Subject i
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- 89-012 Unmonitored release of 192,000 gallons condensate storage water (also LER'259/89-004 and NRC Violation- 259,-~260,296/89-35-04) x 89-019 Unit 1 condenser pump pit floor flooded-
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89-027 Clean spill in radwaste building 1
'89-048 -CCW-spill in Unit 1 turbine building 89-050 fUnit 2 condenser room flooding-89-059 Overflow / Contamination'radwaste precoat tank r
'I 89-061 Radioactive spill / personnel-contamination 89-069 Radwaste fire pump bladder rupture .
!89-091 Overflow of Fuel Pool-(also NRC Violation f" 260/89-53-01)89-094 Spraying'down Unit 1 HPCI-
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_ Unplanned ESF due to transfer of 480 Volt-
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90-024 Shutdown Board ;(LER.259/90-002)90-025 Unplanned loss.of fire protection. hose stations e for'all three units (LER 259/00-004 3 s90-046' Fire protection system -isoletion (LER 259/90-007)
90-050- Reactor an? refuel: zone isolation (LER260.'0-003) j i
90-55 PCIS Group 6 isolation during SI: performance k (LER 260/90-00_4);
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/ During the inspector's review of 'the above IIRs a large _ number of : s L personnel' errors were noted. In particular it is noteworthy to recognize '
- .that the licensee experienced 10 separate events during 1989 that involved l failure to control fluid systems resulting in spills, flooding,' .or -
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l uncontrolled loss of'large-amounts of'.potentially contaminated water, .Two- :
of these failures resulted 'in 'NRC violations for failure to respond promptly to off-normal _ conditions, ,
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L operations andithe Site Quality Organization to determine the extent' of4 -
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corrective actions associated with this problem. Based on this discussion j and examination .of various additional ' documentation ~ provided ~ by . the
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l licensee, the inspector ' determined .that the problem has been adequately: '
resolved due to the following corrective actionswhich took- placeLin t L December 1989:
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Reassignment of an exnerienced .SRO to the newly created position -of '
Water and Waste Coordinato ;
Assignment of operations personnel to newly created Radwaste U' nit'
Operator position which is now fully manned around the clock, j
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Each SOS was counseled with increased emphasis placed on attention to i detail and prompt response to off normal condition j Training conducted with all operations personnel on the above events, j i
The inspector noted that these. actions appear to have been effective by t the absence of any similar events during 1990. .This is made further f evident in the danease in the-overall average radwaste. input rate (which ;
represents piant leakage) from 25 gpm to 10 gpm during the sameltim perio .
s Fire Protection Problems l The inspector selected for review varior' ' ERs which the licensee has
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submitted since January 1, 1989, in - th" plant operations are . LERs' ;
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reviewed included the-following:
Report Number Subiect-259/90-002 Unplanned ESF actuation (also IIR 90-024)
59/90-004 Loss of all three units' hose stations :
(also IIR 90-025) -!
259/90-006 Unplanned ESF- actuation (auto D/G ' start) {
i.59/90-007 Isolation of high-pressure fire protection- 1 (also IIR 90-046)
I 259/89-021 Failure to establish firewatch 260/89-020 Unplanned ESF actuation i 259/89-022 Unplanned ESF actuation (CREV isolation due j l- to maintenance error)- 1 .
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259/89-023 Inoperable EECW and D/G (due to error- i during31).
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F 260/89-025 Removal'of firehose compensatcry measure due i to personnel error 7 260/89-026 Inoperable D/G (due to main'tenance error). !
- 296/90-022 Unplanned ESF actuation due to electrical
L board. transfer !
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296/89-004 Unplanned ESF actuation (auto D/G start, l inadequate work request) ,
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L During the. review of the above LERs the inspector noted a definite trend ?
in personnel errors resulting in either unplanned ESF isolations' or
inadvertently not satisfying TS reauirements for fire protectio I equipmen '
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The personnel errors related to fire protection appear to be related to '
plant operations activities. The inspector met with licensee management to discuss this problem. The inspector was informed during the meeting that the problem was due in part to the recent organization change and change in responsibility for fire protection and at the same time a significant amount of modification work was ongoing on fire protection equipmen Licensee management informed the inspector of the following corrective action in this area:
Increased emphasis by plant management toward the goal of zero personnel errors, necent assignment of an experienced SRO responsible for managing the fire protection progra The inspector noted that no similar failures have occurred since the event of April 26, 1990. Although this represents a positive change indicating that management may be correcting the problem with personnel errors, insufficient time has lapsed to determine if the effects are long lastin The resident staff will continue to monitor licensee activities in 'this are l Temporary Alterations The plant has had an extensive history of abuse of the temporary altera-tion program which resulted in a large backlog of outstanding open TACF This constituted a condition which makes management + tatus of the configuration control program difficul This issue en identified by the NRC as IFI 260/88-02-02, As of January 1988 the- been approx-
, imately 200 existing TACFs for Unit 2 with greater than /00 for all three l units. At that time the licensee agreed that this issue was a problem and I committed to a significant reduction in open TACFs.
l l i The inspector noted that licensee management has continued to devote i attention to this area with the current number of open TACFs at 29 for i Unit 2. Only three new temporary alterations have been issued for all three units during 199 Although 29 is still too high and further reduction in the backlog is needed, the licensee has- made_ significant prcgress in this area largely due -to management attention by both plant OpereUons and Technical Support personne Licensee Technical Support personne' responsible .'or oversight of this program stated that although the goal i still sero open TACFs for Unit 2_the actual commitment is to
, be below 10 % -a T CFs before restart. There are apparently seven TACFs .
I that tne licensee ieuls will still be necessary at restart. The resident staff will continue to follow the licensee progress in this area with. a review of all open TACFs prior to restar . Surveillance Testing i
This area concerned the corrective action program as it applies to i'
surveillance testing. The inspection was performance based and included reviews of deficiencies identified during the performance and review of o
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sis to verify that adequate corrective actions had been initiated -in ,
accordance with the licensee's approved programs and procedure l Trending was identified as an area where PMI-17.1 did not sai.isfy the !
requirements of SDSP 3.13. Test deficiencies which are determined. to be t CAQs will normally rese3t in the initiation of a WR,- CAQR, or PRD to<
effect corrective actions. Procedure PMI-17.1 leaves the trending of tett i deficiencies to these programs instead of including; a test deficiency ',
trend analysis. A licensee quality audit identified that ,the . PMI-1 method did not meet the = requirements for a trending program contained in !
