IR 05000295/1986005

Insp Repts 50-295/86-05 & 50-304/86-05 on 860215-0414. Violation Noted:Surveillance for Reactor Coolant Iodine Following 15% Power Change Missed & No Corrective Action Taken

ML20210U557
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	05/28/1986
From:	Burgess B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20210U548	List: IR 05000295/1986005 ML20210U544 ML20210U551
References
50-295-86-05, 50-295-86-5, 50-304-86-05, 50-304-86-5, NUDOCS 8606030018
Download: ML20210U557 (23)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Reports No. 50-295/86005(DRP); 50-304/86005(DRP)

Docket Nos. 50-295; 50-304 Licenses No. DPR-39; DPR-48 Licensee: Commonwealth Edison Company P. O. Box 767 Chicago, IL 60690 Facility Name: Zion Nuclear Power Station, Units 1 and 2 Inspection At: Zion, IL Inspection Conducted: February 15 through April 14, 1986 Inspectors: M. M. Holzmer L. E. Kanter J. N. Kish Approved By:

F B. L. Burgess, Chief 28/86 Reactor Projects Section 2A Date Inspection Summary Inspection on February 15 through April 14, 1986 (Reports No. 50-295/86005(DRP);

50-304/86005(DRP))

Areas Inspected: Routine, unannounced resident inspection of licensee action on previous inspection findings; gaseous releases; operation in an unanalyzed condition for negative flux rate reactor trip (NFRT) protection; reactor trip on NFRT during surveillance testing; unusual event caused by two of three diesel generators inoperable; automatic start of 0 diesel generator during surveillance testing; innoerability of IC containment spray pump; reactor trip breaker response time tesir.i:V, reactor trip due to reactor trip breaker not

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fully racked in following testing; failure to obtain iodine sample in the time allowed by Technical Specifications; surveillance; maintenance; LER; operational safety verification and engineered safety feature walkdown; and training. In addition, an enforcement conference was held on March 31, 1986 regarding the inoperability of the IB auxiliary feedwater pump from December 21, 1985, to January 12, 198 Results: Of the 16 areas inspected, no violations or deviations were identified in 15 areas, and one violaticn was identified in the remaining area (failure to take adequate corrective action to prevent recurrence of a condition adverse to quality - Paragraph 13).

8606030018 860529 PDR ADOCK 05000295 O PDR c.,=--_:-..-- - - - . - . - . - . - . . . - - - - . . . --.

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l DETAILS

1 Persons Contacted

• Plial, Station Manager '

,* Fuerst, Superintendent, P.roduction

• T. Rieck, Superintendent, Services-1 W. Kurth, Assistant Station Superintendent, Operations R.' Johnson, Assistant Station Superintendent, Maintenance

L. Pruett, Unit 1 Operating Engineer

• J. Gilmore, Assistant Superintendent, Planning N. Valos', Unit 2 Operating Enginee'r,

• R. Budowle, Assistant Superintendent, Technical Services i

• M. Carnahan, Training Supervisor-  !

• R. Cascarano, Technical Staff Supervi.sor-

, A. Ockert, Assistant Technical Staff Supervisor ,

'*C. Schultz, Regulatory Assurance Administrator l R. Aker, Station Health Physicist

• J. Ballard,_ Quality Control Supervisor

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W. Stone, Quality Assurance Supervisor D. McHenamin, Quality Assurance Engineer

• G. Trzyna, Radiation Chemi.stry Supervisor

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• F. Woodin, Industrial Relations Supervisor

• J. Rappeport, Quality Assurahce Engineer

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• Indicates persons present at ex-it intervie r Summary of Operatioras ,

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Unit 1 5 The unit operated at power levels up to 1G0% until Merch 11, 1986 when the unit tripped from full pcwer at 3:45 p.n:. as a result of the 1B ,

Reactor Trip Breaker (RTB) not being properly racked into p' lace. See

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Paragraph 12 of this report for further details of this even On

March 16 at 7

27 p.m. the Unit vent critical and on March 17 at 7:52 the unit was-tied to the grid. The unft operated at power le s is up to

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100% for the remainder of the inspection period.

Unit 2

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The unit operated at pcwer icvels up to IM% until 4proximstely 2:30 on February 28, 1986 when the unit was ragoed down and taken off line to perform the overspeed trip vibration test on the newly 'instaned Brown-

Boveri low pressure ; steam turbir.e. Gn March 2,1986 the un'it was tied .

to the grid and power was increased to full pover. The unit operated at !

full power for the next 23 day On March 24, the unit tripped from full power during reactor protect $on system testing. See Paragraph 7 of this report for further details on

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this event. The unit went critical at 4:05 a.m. on March 25 and was tied to the grid at approximately 10:50 p.m. The unit operated at power levels-up to 100% for the remainder of the inspection perio No violati.ons or deviations'were identifie . Licensee Action On Previous Inspection Findings _

(Closed) 'Open Item (295/85042-05): Failure of Lake Discharge Tank Isola-tion Valve to Close on High Radiation Alarm. This item was considered open pending investigation by the licensee concerning the operability of the solenoid nperator for the lakt discharge tank radiation monitor. A work request was initiated to verify the operability of the solenoid operator associated with the valve. This was believed to be a possible source of potential failure. However, investigation by Electrical Mainteraance shop personnel showed the valve operator to be functioning correctl The failure of the radiation monitor was attributed to a failed detector tube as described in LER 295/85037-01-L (see Paragraph 16 of this' report).

(Closed) Open Item (304/85029-05): Automatic Closure of Blowdown Containment Isolation Valves. At the request of the NRC resident inspector, LER 304/85013 was resubmitted to address the cause of tha ESF actuation. The revision of the LER was reviewed and found to be adequat (C1csed) Unresolved Item (304/85032-01): Inadequate Documentation of Environmentally Qualified (EQ) Motor Operator Valve (MOV) Wirin This unresolved item originated as a report to the NRC pursuant to the requirements of 10 CFR Part 21, and was the subject of LER's 3C4/85-18 and 304/85-18 (Revision 01). A foll6wup inspection i (295/85041 and 304/85042) by KRC flegion III inspectors examined the safety and reporting aspects of the vnqualified wiring in safety-related MOV's and no violation or deviations were identified. This item is considered close Ne violations or deviations were identified.

