IR 05000295/1989015
| ML20247J106 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 07/24/1989 |
| From: | Hinds J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20247J097 | List: |
| References | |
| 50-295-89-15, 50-304-89-15, GL-83-28, NUDOCS 8907310238 | |
| Download: ML20247J106 (15) | |
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U U.S. NUCLEAR ~ REGULATORY COMMISSION
REGION III
Report Nos. 50-295/89015(DRP);50-304/89015(DRP)
Docket Nos.~50-295; 50-304 License Nos. 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
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Inspection Conducted: May 9 through June 29, 1989
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. Inspectors:
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M. M. Holzmer-R. M. Lerch J. D. Smith
'T. E. Taylor R. J. Leemon R. B. Landsman G. A. VanSickle C. D. Pederson P. L. Eng.
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Approved By:
J. M.
inds, Jr.,
"f M 24 Re or Projects Section 1A Date
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Inspection Summary
. Ins,pection from May 9, through June 29, 1989 (Report Nos. 50-295/89015(DRP);
50-304/89015(DRP))
hreas Inspected:
Routine, unannounced safety inspection by the residents and regional inspectors of licensee action on previous inspection findings; summary of operations;.May 8, unplanned gas release due to personnel error and June 24 loss of all Unit 2 Control Room annunciators, operational safety verification and engineered safety featum (ESF) system walkdown; surveillance observation; maintenance observation; licensee event reports (LERs); training; quality program effectiveness; TI 2515/93 and TI 2515/100.
..Results: Of the ten areas inspected, no violations or deviations were identified in 7 areas, and three violations were identified in the remaining areas.
(1. Failure to have procedures for sampling fuel oil, Paragraph 12; 2. Failure to establish meaningful corrective actions, Paragraphs 9; and 3.
Failure to control procedure resulting in an unplanned gas release, Paragraph 4).
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DETAILS
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Persons Contacted I
- T. Joyce. Station Manager l
W. Kurth,. Superintendent, Production T. Rieck,-Superintendent, Technical
- P. LeBlond, Assistant Station Superintendent. Operations R. Johnson, Assistant Station Superintendent, Maintenance J. Gilmore, Assistant' Station Superintendent, Planning R. Budowle, Assistant Station Superintendent, Technical Services u
N.,Valos, Unit 2 Operating Engineer M.-Carnahan, Unit 1 Operating Engineer E. Broccolo, Jr., Operating Engineer R. Cascarano, Technical Staff Supervisor A. Ockert, Training Supervisor T. Vandevoort, Quality Assurance Supervisor G. Kassner, Lead Health Physicist V. Williams, Station Health Physicist
- C Schultz.-Quality Control Supervisor
- W. Stone, Regulatory Assurance Supervisor
- T.- Saksefski, Regulatory Assurance W. T'Niemi, Master Mechanic A. Bless, Regulatory Assurance Engineer J. Yost, Quality Control Inspector K.-Depperscheidt, Master Electrician L. Simon, Maintenance Supervisor.
E. Campbell, Master Instrument Maintenance P. Pawlar, Electrical Engineer L. Sochen, Electrical Engineer J. La Fontaine, Assistant Superintendent, Work Planning E. Fuerst, Engineering G. Armstror.g. Shift Engineer K. Bennett, Shift Engineer U. 3rcyn, SMft Engineer T. Flowers, Shift Engineer N. Lucas, Shift Engineer M. Straka, Shift Engineer
- Indicates persons present at the exit interview.
2.
Licensee Actions on Previous inspection Findings :$2701, 92702)
c (Closed) Unresolved Item (304/86024-01): Review to determine whether the CommonwealthEdisonCompany(CECO)QualityAssurance(QA)programisin compliance with their commitment to ANSI N18.7-1972 regarding post-mod-fication testing.
The Nuclear Regulatory Comission (NRC) inspection program for Generic Letter (GL) 83-28, " Salem T1" addressed the adequacy of the licensee's post maintenance / modification testing program.
The GL 83-28 inspection activities for Zion Station are complete. This item is considered closed.