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STD-3.1.10 Trend Analysis. The licensee is in the process'of correcting this concern. This issue is further discussed in paragraph <
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The inspector held discussions with -licensee personnel on the control of l test deficiencies, CAQ/ACP trending, and implementation of the QA and CAQ ;
programs.. The inspector reviewed documentation identifying ' surveillance
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testing deficiencies that were issued or performed since October 198 The' inspector also reviewed the proposed corrective actions to resolve the identified deficiencie The following documents.were reviewed:
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Lis+, of all open test deficiencies
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NQA&E Audit Reports
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BFAB9003: Technical Evaluation of the RHR System BFA90013: Conformance to Technical Specifications ;
i?"0017: Correction of Deficiencies / Corrective Action Program
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Site Qu.'<ty Monitoring' Reports -
QBF-S-89-1832: SI Performance Observation I QBF-S-89-1866: SI Performance Observation QBF-S-89-1927:' SI Review QBF-S-89-1972: SI Review t QBF-S-89-1974: SI Review 1
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CAQRs/PRDs +
BFP890760: Deficiencies Identified During 2-SI-4.2.C.I.2FT-BFP890821: Deficiencies Identified During 2-SI-4.5 A.1.d(I)
BFP900169P: Deficiencies Identified During 3-SI-4.2.K-3A
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Incident Investigations II-B-90-035: Unidentified Reactor Scram, .
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II-B-90-038: Inadequate Compensatory Sample-for RCW Effluent !
Radiation Monitor II-B-90-056: Unplanned ESF Actuation During 0-SI-4.2. II-B-90-057: Missed Steps on 3-SI-4.2.K-3A l For each of the documents reviewed, the inspector verified that approved -
procedures were mplemented and_ adequate corrective actions were l- . identified for resolution of the- deficiencies.. No discrepancies wer <
l identified during the performance of the review '
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The inspector concluded that the licensee had programs to evaluate, resolve, and follow-up on deficiencies identi.'ied during the performance ,
and review of surveillance testing and that the programs were being !
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implemented at BF . Maintenance t
The NRC inspector reviewed the licensee activities _ in the quality i-verification area that occurred over the past six to twelve months. The review was of the licensee's activities in the Quality Monitoring, Quality j Surveillance and Maintenance Sita Organizations, The items specifically 1
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reviewed were:
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Quality Monitoring Reporcs involved with corrective maintenance, !
preventive maintenance and post maintenance testing (
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Temporary Alterations involved with Maintenance Requests j r
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Quality Surveillance Reports involved with performance of maintenance and Temporary Alterations
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Failure Investigations involved with maintenance and LERs o Maintenance work activities which required rework due _ to personnel errors !
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Trending of Preventive Maintenance 2
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Actions by Maintenance Managers involved with quality verification These items are indicators that demonstrate the licensees commitment to >
quality in the area of maintenance activities,
' Quality Monitoring !
The site quality monitoring activities are controlled by procedure OMP 102.1, Quality Monitoring Program - Site. This procedure, ~
resulted in the establishment of a monitoring matrix which contained the areas to be monitored such as: MA-1, Corrective Maintenance; J MA-2, Preventive Maintenance; MA-7, Maintena'n ce Organization and Administration; MA-9, Post Maintenance Testing; ' and MA-14 Work l Control. The inspector reviewed the Quality = Monitoring group activities in the areas of Corrective Maintenance,. Preventative '
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Maintenance and Post Maintenance Testin In the area of corrective maintenance the tinspector reviewed 13 quality reports involving the monitoring of maintenance activities in l, the following area: Fire Protection which._ included work on a' ;
-pressure control valve; Diesel Generators 1which included work on a i ground detector meter and DG starting air meter; Control' Rod Drive system air lines; Residual Heat Removal system which included part of the Unit 3 layup program; compliance with procedure SDSP 7.6,
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Maintenance Management system; Control Bay Chill Water System which included the repairs to a pipe depression; and compliance with G-SPEC 38 which included minimum turning radius of electrical cables / conductors. The most significant item reviewed involved CAQR BFP 90001 This issue concerned minimum turning radiu The results of the review indicated that the subject CAQR. did not constitute a programmatic deficiency. Additional areas observed during the review concerned the use of COTS method of correcting, minor deficiencies. COTS review identified the following:
No. 1460-01, incorrect .information for foreman; 1460-02, name of craftsman performing the work r.ot listed; 1460-03, typographical error in work instruction; and 1772-06, Blanks not marked N/A, b. Temporary Alterations The inspector reviewed three temporary alt 2 rations which involved the following: .
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TACF 0-89-001-018 was installed using MR 898849.. This activit?
involved the renoval of the check valves on the discharge sih of the Unit 1/2A diesel generator fuel oil pump 2. This TA initiated to verify that the removal of the check valve w4s necessar TACF 2-90-001-79 was installed using MR 876u This activity involved the installation of mounting brackets and platform to the fuel handling boom. This TA'was initiated to f acilitat core off loading.