, Station Management Change _g The following personnel changes were effective en April 7, IS86:

J. Gilmore - From Unit 2 Operating Engineer to Assistant Superintendent, Plannin N. Valos - From Assist.3nt to the Operating Etgineer to Unit 2 Operating Enginee There has been a high rate of turnover in the upper and middle levels of station management in the past year, due priinarily to a company-wide reorganization of management at all nuclear generating staticas in March 1965 and to the promotion of the previcus Station Manager in September :

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1985. As a result, there are approximately 12 positions of upper and middle level station management, including the Station Manager for which the current persons have been in their new positions for approximately

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seven months or less. There are an additional 14 positions of upper and middle management for which the current persons have been in their new positions between seven and 14 month The resident, inspector discussed this condition with the Station Manager and stated that,.while the individuals in question have each spent many years at the Zion Station in positions of responsibility and have performed well, the large number of changes might be disruptive to the overall flow of work at the station while the incumbents become ,

accustomed,to their new duties and working relationships. The resident inspector also noted that there could.be an adverse impact on personnel in. lower level positions at the station while becoming used to new supervisors. The resident inspector suggested that in the near to mid future changes.in management positions be phased in gradually to prevent potential adverse effects. The licensee acknowledged the resident inspector's comments and agreed to consider them. This is considered an Open. Item (295/86005-01; 304/86005-01). The stability of the station .

management will be reassessed in approximately six month No violations or deviations were identified. One Open Item was identifie . February 16, and March 19, 1986 Unplanned Gaseous Releases I

! On February 16, 1986, the Zion Station experienced an unplanned gaseous release at 5:25 p.m. while making up to the Refueling Water Storage Tank (RWST) on Unit 1. The release was caused by a missed step in Station.

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Operating Instruction (SOI) 2, which required that 1FCV-VC1118 be

- verified closed during makeup to the Unit 1 RWST. At the time, IFCV-VC111B, which is normally closed, was open causing the volume control (VC) letdown to flow into the RWST instead of to the suction of

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- the charging pump It is not yet known why 1FCV-VC111B was open. The operator was counselled by the Shift Supervisor regarding this inciden This will be considered an Unresolved Item pending determination of why

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the valve was open.

I' On March 19, 1986, another unplanned gaseous release occurred, at

approximetely 6:30 a.m., while making up to the Unit 1 Volume Control Tank (VCT). The release was caused by leakage through IVC 8119, (Relief

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. Valve on Letdown Heat Exchanger). A work request was written and the repair work included cleaning boric acid from the valve body and

, tightening the bonnet bolts. The licensee, however, is unable to locate o a deviation' report on this event. .This will be considered an Unresolved

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Item pending location of the deviation repor e

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In both cases Technical Specification limits were not exceede '

Both events will be considered as one Unresolved Item (295/86005-02). No

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deviations were identified.

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. Operation of Units 1 and 2 in an Unanalyzed Condition Due-to Incorrect Negative Flux Rate Reactor Trip Setpoints On February 21, 1986, at 2:54 p.m., the NRC was notified that the negative flux rate reactor -trip setpoints for both units were nonconservative for certain rod drop accidents. The nuclear instrumentation system (NIS) for Westinghouse pressurized-water reactors (PWRs) incorporates a negative flux rate reactor trip (NFRT) to prevent exceeding departure from nucleate boiling (DNB) conditions in the event of multiple dropped control rod The trip senses a preset change in NIS reactor power as a function of a given time constant, and provides an output to the reactor protection system. The licensee had been using a power change of -15% with a time constant of 5 seconds (-15%/5sec), while the Westinghouse analysis assumed the use of -5%/2se The licensee identified this discrepancy on February 21, 1986, while reviewing correspondence from Westinghouse regarding their Reactor Protection Setpoint Study (CWE-86-510). The licensee initiated'a Deviation Report (DVR) on this condition and implemented interim restrictions which provided that. rod control bank D height must be at_215 steps or greater when automatic rod control is used for power operation above 90% reactor powe On_ February 24, 1986, the licensee requested by telephone that Westinghouse determine whether it would be feasible to perform a safety analysis which would show no safety concern even if the NFRT were set at -15%/5sec. The licensee also asked that Westinghouse reexamine the use of their interim measures to assure that they were still acceptable (these measures had been used previously). Westinghouse responded later that day that the interim measures as used previously had already assumed

.that the NFRT had been set at -5%/2sec, and that they could not assure that DNB limits would not be exceeded in the event of multiple dropped rod After conversations with the NRC Region III office, the licensee declared the PFRT inoperable for Units 1 and 2 and initiated steps to obtain an emergency change to Technical Specification (TS) 2.1.1.C.6 and 2.1.1. and'to Table 3.1-1 to permit rescaling the instruments to -5%/2sec. The emergency TS change was granted by telephone the same day, and included a special allowance to continue power operations for 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in order to rescale the NFRTs. The TS change was confirmed in a letter dated March 10, 1986. The licensee completed the installation of the new setpoints on February 24, 198 This event resulted from a misunderstanding which occurred in 1979 of the requirements of the Westinghouse dropped rod analysis. The NRC Region III office met with the licensee on April 29, 1986, and the licensee provided a briefing on the circumstances which led up to this event. Operation in an unanalyzed condition as described herein is considered an Unresolved-Item pending the resolution of several items raised at the meeting with the licensee on April 29, 1986, and additional inspection if deemed appropriate (295/86005-03; 304/86005-02).