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(Closed)OpenItem(304/84026-03): Delta Flux Calculation Program Nonoperable. A new Delta Flux. Calculation Program was loaded and validated on both units on Novermber 14, 1985. The program incorporates a message to have the operator initiate a log of Delta-I whenever the flux difference alarm is inoperable. This item is considered closed.
(Closed) Violation (304/84012-05): Failure to accomplish activities affecting quality under suitably controlled conditions. Licensee's corrective actions included:
rewriting instrument maintenance procedures to more specifically fit the plant conditions for which they are used;.
and operating supervision was instructed to use proper procedure change formats, and not to authorize changes unless a thorough understanding is achieved.. Based on this corrective action, safety significance of the issue and the time since the violation was issued, this item is considered closed.
(Closed) Unresolved Item (295/87032-01; 304/87033-01):
NRC review of four deficiencies associated with testing of pressure isolation valves (PIVs). An enforcement conference was held in Region III on October 30, 1987 to clarify the circumstances associated with the four deficiencies.
As a result, a Notice of Violation (N0V) and Proposed Imposition of Civil Fenalty was issued to the licensee on January 4,1989. The NOV stated that the.four deficiencies, in the aggregate, was considered a Severity Level.III violation and imposed a $100,000 civil penalty on the licensee.
The unresolved item is considered closed.
(Closed) Violation (295/87032-03; 304/87033-03):
In the licensee's February 3,1988 response to the NOV discussed above, the licensee denied portions of the violation. On May 26, 1988, the Commission acknowledged receipt of the licensee's letter and reaffirmed the validity of the violations as originally defined.
The licensee paid the civil penalty on June 27, 1988. The inspector has reviewed the licensee revised test procedures for testing of Pressure Isolation Valves (PIVs) and found that the test procedures are technically valid.
Leak rates are currently being trended and some corrective actions, including replacement of some leaking valves, and training of the technical staff on conduct of testing has been completed.
Also, additional guidance on the technical review of procedures has been formalized and clarified, including the verification that test instrumentation' is properly calibrated and documented.
Corrective actions implemented thus far appear to La adequate.
This violation is considered closed.
Despite improvements in the testing of pIVs, Unit 2 continues to cperate
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with the safety injection (SI) discharge header pressurized. Licensee investigations indicate that at least one pair of PIV in the SI cold leg injection path is leaking.
Identification and elimination of the source 1.
of the leakage will be tracked as an Unresolved Item (304/89015-08).
(Closed) Unresolved Item (295/88005-02; 304/88006-02): Determination of cause for reactor trip on February 24, 1988. The licensee issued its
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evaluation of the subject reactor trip in LER 295/88005.
The LER was
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closed in inspection report 295/88016; however, this unresolved-item was inadvertently left open.
This item is considered closed.
(Closed) Violation (295/88012-03;304/88013-02): Failure to perform PT-2L as required. The inspector reviewed the licensee's corrective actions as defined in its August 5, 1988 response to the NOV. The inspector also reviewed a memo emphasizing the importance of proper documentation of tests. This violation is considered closed.
(Closed) Violation (295/88012-05; 304/88013-04):
Failure to accurately address PT-2L status in response to inspection report 295/87032; i
304/87033..The inspector reviewed the licensee's response to the NOV and noted that station personnel have been made aware of the importance of verifying that written responses to the NRC must be accurate. This item is considerecicksed.
(Closed) Unresolve Item (295/87032-02;304/87033-02):
Clarification of licensee interpretation for testing of PIVs. On November 13, 1937, the licensee submitted a proposed technical specification change which clarifies the testing frequency and acceptance criteria for PIV testing.
The Technical Specifications were revised accordingly on April 15, 1988.
This item is considered closed.
No violations or deviations were identified. One unresolved item was identified.
3.
Summary of Operations (71707)
Unit 1
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The unit operated at power levels up to 100% for the entire report period.
Unit 2 1he unit operated at power levels ups to 100% for the entire report
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period.
i No v'olations or deviations were identified.
4.