TACF 2-90-002-303 was installed using WR C020188. This activity
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involved the installation of hinged locking clasps on the wire cage surrounding the northwest drywell equipment acces This TA was initiated to facilitate site security opening and closing the access.
l All items involved in the TACFs were well documented and all work I
activities were adequately controlled. TACF 0-89-001-018 resulted in the issuance of DCN W9097 which authorized the removal of all Unit 1 and 2 DG fuel oil pump check valves, c. Quality Surveillance The inspector reviewed quality surveillances which were done in process as well as post performante and involved with the following:
testing of a one inch fuel pool heat exchanger relief valve; review of completed maintenance requests and preventive maintenance packages; repair of cable jacket damage by the use of a Raychem cable repair sleeve; management involvement in reducing the large amount of backlogged PMs; annual PM of Unit 1/2 diesel generator C; weekly l inspection of control bay chiller 18; and calibration of temperature
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indicator 2-TI-076-15. During the review, the inspector noted that i adverse conditions were identified and each item was resolved by the ;
use of COTS. The surveillance indicated adequate monitoring of field !
activities, i
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d. Failure Investigations and LERs ;
The inspector reviewed the following LERs: ;
- LER 50-259/89022, which documented that on. August 10, 1989, at approximately 1000 hours0.0116 days <br />0.278 hours <br />0.00165 weeks <br />3.805e-4 months <br />, train A of the Control Room Emergency Ventilation system unexpectedly actuated due to a signal' system that was out of service at the time of this event. Investiga-
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tion of the actuation revealed that the radiation detector internal calibration source (check source) had been inadvertently inserted during insulation work in the area. The cause of this i event was the insertion of the radiation detector check source ;
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due to bumping of the check source assembly. The root cause was human factors in that the detector was not labeled as sensitive equipment; therefore, it was not' protected from ongoing wor LER 50-260/89020, which documented that on July 2,1989, at 1335 ,
hours, the logic circuit associated with the unit 2 reactor zone '
ventilation radiation monitor was deenergized during replacement of a fus This resulted in the isolation of unit. 2 reactor zone ventilation, and the refueling zone ventilation; _ and- the initiation of standby gas treatment and control room emergency ventilation. This event was caused by electricians incorrectly jumpering the fuse and associated circuit. After completion of l the investigation, _ the jumper was properly installed and the fuse replaced. The ventilation systems were- returned- to - normal
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at 1525 hours0.0177 days <br />0.424 hours <br />0.00252 weeks <br />5.802625e-4 months <br />. The electricians involved were counseled on the l need to research unfamiliar equipment or condition Training was provided to electrical maintenance craft and. planners on alarming fuses and circuit In addition the maintenance instruction for fuse replacement was revised to ' add a caution about this type of fuse circui LER 50-260/89026, which documented- that -on August 10, 1989, at 1750 hours0.0203 days <br />0.486 hours <br />0.00289 weeks <br />6.65875e-4 months <br />, the "B" EDG was declared inoperable 'along with its associated Unit 2_ residual heat removal system pump and core spray system pump which resulted in not meeting the minimum core cooling system requirements of Technical Specification The "B" EDG was declared inoperable when minimum air start system pressure requirements could not be met due to an air leak on the high pressure head of the right bank- air compressor for the EDG starting air syste The cause of this event was personnel error during the reassembly of the high pressure head of 'the air compressor -
following maintenance earlier in the day. Failure to reassemble the head correctly and allowing debris to remain in the head P P-
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bolt heles prevented proper torquing of the head bolts. Also_ I contrNuting to this event was a malfunctioning unloader valv ;
This malfunction increased the stresses on the head gaske .
Thr.se problems resulted in the failure of the head gasket and
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suesequent inoperability of the EDG. As a result of this event, cppropriate personrel corrective . action was initiated for the maintenance personnel involved in this event. Other appropriate maintenance personne) were also made aware of this even Additionally, the procedure used to~ repair the tir compressor in this event was enhanced to prevent recurrence of_these problems during future repair The inspector also reviewed five failure investigations .which involved tne following; radiation monitoring power supply, emergency -
equipmc.at cooling water system check valve 0-CKV-67-652, spent fuel pool cooling system alarm, 0-PDM-78-22, core spray system valve, ,
2-M0V-75-23, and standby gas train trains A and B, humidity control' ;
heater circuit breakers, i During this review the inspector noted that in the case of each LER the problem was identified and corrected. 'It was also.noted'that for the failure investigations, each item was' thoroughly reviewed and the root cause was noted. The failure investigation for the failed spent fuel pool coolinC alarm was initiated because of a trend in the number of failures in a given amount of tim ,
e. Maintenance Requests The inspector reviewed three MRs,-which involved the following:
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MR 781568, which required the replacement of 0-rings for relay i AD3 (AY) in panel 25-45 '
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MR 781569, which required _ the replacement of 0-rings _for relay AD2 (A2) in panel 25-45 !
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MR 89330, which required HFA relay ASLR (RW) in Shutdown Board 3EC to be calibrated and the latch engagement to be checked per NRC Bulletin 88-0 All three MRs were not worked correctly per procedure This -i involved not performing post maintenance testing and inappropriate signatures. The inspector noted that the licensee corrected these deficiencies and took additional personnel action f. Additional Reviews and Dbservations The inspector reviewed memos from line management to maintenance 3 personnel emphasizing quality on the job. These memos discussed the l following: '
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Prioritie This memo listed the priorities as 1) Safety, 2) Quality, 3) Team Effort, 4) Attitude /0etermination, ;
5) Efficiency, and 6) Productio This memo went.on to state that if the first four were firmly established, the-last two would occur naturall QA Record This memo emphasized that test data must 'be included when work authorizing documents were sent 'to history files. The personnel were to ensure that data was included when MRs, PMs, and sis were signed off as complete Procedure Compliance. , . This memo emphasized that attention to detail was a key ' element in the accuracy, completeness,'and p ocedural compliance associated with completed work packages, t
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Task Closure Verification. This memo emphasized the need for' :
all responsible general foreman to - verify. that _ tasks are ~
completed in a safe and quality manner consistent with applicable instructions and procedure Job Briefin This memo emphasized the following and stated:
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Prior to starting a job, conduct' a pre-job . briefing or discussions with appropriate personnel to ensure: a clear ,
understanding of the following:
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1) Work to be performed (including the correct components, train, system and unit to be worked).
2) Impact on other work and operating activities !
3) Communication requirements 4) Radiological control requirements-5) Material and tools required for the job 6) Tagout boundaries
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During these discussions, plant personnel' should be encouraged :
to use specific equipment identification nomenclature in verbal l
communication The above memos indicated .line management involvement in quality verificatio Additionally, during this QVI, the licensee completed a QA Audit of the maintenance activities. At the QA. exit the lead auditor discussed with senior plant managers the. findings observed during the ,
. audit. These findings include a lack of understanding by maintenance personnel of independent verification and the M&TE usage log did not '
accurately. reflect usage of M&TE. This audit is another indication of senior TVA management _ involvement in QV activitie .