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l One Unresolved Item was identifie . March 24, 1986 Unit 2 Reactor Trip On High Negative Flux Rate During Testing

"On March 24, 1986, Unit 2 tripped from full power during reactor protection system (RPS) testing. Operators were performing concluding step 11X of Procedure PT-58, Reactor Protection Logic Tests, Reactor Normal, which requires that the instrument fuses to the source range nuclear instrumen-tation drawers, N-31 and N-32, be reinstalled. The operator performing the step reinstalled the fuses to channel N-31~, and about five seconds later he reinstalled the fuses to channel N-32. The trip occurred when the fuses to N-32 were reinstalled, and the first-out annunciator panel indicated that the reactor tripped on high negative flux rate. Following the trip, all safety systems functioned normally. . The feed breakers for nonessential bus 242 did not automatically transfer from the unit auxiliary transformer to the system auxiliary transformer. Since essential bus 247 is normally powered from bus 242, the resultant undervoltage caused the 0 diesel generator to automatically start and to provide power to bus 247 as designe Although the investigation into the cause of this event _is in progress, the licensee suspects that there may have been electrical noise or radio frequency noise which was picked up in the power range drawers. The two power range drawers which produced the NFRT were in the same channels as source range drawers N-31 and N-32. The NFRT occurs when two of the four power range NFRT bistables deenergize. In addition, the setpoint for the NFRT which had been lowered on February 24, 1986 as described in the

. proceeding paragraph may~have contributed to the trip. The licensee will submit an LER which will provide the results of their investigatio No violations or deviations were identifie . February 19, 1986, Unit 2 Unusual Event Caused By Diesel Generator (DG) -.

Failures i .On February 19, 1986, at-about 9:25 (CST) with the unit at full power, an Unusual Event (UE) was declared for Unit 2 in accordance with the

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Generating Stations Emergency Plan (GSEP) when the second of three DGs

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for operation (LCO) to be in the hot shutdown condition. The 2A, 2B, and 0 (shared or swing) DGs were being tested prior to removing the 2C containment spray pump from service to repair a minor jacket water pump leak on the 2C containment spray pump diesel. At 8:32 p.m. the 2A DG failed its performance test, PT-11, when it shut down without operator action shortly after starting. The 0 DG was imuediately tested, but l then shut down without' operator action at 9:17 p.m., a few seconds after

the equipment operator released the start switch. At 9:25 p.m., the UE was declared for Unit 2, and a ramp power reduction was initiated. The NRC was notified via the Emergency Notification System, and the resident inspector was informed. Other notifications were made as required.

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.With the 0 DG inoperable,_ Unit 1 was placed in a seven day LCO to be in hot shutdown in accordance with Technical Specification (TS) 3.15. Consequently, the 1A and IB DGs were tested immediately in accordance with the TS and successfully passed their PT-11 surveillance The cause of the 2A DG failure was identified to be valve 200-0081 found to be nearly fully close is a manual fuel oil isolation valve between the diesel fuel oil day tank and the engine. The valve is a plug type valve and can be closed by rotating the handle through 90 degrees of trave The valve was found to turn freely by hand. The engine failure was therefore attributed to insufficient delivery of fuel, starving the engine, and resulting in a low r.p.m. shutdown. To correct this condition, the licensee opened 200-008 At 11:50 p.m. the Unit 2 rampdown was terminated at 60% reactor power, after the 2A DG was successfully started and loaded to four megawatts (MW). At 12:30 a.m. on February 20, 1986, the PT-11 test of the 2A DG was successfully completed, and the GSEP UE was terminated. Units 1 and 2 remained in a seven day LC0 to be in the hot shutdown condition due to the inoperability of the 0 D On February 20, 1986, after troubleshooting the 0 DG failure to start, a PT-11 operability test was conducted. The test took place at 9:35 p.m.,

and the 0 DG tripped as before. In a Confirmatory Order dated February 29, 1980, the NRC required Commonwealth Edison to base the DG surveillance interval and the LCO allowable outage time for one inoperable DG on the number of DG test failures in the previous 100 valid start attempts. This failure of the 0 DG was classified as a valid failure and caused the allowable outage time for both units to decrease from seven days, as stated in the Zion TS, to 32 hours3.703704e-4 days <br />0.00889 hours <br />5.291005e-5 weeks <br />1.2176e-5 months <br /> as stated in the Order. The licensee reviewed the DG surveillance history for both units and determined that if the 1A and 18 DGs were tested a total of four more times that a failure of the 0 DG which occurred 96 starts ago would be dropped and the allowable outage time would increase to the TS value of seven days. Only one more start of the Unit 2 DGs was needed to drop the most distant 0 DG failure. As a result, PT-11 surveillance testing was conducted on both units until 9:30 p.m. on February 21, 1986, by which time both units had been restoted to a seven day LC The licensee continued to troubleshoot the cause of the 0 DG failure, and, despite the fact that the 0 DG passed severai subsequent test starts, the licensee continued to consider th: DG inoperable becatse the cause of the original failure remained unknown. On February 23, 1986, the licensee identified a faulty relay in the engine str t circuitry of the 0 DG. The relay was replaced, and the 0 DG was successfully tested by conducting a PT-11 surveillance. The 0 DG was declared operable and the LCO on both units was terminate Root Cause Analysis and Corrective' Action The failure of the 2A DG was attributed to the mispositioned valve 200-0081 starving the engine and causing a low r.p.m. shutdown. The licensee immediately opened the valve, and removed the handle which

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operates it to prevent inadvertent operation of the valve by bumpin The other four DGs were inspected to see if the same valve was in the correct position and to verify that either the handle was removed, or that it was attached in such a manner that inadvertent operation by being bumped would not be possible. The licensee failed to discuss the root cause and corrective action for this mispositioned valve in their LER 304/86-010, which discussed the cause of the O DG failure and the U At the request of the resident inspector, the licensee will resubmit LER 304/86-01 The failure of the 0 DG was attributed to the failure of the 4 MX rela The 4 MX relay " seals in" the start signal when the engine is started manually from the control room or the local DG engine panel. If the start signal is not " sealed in," the 4 MX1 relay deenergizes, causing the 20 5 relay to deenergize, which shuts down the engine. The 4 MX relay, Kurman Model No. 26D3C, was found to have one of the contact arms, which is actuated by the relay, slightly loose causing an intermittent misalignment of the contacts. The 4 MX relay was replaced for the 0 D No violations or deviations were identifie . February 28, 1986 Automatic Start Of The 0 DG During Surveillance Testing On February 28, 1986, while performing Engineered Safety Feature (ESF)