Unplanned Gas Release (93702)
On May 8, 1989, at 0700 hours0.0081 days <br />0.194 hours <br />0.00116 weeks <br />2.6635e-4 months <br />, Zion Unit I was at 99% power and Unit 2 was at 76% power. Operating radvaste personnel were preparing to fill i
the 1A mixed bed demineralized (MBD) with resin. The inlet and outlet valves, IVC 8524A and IVC 8522A, of the MBD were closed and tagged 00S.
The procedure in use was Procedure 501-70, " Demineralized Resin Removal."
By 0945 hours0.0109 days <br />0.263 hours <br />0.00156 weeks <br />3.595725e-4 months <br />, Radwaste personnel had performed S01-70 Steps 4.1.C.1 i
through 4.1.C.5, which call for verification of closed position for the MBD inlet and outlet valves, and the Spent Resin Storage Tank inlet valve, and opening of the MBD vent and drain valves.
Upon opening the MBD vent and drain valves, the Auxiliary (Aux) Building Vent Stack Monitor, ORE-0014, immediately alarmed high in the control room. At the same time, an apparent decrease in Unit 1 volume control tank (VCT) level was noted by the reactor operator.
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-By 0955, it was determined that the probable cause of the high alarm and i,
apparent VCT level decrease was leakage through the MBD inlet and outlet valves.
Immediate actions were taken in accordance with procedures
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A0P 1.1, " Excessive RCS Leakage" and A0P 5.1, "High Radiation Alarm."
l The MBD vent and drain valves were closed, OD Aux Building Exhaust fan and OB supply fan were secured to reduce ~the stack flow rate, and the
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Radiation Protection (RP) department was not ified to validate the alarm i
and quantify the release rate.
Radiation protection personnel validated the alarm and took local samples
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Gas samples were taken in the Unit 1 VCT room, cn the 617' elevation Aux Building general area, and on the 642'
elevation Aux Building level (in the vicinity of Monitor ORE-0014).
At 1100, addition samples were taken on the Aux Building Vent Monitors
- 1RT and 2RT-PR25, and on the particulate and iodine monitors for Aux Beilding flow, 10PR038 and 20PR038.
At 2004, Pipe Chase Radiation Monitor 1RT-PR07A alarmed high. The Aux Building was declared an exclusion area. Two radiation technicians (RTs) were contaminated by'the. noble gas which became trapped in their clothing. The RTs were given~whole body counts and were found to have no body burden..
By 1111, the RP department reported their estimate of the maximum offsite release rate-to tne licensed Shift Engineer (SE). Their calculations showed that the release rate had been, for a brief period (less than 10 minutes), above the level classified as a General Site Emergency Plan (GSEP) Alert condition, as defined in procedure EPIP 330-1, but had since decreased to the Unusual Event (UE) condition.
A'GSEP 'E was declared per EPIP 330-1. Nuclear Accident Reporting System U
(NARS) notification was initiated within the 15 minutes required by the EPIP procedure. Wisconsin Division of Emergency Government (WDEG) could not be reached initially over the fiARS line, and so station had to use an.outsido line. The transmission was received by WDEG at 1137. By 1145, all required Federal and State Agencies had been notifien.
In reporting the event, the station stated that the maximum instantaneous release rate had briefly exceeded the threshold for an Alert condition, but that the release rate had decreased and that the event was classified es an UE.
Shortly thereafter, the Lead Health Physicist (HP) reviewed the original release rate calculation. He noted that the calculated release rate
- seemed abnormally high, based on the maximum indication on monitor ORE-0014. 'It was discovered that the release rate calculation was in error, and that the actual release rate was never above the threshold for declaration of an UE.
It was also determined that no Technical
Specification limits or 10 CFR 20 release rate limits had been exceeded.
l Based on this determination, the UE was terminated at 1225. The appropriate State and Federal agencies were notified.
The State of Wisconsin acknowledged the event termination, and notified the plant at 1330 that they would be taking soil and vegetation samples at the state line.
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After tenninating the event, health physics personnel used an isotopic l
analysis of reactor coolant samples from that morning to recalculate the original release rate estimate. The revised release rate was quantified
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at 0.01% of 10 CFR 20 and Technical Specification (TS) limits for Iodine, and 4.67% of 10 CFR 20 and TS limits for Noble Gases. The total activity released during the event was 9.6 curies.