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Conclusions:
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As result of the above reviews and observations the ~ inspector determined that:
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Quality Monitoring and. Surveillance, the onsite oualit organization, is adequately' pursuing activities involving quality in' the. field (item a.: and c. above).
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The maintenance line management is involved in reviewing work'
activities and methodologies to. ensure quality. is emphasized
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over production _(item b., e., and f..).
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Failure investigations are used and root causes are identified (item d. above),
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A corrective action program for maintenance' activities is inplace and is effective (all items above).
The inspector also reviewed trending in the maintenance . group and, although trending of PMS was very adequate ' additional trending of CAQ/ACPs_ needs to be formalize This-item'it documented ;in the :IFI on
trending for this repor . Design Engineering Support to Correct Deficiencies- Plant Stack Dilution Fan Damper Leakage:
(1) Description of Activity CAQR BFP880304, Plant Stack Dilution Fan: Damper Leakage, was written on April 21, 1988, to document, the _ absence of a-convective flow in the plant stack. This' design-deficiency was-identified by base-line test 2-BFN-RTP-065 which was. performed to determine if a natural draft' exists within the stack due to convective forces. A -natural draft is required to prevent a ground level release with only the Standby Gas Treatment System operating because credit; cannot be.taken for_ the stack dilution fans or the cubicle exhaust fans and their associated ductwor These items had never _been -designed nor procured as safety-related component (2) References (1) LER 88-039-01, control Room Operator Dose after Design Basis Event May Exceed '10 CFR Limits Because of Design :
Erro (ii) Special Test 89-07, Off Gas Stack Back Flow Measurement, "
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t (iii) Off Gas Stack Backdraft/ Resolution Feasibility Study, l Revision 1, BFNP TSD-M078, dated February 23, 199 ;
I (iv) Memorandum from W. C. Thomison, Acting Technical Support Superintendent, BFNP, to Plant Operations Review Committee, ;
BFNP, Subject: BFNP - Closure of Special Test (ST) 89-07, !
"Off Gas Stack Backflow Measurements - System 66, dated January 4, 199 I (v) DCN No. W11053A, Prevent Ground Level Releases, dated i April 6, 199 J
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(vi) DNE Calculation, No. ND-02066-900030, Pc.. Accident Off Gas Release Potential, dated June 19, 199 !
(3) Conclusions The licensee determined that the root cause of the above ;
design-deficiency was failure to verify or justify assumptions
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used in engineering calculations. The original off-site dose l calculations prepared for BFNP assumed that- all of the SGT- ,
system effluent would' be released .at the top of the stack-because of zero back-leakage through-the off-gas dilution fan damper and ductwork. This assumptionrof zero ground releases
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from the stack was' documented as an NRC commitment. in FSAR '
Chapter 14, Analyses. This assumption was not valid, however, !
in that leak-tight dampers and ductwork were. never originally !
specified for the off gas dilution fan ' exhaus Consequently, l use of this unverified assumption .in the off-site dose L calculation resulted in an NRC- commitment that was beyond the-functional capabilities of the : off gas system dilution fan
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L 4 i damper /ductwork design. The' procedural . deficiency: that allowed l the 'use of unverified / unjustified assumptions' in engineering calculation was corrected.on September 27,;1987, when Nuclear i Engineering Procedure- (NEP-3.1), Calculations, was issued for us ?
I-The inspectors reviewed the referenced documents and conducted -
interviews with licensee engineering staff . to determine ~ the technical adequacy of the corrective action taken for.
- ' disposition of the identified deficiencies. . The 11nspectors
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determined that reference "V" was being developed to correct the hardware non-conformances. the stated design objectives were:
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To minimize ground level releases !
_ : Provide air flow greater than or equal to-1100 CFM required by the WRGERMS-
_ Minimize release in the SGT- system building during normal j operation j t
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i Hardware changes required to accomplish the above objectives include installing redundant safety related isolation dampers, ;
(2 in series for single failure protection), in (1) Units 2 and i 3 dilution air ducts; (2) Cubicle Exhaust L Duct, -(3) Steam Packing Exhauster Duct;- and (4) six inch cross-tie lines from .,
the SGT system headers to the Units 2 and 3 dilution' air duct .
Additionally, Unit I dilution ~ air duct and its associated six i inch off gas line will be blanked off. Also', to ensure minimum 1 air flow to_ the WRGERMS the speed of: both Units 2 and 3 i dilution fans will be increased within the limits of the !
existing moto Finally, electricai design changes will- ;
provide Class IE power, controls and. indication for the
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installed isolation damper ;
r The plant modification package was reviewed to verify that; ..
selected design-output documents - were . consistent with the I hardware. changes. Additionally, the inspectors verified that- "
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appropriate technical and quality requirements had been ;
specified on procurement documents for procuring necessary material Post-modification test requirements and test ~ l acceptance criteria were not included _ in the DCN package. ~In .
response to the inspector's request for information concerning !
this issue TVA management stated that a test scoping document ;
had not yet been prepared for this. plant modification. At the j
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time of the inspection the.DCN package was still being reviewed
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and commented on by TVA engineer ;
Nuclear Safety Evaluation No. SEBFDCN900092, l prepared .in accordance with the requirements of 10'CFR 50.59, lists special !
requirements that have to be performed prior to declaring. the- !
system operable or closing the' DC Additionally, two !
compensatory measures determination forms were included in the safety evaluatio Discussions wereL held with 11censee's-engineering personnel- concerning. licensee's actions required to i (1) satisfy these : special requirements and'-(2) implement- the '
compensatory measure ;
The inspectors concluded that CAQR BFP880304, Revision 2 was -
being properly -dispositioned by the licensee. The developed
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corrective action plan as implemented > by DCN No. W11053A xis - 1 incomplete in that the DCN is in the review and comment stage L prior to approval of the design output documents. < The scope of -
that plant modification, however, adequately addresses - the '
identified material: nonconformance Development. and r preparation of the DCN was done in a controlled manner; and- .