actuation testing, the 0 DG failed to start from ESF logic train B after having successfully started from ESF logic train A. Another test of the ESF logic train B start was conducted in the presence of the cognizant Technical Staff engineer, and the failure to start was repeated. About one minute later, with no switch manipulation, the 0 DG started, ran for approximately ten seconds, and tripped. This automatic actuation of an ESF was reported to the NRC pursuant to 10 CFR 50.72 and 10 CFR 50.7 The cause of the failures to start was attributed to open solder joints on the sockets of 11 pin type plug-in relays in the DG control circuitr These joints provided intermittent electrical contact for the affected relays. Following the identification of the bad solder joints, inspections were performed on the relay sockets for all five DGs. These inspections were perforn;ed on March 3,1986 and March 6,1986 for the Unit 1 and 2 DGs respectively. Following inspection of all five DGs, the licensee identified 15 out of 60 scckets which had one or more oeftctive solder joints. The defective sockets were resoldered, and the relay socket inspection will be added to the five year DG cvu haul procedur The licensee attributed the bad solder joints to flexing of the circuit boards to which the relay sockets are rounted. The flexing of the circuit' boards wac caused by excessive stress imposed by a retaining bar which holds the relays in the sockets. The flexing is thought to have prematurely deteriorated the solder joints. The additions to the five year overhaul procedure will include inspection of the solder joints

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as well as the tightness of the retaining bars. This will remain an Open Item pending completion of this procedure revision (295/86005-04;

304/86005-03).

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The inoperability of the 0 DG placed both units in a limiting condition for operation (LCO) which required both units to be in the hot shutdown condition in seven days. The licensee successfully tested the 1A, 2A, IB, and 2B DGs by performing PT-1 The 0 DG would have been capable of a manual star The unexpected start of the 0 DG was due to a sticky plunger on a slave safety injection actuation relay (SIX1-B). The SIX1-B relay, a Westinghouse BFD-84 model, was replaced, and the suspect relay was disassembled.and examine The sticky operation was apparently due to roughness and burs found in the plunger sleeve. The SIX1-B relay is a normally deenergized relay. Most BFD relays used in reactor protection and ESF logic circuitry are normally energized. All normally energized BFD relays were replaced for both units during the most recent unit outages. The SIX1-A relay was also inspected, and found to be functiona No violations or deviations were identifie One Open Item was identifie . February 24, 1986 Failure Of The IC Containment Spray Pump To Start On February 24, 1986, with Unit 1 at full power, the 1C containment spray (CS) pump failed to start following postmaintenance testin The IC CS pump is powered by direct drive from a diesel engine which is started by one of two cranking batteries. The No. I cranking battery had been replaced, and the pump was being tested in accordance with PT-6, " Containment Spray Tests and Checks," when it failed to star The IC CS pump was declared inoperable, placing Unit 1 in a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> limiting condition for operation (LCO). The cause of the failure to start was determined, and after testing, the IC CS pump was declared operable on February 26, 1986, prior to the expiration of the LC Investigation by the licensee identified two problems:

• The cable lug on the No. 2 cranking battery was loose, and

• The setpoint of dropout resistor R18 was incorrec The No. 2 battery cable lug was replaced and crimped using a calibrated crimping tool. The lugs of the remaining CS pump starting batteries for both units were also checked for tightnes The licensee has ordered a new type of battery lug, which will be impregnated with lead, which should eliminate the problem with looseness between the battery lug and the battery cabl The diesel start circuitry is designed to start the diesel from one of the two cranking batteries. The battery which is selected as the primary battery is alternately selected by means of a ratchet type switching device. In the event that the voltage for that battery is insufficient to start the diesel, the circuitry automatically selects the other battery to supply cranking power to start the diesel. The voltage at-which the circuitry automatically switches is determined by the setpoint

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of resistor R18. The No. I cranking battery had been selected as the primary starting battery, and, since the dropout voltage of R18 was too high, the voltage drop experienced upon the start attempt caused the automatic switchover to battery No. Because the No. 2 battery cable lug was loose, the IC CS pump did not start. R18 was adjusted and the IC CS pump successfully passed PT- A review of PT-6 revealed that when the CS diesel is started, it is assumed that the No. 2 battery is the primary source. The PT then directs that the No. I battery be manually selected and another start performed. As a result, if the No. I battery happens to be selected as the primary starting battery, the No. 2 battery does not get tested. In addition, the automatic switchover feature is not tested by PT-6. There is no Technical Specification (TS) requirement to conduct a test of the automatic switchover feature for the CS pump diesel cranking batterie In addition, there is no TS requirement to test each starting battery on a periodic basis. The licensee has initiated a change to PT-6 which will ensure that both starting batteries are tested when the TS testing of the CS pump is performed. When these tests are to be done, an operator will be observing the voltage and current indication for the batteries to ensure that premature switchover is detected if it occurs. This procedure revision will be tracked as an Open Item (295/86005-05; 304/86005-04).

No violations or deviations were identifie One Open Item was identifie . March 3, 1986 and March 31, 1986 Reactor Trip Breaker Response Times in Excess of 100 Milliseconds On March 3, 1986, while conducting reactor trip breaker (RTB) response time testing, the IB RTB tripped at 192 milliseconds (msec) which exceeded both the licensee's administrative requirement, 100 msec, and the vendor design specification, 167 msec. The RTB's are Westinghouse DB-50 breakers.

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Subsequent response time testing of the breaker on March 4, 1986, did show minor sluggish trip times of 115 and 116 msec on two out of about .

six retest Prior to the March 3 test, the 1B RTB response times were in the range of 88-95 mscc, The IB RTB was replaced with the 1A bypssc RT Four subsequ(nt response time tests were performed on the 1A bypass RTB with satisfactory result A Westinghouse representative was onsite March 7, 1986 and several tests of the IB RTB were performed by the licensee in his presence. The NRC senior resident inspector also witnessed portions of this testin The Westinghouse representative observed that there appeared to be no major problems with the breaker as indicated by the bench tests. The RTB trip times were in the range of 87 to 92 msec. The Westinghouse representative recommended lubrication of the operating mechanism of the RTB. (This is beyond the lubrication requirements of the licensee's preventive

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l maintenance procedure which was verified to conform to the Westinghouse guidelines for DB-50 RTB maintenance). The breaker was retested after l lubrication of the operating mechanism and the response time decreased