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l A second unplanned gas release occurred the next day as described below.
The second release does not, by itself, meet the criteria for a GSEP l
event. The second report was issued because of the heightened sensitivity following the May 8 GSEP event.
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On May 9, 1989 at 1700 hours0.0197 days <br />0.472 hours <br />0.00281 weeks <br />6.4685e-4 months <br />, Zion Unit I was at 98% power. The Operating department was preparing to return the IB MBD to service, following an unplanned gaseous effluent release on May 8.
The 1A MBD was
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out of service and empty. The 1A MBD inlet and outlet valves were closed and tagged 00S, and were known to be leaking after the May 8 event. To facilitate maintenance repairs on these valves, the 1A MBD vent and drain valves, IVC 8525A and IVC 8528A. were open and tagged 00S. The 1A and 1B MBDs were both isolated from the reactor coolant system (RCS) letdown by the Cation Bed Bypass valve IVC 8514 being in the closed position, and the 3-way Demin Bypass valve IVC-TCV129 being in the divert position.
At 1700, an operating Shift Foreman (SF) was sent, with an equipment
attendant (EA), to perform the partial clear on Out of Service 91-0924, in order to return the IB MBD to service.
Radio communication was established between the SF and the control room.
The partial clear required opening the Cation Bed Bypass valve, opening the IB MBD outlet valve, and closing the 1A MBD vent and drain valves.
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At 1700, the SF opened the Cation Bed Bypass valve and the IB MBD vent and drain valves. This established a path from RCS letdown to the 1A MBD, and out to the Aux Building Equipment Drain Tank (ABEDT), which eventually vents to the Aux Building Vent Stack.
This caused a decrease in VCT level and a small increase in activity as seen by Aux Building i
Vent Stack Monitor ORE-0014 (R-14).
At 1705, the SF contacted the control room and was told that all indications looked normal. The decrease in VCT level had been expected as a result of opening the 18 MBD outlet valve.
The control room was not aware at this time that the 1A MBD vent and drain valves were still open. The SF closed the 1A MBD vent and drain valves, per the partial citer. Cennirrer.tly, tne unit operator started charging, in order to regain VCT level.
The VCT level was observed to recover rapidly.
At 1715, the SF again contacted the control room, to report that. the
partial clear was done. At this time, the unit operator was not sure what was causing the rapid recovery in VCT level.
In order to return the
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unit to a known safe configuration, operating personnel decided to return all valves to the original Out of Service lineup. This meant closing the Cation Bed Bypass valve, closing the 18 MBD outlet valve, and opening the 1A MBD vent and drain valves. When the vent and drain valves were opened, Monitor R-14 alarmed high. This alarm was caused by the release of gasses from the draining (to the ABEDT) of RCS water which had been in the 1A MBD. Health Physics was called in to quantify the release
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rate. At 1920, the HP reported a maximum release rate of 6.19 E3 uci/sec.,
which is well below the TS and GSEP UE limits.
The release was apparently caused by a combination of inadequate job planning, inadequate communication, and lack of sequencing on the partial clearance. The two Senior Reactor Operators who independently verified the partial clearance sequence had read the night orders which delineated the required valve sequence prior to approving the clearance. The job planning did not include measures to ensure that the 1A MBD vent and
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drain valves were closed before unisolating the MBD.
Proper sequencing of the partial clear would have required the vent and drain valves to be clow t4fure ooening the Cation Bed Bypass and IB MBD outlet valves.
This~is considered a violation. (295/89015-01(DRP)); 304/89015-01(DRP))
5.
Loss of Unit 2 Control Room Annunciators (93702)
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At'1515 hours0.0175 days <br />0.421 hours <br />0.0025 weeks <br />5.764575e-4 months <br /> on June 24, 1989, power was lost to all Unit 2 Control Room annunciators (visual and audible alarms). Unit 2 was at 99% power and remained stable throughout the event. Unit I was at 98% power and was not affected. All other Unit 2 Control Room instrumentation was functioning properly.
The power loss occurred while the licensee was troubleshooting a ground on the electrical bus for the balance-of-plant (non-safety-related)
Licensee personnel then switched power for the control room annunciators from the normal power supply to the emergency power supply. With the power supply change, all power supply fuses for the annunciators blew. Tne licensee declared an Alert condition under its emergency plan.