resolution of this issue was done from a nuclear < safety' . ,
standpoin b. Potential Uncontrolled Leakage Paths
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(1) Description of Activity CAQR BFP900164 was written on June 11, 1990, to document previously unidentified leakage paths associated with the deficiency described on CAQR BFP880304 Revision The :
potential leakage paths are (1) frcm the stack liner drain line to the stack drain sump; (2) from the off gas treatment building sump to a connection to the stack liner drain line; (3) from the
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radwaste building sump to a connection to the stack liner drain line, and (4) from the drain of the SGT system piping into the off gas condensate sump in the radwaste buildin ,
(2) References CAQR BFP8S0304, Plant Stack Dilution Fan Leakage, Revision 2 l Drawing No. 0-47E830-1, Flow Diagram Radwaste l
Drawing No.17W920-2, Mechanical Heating and Ventilating Stick Gas Dispersal System
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Drawing No. 17W401-1, Mechanical Off gas System Drawing No. 17W401-2, Mechanical Off gas System (3) Conclusion:
Baseline test 2-BI'N-RTP-065 demonstrated that the SGT system exhaust would baci flow from openings at the base of the stac This condition caused the drains from the SGT system piping and from the stack-liner to be pressurized by radioactive gase These gases could escape either from a break in the drain piping itself or by failure of the water sealing system in the three i sumps to which it is connected. - The drain- lines are not designed to be seismic Class 1 and the sumps and their Support-ing electrical equipment are not safety-related equipmen No l credit can be taken -for them with regard to limiting post-L accident release The above determination was made during detail. design of DCN W11053 That portion of the three inch stack liner drain line l
and related pipe supports within - the stack was seismically analyzed during preparation of the DCN. CAQR BFP900164 was -
written to initiate corrective actions for the remaining portion of the drain lines, that are routed underground, to ensure - '
their structural integrity during a seismic event, The developed corrective action . plan included performance of a l seismic analysis of the underground drain line connected. to the SGT system header to verify its structural integrity. A'
normally locked-close valve- would be instalied in this line:
at the radwaste building to establish a boundary between ,
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seismically and non-seismically qualified drain line In a similar fashion a normally. locked-close valve would be installed in the exposed part of the stack liner drain lin This line has previously been seismically analyzed and its structural integrity verified under DCN W11053 The inspectors verified that CAQR BFP900164 was being dispost-tiened in accordance with the administrative. controls of the licensee's correctivt actions program. A determination ' of QA programmatic deficiency was performed and the deficiency was reviewed for its effect on Unit 2 startu The completed restart review check list recommendations identified CAQR BFP900164 as a restart item with corrective action required to be completed prior to Unit 2 startup. The inspectors concluded that the deficiency documented .on CAQR BFP900164 was being adequately dispositioned by the licensee. The capability. of the design. engineering process to . identify additional release pathways demonstrates a controlled and thorough technical-approach to the resolution of this problem from a nuclear safety standpoin c. Control Bay Chilled Water Pump Failure to Supply Design Flow Rate (1) Description of Activity CAQR BFP900186 was written on June 7, 1990, to document failure to Units 1 and 2 Control Bay Chilled Water pumps ' to supply -
design flow rate. Restart test 2-BFN-RTP-031A, . Control Bay HVAC, documents on TE07 and TE10 the above deficienc Test Exception (TE)07 was written on November 30, 1988, with a disposition of performing maintenance on the pumps followed by .P re-testin TE-10 was written on December 15, '1988, upon failure of the retest to demonstrate adequate pump performanc (2) References (i) Drawing No. 0-47E866-3, Flow Diagram, Heating and Air Conditioning Hot and Chilled Water, Revision 4 (ii) RTP Test Instruction No. 2-BFU-RTP-031A, Control Bay HVAC, Revision (iii) Temporary Alteration Cor. trol Form No. 0-88-002-031, Change Instrument Setpoints 0-TS-31-7 44 Degrees F- to 3 Degrees F i 5 Degrees F; 0-TS-31-12 44 Degrees-F to 3 i Degrees F (iv) DNE Calculation No. MD-02031-880378, Chilled. Water Temperature Determination for Units I and 2 Water Chillers A and B, dated December-19, 1988
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(v) Special Test 89-01, Control Bay Chilled W.ter Pump Test, System 31, Revision 1 (vi) Special Test 89-01, Unit I and 2 Main Control Room AHU Electrical Cooling Load Determination, Revision 0 (vii) QIR No. LMEBFN9005, RO, Mechanical Control Room (MCR) Heat Loads, February 20, 1990 (viii) DNE Calculation No. MD-Q0031900002, Browns Ferry Control Building Analysis, Revision 0 (3) Conclusion Failure of Units 1 and 2 Control Bay Chiller Water pumps to deliver design flow rate was reviewed by Nuclear Engineering to evaluate its effect on plant operation. Compensatory measures were implemented via Temporary Alteration Control Form No. 0-88-002-031 which lowered the'setpoints of Water Chillers A and B temperature switches. Design basis information for this setpoint change was provided by reference'(iv), DNE Calculation No. MD-02031-88037 Pursuant to development of. a long-term resolution for CAQR BFP900186, the lic;nsee has performed a number of special test Special Test 89-04 was performed to determine the cause of the low chilled water flow rate. Several problems were identified and corrected d.tring this test which resulted in' flow rates greater than that measured in the restart test.' These values were, however, still less than the required design flow by approximately ten percent. Special test 89-09 was subsequently performed to monitor the operation of Units 1 and 2 control bay elevation 617 air conditioning system for 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> Data collected during this test was used in preparation of reference (viii) DNE Calculation No, MD-Q0031-900002. The purpose of the calculation was to determine the electrical. heat load that existed in the main control room during performance of ST 89-0 This electrical heat load along with pertinent information concerning tagged out ' equipment can be used by the electrical engineering staff to determine the electrical heat loaa that would exist during a Unit 2 Loss of Coolant Acciden The inspectors determined that the root cause of the deficiency was unverified and unjustified engineering assumptions concerning electrical heat loads in the control bay made during original plant design. The liceuee's corrective action plan is intended to provide an accurate evaluation of the electrical heat load for the control bay and subsequent 1y' determine the minimum chilled water flow requirements. At the time of the inspection, Nuclear Engineering, (Electrical Engineering) provided an informal response to reference vii addressed to the Lead i
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Mechanical Enginee The :
stated that they were unable to analytically demonstrate a j reduction in electrical heat loads in the main control room 1 panel, because of insufficient .information 1 concerning load *
diversity. They stated, however,' that. a test. was performed to ;
determine the actual heat loads generated. . Preliminary review; 't of the test data has been performedi with.the final _ test results ,
scheduled for issue' on July 20,'199 l
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The'irispectors concluded that the disposition of CAQR BFP90018 t was being .hanc"ed in a controlled and technically adequate !
manner. . Refern.ce vii was prepared on February 20, 1990, and i transmitted to the Lead Electrical Engineer with request for a *
response by March 26, 1990. This response was provided in an . !
informal memo dated July 12. 1990,. at the. time of the i inspection.- This action 'is an isolated example of untimely j response which is further discussed in paragraph 8.f of this .