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by approximately 10 msec. The licensee intends to add the lubrication suggested by the Westinghouse representative to their maintenance procedur On March 31, 1986, while performing periodic test (PT) 5, Reactor Protection Logic Tests on Unit 1, the 1A RTB tripped at 178 msec which exceeded the licensee's administrative requirement. Two subsequent response tests of the undervoltage trip, both resulted in 78 msec trip times. Testing of the RTB shunt trip (which normally operates faster than the undervoltage coil) resulted in response times of 42, 142, 40, 42, 43, 41 and 41 msec. Later the same day the undervoltage trip was tested an additional ten times and the results were all within the expected range of 76-82 mse The 80 msec and 40 msec times were as expected, based on the licensee's past trending of RTB response time The licensee suspected that the process computer was randomly adding

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100 msec to the response time.

i At the request of the NRC, an independent calibrated timing device was utilized in testing the RTB on April 4, 1986. Commonwealth Edison representatives from the corporate office were onsite to assist in the licensee's troubleshooting of the 1A RTB and process computer. The test used the same points monitored by the Westinghouse Process compute Trip time results were in the range of 79-82 msec. Testing on the process computer which was independent of the RTBs reproduced timing errors, +100 msec, +200 msec and -100 mse Root Cause Analysis The licensee's analysis has identified the following problems:

• The process computer had a software problem which interfered with accurate determination of RTB trip times, and

• The procedure for maintenance of Westinghouse DB-50 RTBs, while meeting the Westinghouse guidelines, could be improved by adding several points of the operating mechanism to the list of points receiving lubricatio In addition, analysis by the NRC indicates that the test results obtained using the licensee's procedure for testing their RTBs, PT-5, were rendered invalid because of errors in the licensee's timing device (the process computer).

Corrective Action The licensee corrected the problem with the process computer by installation and testing of software change The licensee's maintenance Procedure E015-1, Reactor Trip Breaker Maintenance, will be revised to

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add several f-sints of the operating mechanism to the list of points to receive periodic lubrication. The revision to E015-1 will be tracked as an Open Item (295/86005-06; 304/86005-05).

Safety Significance The licensee's records of the 1A and IB RTB trip times over the past year indicate that there has been no gradual trend of increasing RTB trip time The investigation of possible process computer errors has also resulted in repeatable additions of small increments of time to plant events in a few random instance These 100 msec increments have been detected during testing of the 1A and IB RTBs and tests of the process computer independent of the RTBs. Tests of the 1A and 18 RTBs which were independent of the process computer sh1 "ose agreement to the usual PT-5 results obtained using the the proce 1 ;omputer. Only two instances of the IB RTB breaker times in excess of M msec were observed which indicated the need for lubrication of the -perating mechanism. Trip timing using 100 msec was selected by the licensee as a trending action level, and, to date, this action level appears to be adequate. Consequently, there appears to have been a problem with the process computer used for RTB timing, and the operation of the 1A and 1B RTBs appears to have been acceptabl Although the RTB appeared not to be the source of the sluggish trip times observed on March 31, 1986, the licensee needed to be prompted to conduct testing of the RTB independent of the process computer when the results of testing using the computer were questionabl No violations or deviations were identifie One Open Item was identifie ,

1 March 11, 1986 Reactor Trip Due To IB RTB Not Fully Racked In l

On March 10, 1986 the 1A RHR pump was removed from service to repair a bowed shaft, placing Unit 1 in a seven day limiting condition for l

operation (LCO). On March 11, 1986, the unit tripped from full power at 3:45 p.m. The'1B RTB had been racked in following testing and

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maintenance as described in Paragraph 11 above, and PT-5 was being performed to place the 1B RTB in service and open and rack out the IB RTB bypass breaker. The last step of PT-5 required racking out the j bypass breaker. The IB RTB had been improperly racked in, causing a cell switch to remain open. When the bypass breaker was tripped open, l

a turbine trip occurred followed by a reactor tri The RTB and all

other safety systems functioned as designe An NRC region-based inspector was dispatched to the site to assist in the followup of this event (see Inspection Report No. 50-295/86008(ORS) for further details).

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On the afternoon of March 12, the licensee called the NRC Region III

' office to explore the possibility of restarting Unit 1, even though the 1A RHR pump was still out of service. Technical Specification 3. requires that entry into an operating mode shall not be made unless the conditions of the Limiting Condition for Operation are met without reliance on Action Statements (unless otherwise excepted). Zion Technical Specification 3.8.3.C permits the licensee to startup following l

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t an inadvertent trip with one RHR pump out of service. Because Standard

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Technical Specifications do not contain an exception to TS 3.0.4 for RHR pumps, and because, at the time, the licensee was uncertain whether the 1A RHR pump could be restored prior to the end of the seven day LCO even if the unit were restarted, NRC Region III staff personnel expressed

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opposition to the idea of restarting the plant, even though it appeared

to be permitted by the Technical Specifications. The licensee chose to remain in hot stanoby until repairs to the 1A RHR pump were complet The RHR pump was declared operable on March 16, 1986 at 5:00 p.m., and on March 17 at 7:27 p.m. the unit was made critical. The unit was

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synchronized to the grid on March 17 at 7:52 No violations or deviations were identifie . Failure To Take A Reactor Coolant Iodine Sample In The Time Required By Technical Specifications On December 8, 1985, during startep of Unit 1 from a short outage, a

< reactor coolant sample for iodine analysis was not performed during

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the time interval required by Technical Specification (TS). TS Table 4,3.6-1 requires a sample to be taken between 2 and 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> following a 15% power change in a one hour period. The Shift control Room Engineer (SCRE) notified the Radiation Protection (RP) Foreman of the power change;

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however, the sample was drawn too early, approximately one half hour after the power chang >

The cause of the event was a misunderstanding between Station RP and operating personnel. Corrective action included a description of this event in the operators' required reading package. At the request of the NRC resident inspector, distribution was also made to RP personnel, and :

meetings were held with RP personnel emphasizing the time interval for iodine sampling as stated in TS Table 4.3.6-1. On March 2,1986, during startup of Unit 2 from a short outage, a reactor coolant sample for s iodine analysis was again not performed within the required TS time interval. The cause of the event was a cisuaderstanding by the RP Foreman of the time interval in which to obtain a reactor coolant sample.

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The corrective action proposed by the licensee will be a revision to [

PT-0, Surveillance Checks Lists and Periodic Tests, *e require the notification'of RP personnel of a power c*ange and time interval required *

for sampling and analysi CFR 50 Appendix B, Criterion XVI requires that measures shall be '

established to assure that the cause of the condition is determined, and corrective action is taken to preclude repetitio Failure to ensure adequate corrective action was taken to prevent recurrence is :

, considered a Violation (304/86005-06).

One violation and no deviations were identifie . Monthly Surveillance Observation The inspector observed Technical Specifications required surveillance testing on the reactor protection and containment spray systems and verified that testing was performed in accordance with adequate

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procedures, that test instrumentation was calibrated, that limiting -

conditions for operation were met, that removal and restoration of the affected components were accomplished, that test results conformed with Technical Specifications and procedure requirements and were reviewed by personnel other than the individual directing the test, and that any deficiencies identified during the testing were properly reviewed and resolved by appropriate management personne The inspector also witnessed or reviewed portions of the following test activities:

• PT-6 Containment Spray Tests and Checks

• PT-5 Reactor Protection Logic Tests, Reactor Normal

• PT-10 Safeguards Actuation Test Unit 2

• TSSP-16-86 Test for Timing Reactor Trip Breakers

• PT-14 Inoperable Equipment Surveillance Tests (Reviewed Unit 1, 2 and common unit for the month of February)

• * Appendix J-1 Normal and Reserve Off-site AC Power Shift Check Sheet

• * Appendix J-2 Onsite AC & DC Power Availability

• Reviewed Test of ACB Auto Transfer for Bus 242

• For associated PT-14's reviewe No violations or deviations were identifie . Monthly Maintenance Observation Station maintenance activities on safety-related systems and components listed below were observed or reviewed to ascertain whether they were conducted in accordance with approved procedures, regulatory guides industry codes or standards and in conformance with Technical Specifica-tion The following items were considered during this review: the limiting conditions for operation were met while components or systems were removed from service; approvals were obtained prior to initiating the work; activities were accomplished using approved procedures and were inspected as applicable; functional testing and/or calibrations were performed prior to returning components or systems to service; quality control records were maintained; activities were accomplished by qualified personnel; parts and materials used were properly certified; radiological controls were implemented; and fire prevention controls were implemente .

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Work requests were reviewed to determine status of outstanding jobs and to assure that priority is assigned to safety-related equipment maintenance which may affect system performanc The following maintenance activities were observed or reviewed:

• DB-50 Breaker Inspection for the 1B Reactor Trip Breaker .

• NI System Troubleshooting Followit)g Reactor Trip on Unit 1

• OB Fire' pump Overhaul

• Review of Selected National Fi're Protection' Association (NFPA) Codes Following completion of maintenance on improper installation of cables through fire dampers the inspector verified that this system had been returned to service properl No violations or deviations were identifie . Licensee Event Reports (LER) Followup Through direct observations, discussions with licensee personnel, and review of records, the following event reports were reviewed to determine that reportability requirements were fulfilled, immediate corrective action was accomplished, and corrective action to prevent recurrence had been accomplished in accordance with Technical Specifications. The LERs listed below are considered closed:

UNIT 1 LER N DESCRIPTION 85-037-01 Failure of Lake Discharge Tank Isolation Valve to Close on High Radiation Alarm 85-041 Incperable Delta Flux Annunciator 86-001 Auxiliary Feedwater Pump Inoperable Due to Service Water Valve Misalignment 86-002 OB Fire Pump Out of Service for Greater than Seven Days ,86-003 Failure to Identify Exempt Valve in Inservice Testing -

Program per ASME Code 86-004 Radiation Monitor Calibration Methodology Inconsistent with Technical Specification 4.1 Obstruction of Fire Damper in Cable Penetration Vault

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.86-010 Removed Aircraft Fire Damper on Cribhouse Ventilation Fan 86-019 1B Diesel Generator Aircraft Fire Damper Failed to Close UNIT 2 LER h DESCRIPTION 85-013-01 Automatic Closure of Blowdown Containment Isolation Valves85-018 Inadequate Documentation for Environmentally Qualified Valve Motor Operator Wiring 85-028 Loss of Decay Heat Removal Due to Residual Heat Remoyal ,

Pump Cavitation 86-002 Engineered Safety Feature Actuation of Unit 2 Auxiliary Feedwater Pumps86-003 Missed 14 Day Approval of Temporary Procedure Change 86-004 Engineered Safety Feature Actuation of 2MOV-VC8100 Due to Faulty Switch 86-005 Diesel Generator Auto Start Following Loss of Power to 4 KV Engineered Safety Features Bus86-006 Miswiring of Reactor Trip Switchgear During Modification 86-007 Reactor Trip Breakers Opening when Switching Inverter 211 Power Supplies86-008 Missed Surveillance for Reactor Coolant Iodine Following 15% Power Change Regarding LER 295/85-041, " Inoperable Delta Flux Annunciator," the licensee's corrective actions were reviewed and considered acceptabl This violation of Technical Specification 4.2.2.A.6 was identified by the licensee as a result of their new procedure to test process computer software, and there were no similar violations for which corrective actions were inadequate. This is considered a licensee identified violation and no citation will be issued (295/86005-07).

Regarding LER 295/86-001, inoperability of 18 auxiliary feedwater (AFW)

pump due to service water (SW) valve misalignment, the LER is considered closed. This event was described in Inspection Report 295/86002. An enforcement conference was held on' March 31, 1986, (see Paragraph 19 of this report) and a $25,000.00 civil penalty was proposed on April 15, 198 .

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Regsrding LER 295/86-003, " Failure to Identify Exempt Valve in Inservice Testing Program Per ASME Code," the licensee will be transmitting a station position to the NRC in the next submittal of the Inservice Testing (IST) Valve Program that the pressurizer power operated relief valve (PORV) bloch valves will be exempt from quarterly stroking requirements when closed for isolation purposes. Additional corrective action will include upgrading the IST program, and more frequent review of the Inservice Inspection (ISI) valve surveillances. This should be completed by May 1986. This will be considered an Open Item, pending review of the upgraded IST Valve Program (295/86005-08; 304/86005-07).