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repor d. Use of Nonconforming Items The licensee _ corrective action program, paragraph 3.8.3, Conditionall
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Releases, specifies the procedure whereby ;the.. licensee can
"use-at-risk" various nonconforming items. The conditional release L classifications are described as followsi i Type 1 CR permits the nonconforming item to be installed, but
NOT OPERATED, ENERGIZED, PRE 55URIZED, OR CONSIDERED OPERATIONA Type 2' CR permits the nonconforming item to _ be energized, pressurized, and operated ONLY FOR TESTING. The item SHALL'NOT-j
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BE CONSIDERED OPERATIONA t L Type 3 CR consists of two types (i.e. Typej3A and-3B).. ~
For nonconforming items in an operational st'atus,. a Type 3A_ CR l ALLOWS CONTINUED OPERATION of the' nonconforming ite For nonconforming items that are in the-process of being turned over for operations after performance of maintenance, I modification, repair, or test activity a Type 3B CR ALLOWS CONTINUED OPERATION of the nonconforming ite l The program requires System Engineering, Nuclear Engineering, or
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Nuclear Fuels to provice a technical evaluation.and justification for- o L types 2 and 3 CRs. The inspectors determined - that a lower-tier i quality implementing procedure has not been developed: to provide !
- guidance for performing this function. Additionally, in response -to ,
L the inspectors question, concerning the extent to which Syste ['
] Engineers rform reviews and evaluations of design basis documents, t
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i licensee management stated that SDSP 27.6 will define the limited ,
design scope of this group. This procedure was in draf t form at the !
time of the inspection and was not reviewed by the inspector The inspectors reviewed 11 Conditional Release Requests that were outstanding at the time of the inspection. . Based on the small number i the program appears to be well controlled. Requirements for the' .t Shift Dperations Supervisor and PDRC to review types 2, 3A,-and 3B ;
CRs established appropriate checks and' balances which provides.
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assurance that action will be completed from a u nuclear safety J standpoint. Review of the ' Conditional Release Requests revealed, !
'however, that the process is more directed towards providing a basis ,
for using the' nonconforming hardware. -The process does not (1) first: ;
assure the public health and safety and (2) then make provision for
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successfully restoring the plant to on acceptable level of quality.-
The inspectors concluded that requirements for' performing a nuclear "
safety evaluation relative to the CR and use of nonconforming items :
have not been established. . Also, CRs may be used during any mode of' ;
unit operation with no specified time limit for completir.g the 1 corrective actions. The above programmatic weaknesses were discussed l with licensae managemen Licensee management concurred with the inspectors observations and . '
stated that appropriate administrative controls will be established to address the identified weaknesses,
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- ACP for Drawing Discrepancies The inspectors reviewed objective evidence and conducted interviews.' l with licensee's engineering. personnel to assess the effectiveness of l the DD program. Additionally, licensee's commitment to the L'RC
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concerning closure of DDs open against Unit '2 was ' reviewed and .i discussed. The following' references were used during this effor .;
J (1) PI 87-70, Process ig' Drawing Discrepancies,: Revisio g (ii) SDSP 9.1, Processing Potential Drawing Discrepancie j
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(iii)STD 3.1.10, Trend Analysis, Revision 0; (iv) Drawing Discrepancy Daily-Progress Report (Selected samples for 1 July 1990) '
Based on. review of the above documents the inspectors concluded .
that the DD program has not been effective. in resolving drawing "
discrepancie The total number of DDs remaining to be processed is j still-unacceptably high. This number was 1960 as ofL July 12, 1990_ 1 Additionally, the licensee has not been closing 'DDs open against ;
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Unit 2 in accordance with its NRC commitment. A Notice of Deviation was recently written against the licensee. for failing to meet this commitment and is documented in NRC-Report 50-259,50-260.50-296/90-1 I
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Review of SDSP.9.1 revealed a recent change to the DD program _The new program uses the PDD form to document and initiate corrective !
action for apparent discrepancies in the as-built plant configuration-and the drawings which document the as-built plant. Primary respon-
'sibility has been assigned to the System Engineer for resolution o DDs. Procedure STD 3.1.10 establishes requirements'for; trending DD !
At the time of the inspection this program requirement was not being ,
implemente However, . actions are in progress _to, develop this _
program capabilit j An assessment of the effectiveness;of the revised DD program cannot- ,
be made at this time. . The program' requires time'to.be implemented and to demonstrate is effectiveness via Trend Charts and a reduction-- .r in number of the outstanding drawings still to be processe : Timeliness of Corrective Actions -l Statistics revealed that Nuclear Engineering has been one of the E major contributor for delinquent corrective - action Since the i establishment of mandatory Saturday morning meetings, for- t organization managers responsible for escalated CAQRs, there has,been [
a measurable improvement in the performance of this group. -Saturday morning meetings were initiated on March 17, 1990, with the expressed !
purpose of assigning ownership and. accountability for resolving CAQRs i
- that had late action items. The , monthly QA Level 2 Trend Report shows Nuclear Engineering having 62 percent and 66 percent CAQR delinquent actions in January and February;'1990, The delinquent rate fell to 49 percent in March and has continued to i trend lower with delinquent rates of 36 percent and.24 percent in i April and May respectively. Data for the trend report compiled on ;
July 11,1990, shows a delinquent rate of 25 percent. - Additional- f information on SQ trending effectiveness is addressed in paragraph 9 _
of the repor i Followup on Previous Inspection Items
' (Closed) IFI 50-259,296/84-49-02, Modification 'to the RPS Power :
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. Supply Monitoring System !