Regarding LER 295/86-004, " Radiation Monitor Calibration Methodology Inconsistent with Technical Specification 4.11.5," the LER will be closed. The calibration method specified in the TS requires "two known concentrations of radioactive liquids" be used to verify calibration; however, the original procedure utilized two solid sources. The solid sources served as secondary standards that were directly related to a primary liquid calibration performed in July 1979. This is a valid calibration method. Recalibration was done in February 1986 using two liquid sources of known concentratio Corrective action will include revision to the original instrument mechanic (IM) calibration procedure to include two liquid sources of known concentration. In addition, all the radiation monitor procedures will be reviewed to ensure compliance with the recently approved Radiological Environmental TS. The licensee identified this condition during a revision of the liquid radiation monitor calibration procedures f and a review of the liquid release TS 4.11.5. This is considered a licensee identified violation and no citation will be issued (295/86005-09).

Regarding LER's 295/86-006 and 295/86-010, " Obstruction of Fire Damper in Cable Penetration Vault," and " Removed Aircraft Fire Damper on Cribhouse Ventilation Fan," respectively, in both incidents the fire dampers were considered inoperable. In the first case, a cable was routed through the damper rendering it inoperable. Conversations with plant personnel indicate that in the past, the dampers have also been utilized as a passage for the spare source range nuclear instrumentation detector cabl In the second event, the outlet damper was removed for maintenance on the l fan; however, a temporary fire seal was not installed in place of the dampe These violations of Technical Specifications 3.21.6 A and B were identified by the licensee while performing periodic functional tests PT-227 and PT-210, Halon Fire Protection System and Aircraft Detection System Tests, respectively. Short term corrective action has included distribution of a memorandum to all station employees and contractors'

emphasizing the need to comply and be familiar with the Technical Specifications regarding penetration fire barriers. This is considered a licensee identified violation and no citation will be issued (295/86005-10). An Open Item will be issued pending the implementation of additional training on fire barriers, dampers and fire doors in the licensee's Nuclear Employee Training (NGET) course (295/86005-11).

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Regarding LER 304/86-006, "MisWiring of Reactor Trip Switchgear During Modification," this LER will be close The event was addressed in Inspection Reports No. 50-295/86002; No. 50-304/86002. It is currently an Open Item pending further inspection regarding the root cause. In addition, the licensee's analysis of the event will be reviewed in their supplemental repor Regarding LER 304/85-028, loss of decay heat removal due to residual heat

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removal (RHR) pump cavitation, this event was discussed in Inspection Report No. 50-304/85043, and two violations were issued. Further NRC action on this event will be taken, if needed, during followup of the licensee's response to those violations. This LER is close Regarding LER 304/86-002, the licensee corrected a problem with procedure ZED-3 (Zion Electrical Distribution Procedure) to alert operators that opening circuit breakers 11 or 13 in distribution cabinet 213 or 113 will result in automatic starting of auxiliary feedwater pumps. Additional review by the resident inspectors revealed that not all portions of large procedures, such as ZED's, receive 1 year periodic reviews. The licensee intends to correct this problem in a future revision to the Zion Administrative Procedures (ZAPS). Revision of ZAPS to improve four year reviews is considered an Open Item (295/86005-12; 304/86005-08).

Regarding LER 304/86-003, " Missed 14 Day Approval of Temporary Procedure Change," the LER will be closed. In 1985, there were three cases documen-ted on Unit 1, involving departments other than the Electrical Maintenance department, where the 14 day procedure change review requirements were misse Only one of the three occurrences, LER 295/85-34, was similar in nature to the current cas To prevent recurrence, the station is reviewing the administrative controls on temporary procedure change review. Corrective action will include revisions to the Zion Administrative Procedure (ZAP), 5-51-4, Procedure Control and Approval, and the signature form, Attachment B-1 to the ZAP, Administrative Change Request Master Log Index. On April 3, 1986, the revision package was submitted for onsite review, with the date of completion projected for May 1, 1986. This will be considered ar. Open Item pending review of completed package (304/86005-09).

Regarding LER 304/86-008, " Missed Surveillance for Reactor Coolant Iodine Following 15% Power Change," a violation is being issued for this event, (see Paragraph 13 of this report). This LER will be close Three licensee identified violations and no deviations were icentifie Four open items were identified.

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17. Operational Safety Verification and Engineered Safety Features System Walkdown

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l The inspectors observed control room operations, reviewed applicable logs and conducted discussions with control room operators from February 15

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through April 11, 1986. During these discussions and observations, the l

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inspectors ascertained that the operators were alert, fully cognizant of plant conditions, attentive to changes in those conditions, and took prompt action when appropriate. The inspectors verified the operability of selected emergency systems, reviewed tagout records and verified proper return to service of affected components. Tours of the auxiliary cribhouse, and turbine buildings were conducted to observe plant equipment conditions, including potential fire hazards, fluid leaks, and excessive vibrations and to verify that work requests had been initiated for equipment in need of maintenanc The inspectors observed plant housekeeping / cleanliness conditions and verified implementation of radiation protection controls. From February 15 to April 11, 1986, the inspectors walked down the accessible portions of the auxiliary feedwater, component cooling and service water systems to verify operability. The inspectors also witnessed portions of the radioactive waste system controls associated with radwaste shipments and barrelin These reviews and observations were conducted to verify that facility operations were in conformance with the requirements established under Technical Specifications, 10 CFR, and administrative procedure No violations or deviations were identifie . Training and Qualification Effectiveness In order to assist the Commission in evaluating the INPO accreditation program, the most recent revision to the NRC's systematic assessment of licensee performance (SALP) manual chapter will include a new functional area, Training and Qualification Effectiveness. This area will be incorporated into the routine resident and region based inspection programs, addressing the effect of training on the performance of the licensee's staff and contractors. Inspection by resident inspectors will generally encompass training related deficiencies which contributed to plant event In several of the events that occurred during the reporting period, deficient training was observed as one of the contributing factor Three examples are noted belo Review of documentation and interviews with plant personnel on the failure to take a reactor coolant sample following a 15% power change within the required time interval revealed deficiencies in training on both Technical Specifications (TS) and procedures (see Paragraph 13 of this report).