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l This item involved an inconsistency between RPS M-G Set surveillanc I requirements of TS Section 4.1. The: item has been. closed:
for Unit 2 -in Inspection Report 50-259,260,296/89-61. . Work - has -;
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progressed for Units 1 and 3. TVA has submitted a TS change request '
to - the NRC dated, June 4,1990. The amendment proposes _ to revise j the RPS circuit protector trip level setpoints; for Unit 2 and: add- a surveillance requirement, containing the same setpoints for Units. I
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50-259,260,296/90-20-03, RPS Circuit Protector Trip Level Setpoints - }
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b. _(Closed) Temporary Instruction 2515n8, Inspection of Quality-Verification Function '
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Verification activities;of QA reguirements at a TVA nuclear-plant is- -
performed by a number of organizational entities. These are - Site i Quality, Quality Technical Support, Quality - Control' and' Of f-sitc :!
Quality. Since the concept of performance-based techniques has' been-introduced, , these organizations have .made the; change to utilizing ;
these methods in conducting their audits. One recent example.of this- -
technique _is Audit No - BFA 90017.- dated May 16. 1990.- This report i was reviewed by the inspector and foundito: fulfill the expectations >
of a performance-based' audit. _ Also, during discussions with' qualit ;
personnel it was noted that . they have adoptedz this type of i results-oriented program into their activitie ' Weaknesses Identified in Inspection Report 50-259,260,296/89-12- !
A number of weaknesses were -described in. Inspection Report 50-259,- ['
260,296/89-12 which was performed ' April:10, 1989, through ' May 12, 1989. BFN responded to each item soon after the1 report was issued
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I (August 16,1989). However, since that tue a, number of organizational r and QA programmatic changes have taken place. In some cases the !
' weaknesses are not germane or have been resolved. Each item is closed and is briefly discussed below. - The; items have been grouped by subject and the identifying number listed-1s;the TVA Control Number:
J (1) Procedures SLT 890930006, Procedure Intent Changed Without a Second Independent Revie l; QC verification of bolt torquing was not-don Instead, the !
craftsman performed the bolting without QC involve The bolts were subsequently -retorqued .in October 1988 with -QC-verification. The maintenance procedure, MMI-6, was revised in !
June 1989 to specifically : require QC verification for ~ bolting >
with or without a crows foot adapto .
SLT 890930009 The Large Number of Non-intent' Procedure Chang The large number of non-intent procedureEchanges indicates that- I the validation process is not working. In the past, non-intent :
changes were not well define As of October 29, 1989,.
procedure changes involving sequence of steps, setpoints,: torque l i
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non-intent change. The large number of changes were believed
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to result from the procedure upgrade program and re-labelling ,
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program of the control' room and other equipmen !
i SLT 890930010 Overdue Investigations for Out-of-Toleranc ]
Measuring and Test Equipment, j i
The' weakness was described as not neeting the. self-imposed :15 3 day deadline to investigate out-of-tolerance measuring and test o
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equipment.' A study;- conducted by TVA personnel, recommended a 30 day deadline as more reasonable and this was standardized for !
all TVA nuclear facilitie ;
Upon detection of an out-of-tolerance condition, an operability check is required immediately, this requirement has not been
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change The Management' Review Committee does not necessarily ;
investigate these as they may be processed by; an accepted 1 administration control progra j (2) Operations' !
SLT 890930015 Shift Supervisor Knowledge' of Activities. Within:
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The weakness stated deals with the degree of knowledge that the Shift Supervisor has of on going activities. This'is a'subjec-' i tive area. The Shift Supervisor ~ participates in the plan-of-- 1 the-day meeting, evening ' craft turnover meeting, and a- !
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maintenance and modification . coordination meeting. He -is involved in scheduling work to ensure compliance with Technical ,
Specification. Since this finding was identified, changes have .'!
l- been made ' to the . operations organization. A> Shift Support Supervision position was created. This change 'has: resulted in :
increased involvement ofi the Shift. Operations.- Supervisor -in i operational activitie His involvement intwork activities !
I appears adequate and is not burdeneo with trivial detail i SLT 890930018 Compensatory Measures Program,-. ;
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A weakness was noted whereby the operators.did not understand l o the compensatory measures program. L Also noted, ' was that all !
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applicable procedures had. not been revised- to reflect the
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compensatory' measure i At the time these findings. were observed, the licensee was establishing the compensatory ,
, measures program and had a procedures- improvement programL 4 L
underwa Follow up on this matter revealed that procedur SDSP 12.11 has been revised to provide a list- of special-requirements and compensatory measures. Operation personnel were trained on this matter on December 6,198 ;
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SLT 890930004 Backlog of Preventive Maintenance.- k The maintenance _ organization has cddressed the backlog of !
preventive maintenance items. Since July 1989. the backlog has l been reduced from -664 to 71. items as of September 1989.- A- '
further reduction to 50 items was noted on October 1989. This *
j downward trend indicates that'this weakness is under contro ;
f (4) Site Licensin , j SLT 890930001 Packages Submitted for Closure Was not Read !
A review indicated that closure packages submitted _ to the NRC j were not complete or technically adequate. To resolve' thi l weakness. -a meeting was held between NRC and TVA in . September ~ !
1989. Changes in the closure process were agreed upon and since t these changes went into effect, none of the packages submitted- ;
have been rejecte (5) Site Quality ,
SLT 890930012 Site Quality Involvement in the Reso1'ution. of
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Personnel Errors is Mainly Statistical-. j Responsibility for resolving personnel errors lies with the j
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plant Superintendents. Site quality - provides reports and ,
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statistical data for others to use in correcting personnel errors. QA is not responsible for effecting or administrating .I
. actions for this problem' are ,
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l (6) Corrective Action SLT 890930002 Site Quality Assurance Activities in Support of a s QVI,
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' The site Quality Assurance staff performed an audit using the QVI format'., The inspectors' review of this audit revealed that root cat.se determinations were not performed and the impact on j
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future plant operations was not assessed,
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The QVI effort was repeated by TVA during the period of April 17 through May 5, 1989.- The NRC: agreed that the second look wa !*
adequat SLT 890930003 Corrective Actions Not Promptly; Identified. .