The issues on inoperable fire dampers and aircraft fire dampers also oemonstrated weakness in TS training (see Paragraph 16 of this report).

Review of selective procedures and representctive records and interviews with the personnel indicated weaknesses in training for the event where the IB Reactor Trip Breaker (RTB) was not fully racked in (see Paragraph 12 of this report).

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In the' examples described above, deficiencies in specific areas of training were identified. The licensee has initiated steps to correct these weaknesses and will be implementing additional training. This is the first routine assessment of training as indicated by event related performanc The number of deficiencies is not considered to be indicative of normal licensee performance in training, but this area will be the subject of future trend evaluations by the resident inspector No violations or deviations were identifie .

19. March 31, 1986 Enforcement Conference Regarding Inopercbility Of The IB Auxiliary Feedwater Pump .

On March 31, 1986, an Enforcement Conference was held between members of the licensee's site and corporate staffs and the NRC Region III staff in the Region III offices in Glen Ellyn, Illinois. The meeting was held to '

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discuss the inoperability of the IB auxiliary feedwater (AFW) pump which occurred from December 21, 1985 through January 12, 1986. The details of this event are discussed in detail in Inspection Report No. 50-295/86002 and in LER 295/86-00 The licensee presented a detailed review of the event, followed by a root cause analysis and a summary of their corrective actions to prevent recurrence. The licensee stated that the event was a result of personnel errors and that no programmatic deficiencies existed, as indicated by the fact that the personnel errors appeared to be nonrepetitive. Corrective action for these errors was discussed in detai Mr. Davis, of Region III, asked several questions pertaining to the safety significance of this event. The licensee provided the results of their study of the Zion Probabilistic safety study (PSS) which were that ,

the increase in core melt frequency would be less than a factor of tw The licensee also pointed out that the AFW system is a 400% capacity system and the loss of the 1B AFW pump reduced the system capacity to .

300% (the 1A AFW pump is a 200% capacity pump, and the 1B and 1C pumps ,

have 100% capacity each). The NRC acknowledged that the safety significance of this event was relatively minor from the standpoint of increased risk, based on the information provided by the license .

Immediately following the discussion of the loss of IB AFW pump event, a second meeting took place in which the NRC commented to the licensee that there appeared to be an increase of plant events in the past three montns and that the NRC was concerned that an adverse performance trend was developing. Several of the events discussed in this report were cited as examples (see Paragraphs 6, 7, 8, and 12). The NRC noted that there did not appear to be a significant common root cause for all of these, except that they have occurred over a relatively short time. The licensee responded that they were also concerned about the recent performance .

history and stated that they would study the events mentioned for common root causes. The Statiun Manager, Mr. Plim1, also stated that he had discussed these facts with members of his staff alread '

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A list of the meeting attendees is provided as Attachment 1 to this repor No violations or deviations were identifie . Departure of Resident Inspector On March 14, 1986, Mr. J. N. Kish departed the Zion Station Resident Inspector's Office. Mr. Kish has resigned his position with the U. Nuclear Regulatory Ccmmissio . Open Items

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Open Items are matters which have been discussed with the licensee which will be reviewed further by the inspector and which involve some action

' on the part of the NRC or licensee or both. Eight Open Items disclosed during this inspection are discussed in Paragraphs 4, 9, 10, 11, and 1 . Unresolved Items Unresolved Items are matters about which more information is required in order to ascertain whether they are acceptable items, violations or deviations. Two Unresolved Items disclosed during this inspection are discussed in Paragraphs 5 and 6 of this repor . Licensee Identified Violations In accordance with 10 CFR Part 2,' Appendix C, General Statement of Policy and Procedure for NRC Enforcement Actions, the NRC will not generally issue a notice of violation for a violation.that meets all of the following tests: It was identified by the licensee; It fits in Severity Level IV or V; It was reported, if required: It was or will be corrected, including measures to prevent recurrence, within a reasonable time; and It was not a violation that could reasonably be expected to have been prevented by the licensee's corrective action for a previous violatio Three licensee identified violations disclosed in this inspection are discussed in Paragraph 16 of this report. '

2 Exit Interview ,

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The inspectors met with licensee representatives (denoted in' Paragraph 1)

' throughout the inspection period and at the conclusion of the inspection

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on April 14, 1986 to summarize the scope and findings of the inspection activities. The licensee acknowledged the inspectors' coaments. The inspectors also discussed the likely informational content of the inspection report with regard to documents or processes reviewed by the inspector during the inspection. The licensee did not identify any such documents or processes as proprietcry.

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E ATTACIMENT 1

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LIST OF ATTENDEES MARCH 31. T9ETNT5ETIEliTCONFERENCE

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Commonwealth Edison Company B. B. Stephenson, Division Vice President, Nuclear Stations Division R. J. Squires, Staff Engineer, Nuclear Safety Department W. P. Worden, Operations manager, Nuclear Stations Division W. Stone. Quality Assurance Supervisor, Zion Station C. J. Schultz, Regulatory Assurance Supervisor, Zion Station P..C. LeBlond, Nuclear Licensing Administrator, Zion i S. L. Trubatch, Staff Attorney C. Reed, Vice President, Nuclear Operations T. Rieck, Superintendent, Services, Zion Station W. Kurth, Assistant Superintendent, Operations, Zion Station ,

R. Cascarano, Technical Staff Supervisor, Zion Station _

D. Farrar, Nuclear Licensing Administrator L. F. Gerner, Regulatory Assurance Superintendent '

G. J. Plim1, Station Manager, Zion Station NRC Region III ,

A. B. Davis, Deputy Regional Administrator C. E. Norelius, Director, Division of Reactor Projects T. N. Tambling, Director, Enforcement and Investigatio'n Coordination Staff C. W. Hehl, Chief, Operations Branch E. R. Swansen, Acting Chief., Projects Section 2A M. M. Holzmer, Senior Resident Inspector, Zion Station ,

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