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This weakness dealt with valve 2-FCV-74-6 The valve was inadvertently electrically backseated in . March 198 'A-maintenance request was written to-inspect the valve;for damag ;
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The valve failed to open and repairs were completed by April- 8, 1989. A failure investigation report was initiated on April 10, 1989, to determine the root cause The actions taken and the chronology appear reasonabl SLT 890930005 Weaknesses Identified Root Cause Determinations and Input _to NPRD Formal training has been provided to engineers and managers to-
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improve;their ability to analyze failed components and to arrive at the proper root causes. An engineer reviews the. data prior to submittal into NPRDS. These - changes . should improve the information submitted-to INPO and correct this weaknes It was observed _that 'several plant events associated with Temporary Alteration Control were caused'by weak implementation
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of plant ' work activities which ' in turn was due to weak management control. : Since that ' time,. management controis- have'
been strengthened in that- corrective actions using a variety of administration control procedures have_been formalize SLT 890930008 Surveillance Upgrade Progra The weaknesses with the BFN surveillance program are. discussed in inspection report 50-259,260,296/89-43. A Notice- of .-Viola-tion regarding this matter was issued March 2,: 1990. Followup on this matter will be conducted by'the resident inspector.--
SLT 890930011 Test Deficiency Not Dispositioned:as a Conctition Adverse to Qualit The weakness was that a test deficiency was Ldispositioned without proper management attention. The decision as to whether-a test deficiency should be a CAQ or processed as.an administra-tive control procedure is related to safety significance.. In this example, the inspector did not agree with TVA's decision,
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yet the outcome- is essentially the same. The : discrepancy was i- reviewed and ultimately correcte SLT 890930013 Inadequate Root Cause for LER'296/88-0 The root cause identified in LER 296/88-07.was determined to be an untimely implementation of drawing corrections. The inspector believed that the problem was generic and. a program-matic deficiency. TVA agreed and this.-was discussed in- the analysis of the event.
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I Since this inspection finding was identified, the processing of I drawing discrepancies has been revised several times. The issue ,
has been assigned a new tracking number and is currently being reviewed and tracked by the resident inspector j I
SLT 890930014 Standby Gas Treatment Inlet Damper Stroke Time !
The inspector had questioned the' corrective actions' when the inlet damper failed to. meet a stroke- time stated in the FSA !
BFN prepared a safety evaluation to evaluate the effects of the j damper stroke time. TVA-decided to revise the FSAR with more :
general statemerits.to satisfy the requirements of Design !
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Criteria 2-BFN-50-7065 and 2-BFN-50-7064C, This change ~has been !
submitted in June 1989, and the matter is. resolve ~;
SLT 890930017 Personnel Error l A Review of about 50 LERs revealed that many were the result of !
personnel errors and management control' of personnel errors t
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appeared to be lacking. Since the report was issued, BFN has .
placed increased attention on human performance. . Personnel errors are inonitored and each department has established a zero: error "
goal. The efforts appears to be worki.ng 'since- the: number, of :
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personnel errors reported is decreasing.
- 1 Exit Interview '
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The inspection scope and results were summarized on: July 13, 1990, with those persons indicated in paragraph 1. The , inspectors described;the' -!
areas inspected and discussed -in. detail the inspection results liste t below, proprietary information is- not contained in'~ this repor Dissenting comments were not received:from,the licensee.-
Licensee management was informed that- the followingJitems? have been j close :
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IFI 50-259,296/84-49-02, Modification to the RPS.' Power Suppl
IFI 50-259,260,296/90-20-01 Completion of Action Identified to t satisfy STD 3.1.10 Trend analysis, paragraph .
IFI 50-259,260,296/90-20-02, Site Quality Corrective Action Program Overview, paragraph ;
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IFI 50-259,260,296/90-20-03, RPS L. Circuit Protector . Trip, Level-Setpoints and Survie11ance, paragraph 9.-
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I 11._ Acronyms and Initialisms
ACP Administrative Control Progpa j BFN Browns Ferry Nuclear (station)
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j CAQ- Conditions Adverse to Quality i CAQR Conditions Adverse lto Quality Report COTS Correct on-the-Spo !
CR Conditional Release l DCN Design Change Noticer DD- Drawing Discrepancies ;
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DG- Diesel Generator ,
DNE' Division of Nuclear Engineering ECN Engineering Change Notice .
ESF Engineered Safety Features t FSAR Final Safety Analysist Report '
IFI Inspector Followup Item L IIR Incident Investigation Report-- l INPO Institute of Nuclear Power Operations !
IR Incident Report LER Licensee Event Report i MRC Management Review Committee '
MR Maintenance Request .
M&TE Measuring and Test Equipment-NPROS Nuclear Performance, Reliability Data System' ;
NQAM Nuclear Quality Assurance Manual 1 NQA Nuclear Quality Assurance Plan ;
PORC Plant Operations. Review Committee :
PRD Problem Reporting Documant QA Quality Assurance *
OVI Quality Verification Inspection- t RIR- -Radio 11 cal Investigation Report i RPS Reactor Protection System :l SGTS Standby Gas Treatment System SI Surveillance Instructor' <
SOS Shif t Operations Supervisor .
SPOC System Preoperational Check List' .
SQ Site Quality-(organization)'
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ATTACHMENT 1 -
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CORRECTIVE ACTION PROGRAM UNDEP. THE NOAM "9EFORE" 1 -5
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Ps pONST 7 7 7 OPS h0NST C/A PROGRAMS '
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4 * CORRECTIVE ACTION PROGRAM UNDER NQAP "AFTER" ,.
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- STANDARDIZATION OF PROGRAMS
- ENHANCED COMMUNICATIONS AND PROBLEM RESOLUTION THRU COMMON PROGRAMS
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- BETWEEN ORGANIZATIONS
- BETWEEN SITES l * TRENDING ABILITY ON BROADER SCALE
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