The fuses were replaced and power to the annunciators was restored using the normal power supply. The licensee determined the fuses blew because of an incorrect wire connection in the emergency power supply circuitry.
The wiring error was corrected and power was restored from the emergency supply.
Following restoration of power to the annunciators, the Alert classification was terminated at 1550 hours0.0179 days <br />0.431 hours <br />0.00256 weeks <br />5.89775e-4 months <br />. The licensee replaced the normal power supply breaker for the annunciators since it was thought the breaker tripped due to a week spring.
The State of Illinois was notified of the Alert classification and was provided updated information. The licensee is pursuing the course of the reversed Emergency (DRP). Power Supply lead. This will remain an Unresolvea Item 304/89015-02 No violations or deviations were identified.
One unresolved item was identified.
6.
Operational Safety Verification and Engineered Safety Features System Walkdown (71707 & 71710)
The inspectors observed control room operations, reviewed applicable logs and conducted discussions with control room operators from May 9 through June 29, 1989. During these discussions and observations, the inspectors ascertained that the operators were cognizant of plant conditions,
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a 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 and turbine.
buildings were conducted to observe plant equipment' conditions,-including potential fire hazards,-fluid leaks, and excessive vibrations and to verify that maintenance requests had been initiated for equipment in need; of maintaance.
The inspectors by observation and direct' interview verified that selected physical -security activities were being implemented in accordance with the. station security plan.
The inspectors observed plant housekeeping / cleanliness conditions and verified implementation of radiation protection controls.
From May 9, 1989.to. June.29..1989, the. inspectors walked down the accessible portions of the Auxiliary Feedwater (AFW) system to verify operability.
The: inspectors also witnessed portions of the radioactive waste system.
controls associated with radwaste shipments and barreling.
These reviews and observations were conducted to verify that facility.
- operations were in conformance with the requirements established under Technical Specifications, 10 CFR, and administrative procedures.
-No violations or deviations were identified.
7.
Monthly Surveillance Observation (61726)
The inspector observed Technical Specifications required surveillance testing on the Auxiliary Feedwater and Reactor Protection systems and verified whether testing was performed in accordance with adequate procedures, whether test instrumentation was calibrated, whether limiting -
conditions for operation were met, whether removal and restoration of the-affected components were accomplished, whether test results conformed with technical specifications and procedure requirements and were reviewed.by personnel other than the individual directing.the test, and whether any deficiencies identified during the testing were properly reviewed and resolved by appropriate management personnel.
The inspector also witnessed portions of the following test activities:
Auxiliary Feedwater Systeni Performance lest 7A which resulted in the inadvertent start of the EC AFW pump. The cause of the pump start was due to persormel error. This event resulted in the identification of a nislabeled switch for the 2C AFW pump. The start /stop switch positions were reversed.
No violations or deviations were identified.
8.
Monthly Maintenance Observation (62703)
Station maintenance activities on safety related systems and components were observed or reviewed to ascertain whether they were conducted in accordance with approved procedures, regulatory guides industry codes or i
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standards and in conformance with Technical Specifications. Consideration was given to: the limiting conditions for operation while components or systems were removed from service; approvals prior to initiating the work; use of approved procedures; functional testing and/or calibrations prior to returning components or systems to service; quality control records; personnel qualifications and training; certification of parts and materials; radiological and fire prevention controls.
In addition, 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 performance.
Technical Specifications required surveillance testing on the Reactor Ventilation and Containment Isolation systems were reviewed or observed.
Consideration was given to: procedures; calibration of test instruments-tion; limiting conditions for operation during testing; removal and restoration of the affected components; whether test results conformed with technical specifications and procedure requirements; review of test results by personnel other than the individual directing the test; and correction of any deficiencies identified during the testing. PT-21,
" Reactor Coolant System Leakage Surveillance" was reviewed and no problems were noted.
The inspector observed the work activities and reviewed the Maintenance Work Request (MWR) for the removal of water in the oil of IB Diesel Generator. The MWR package was adequate and maintenance. The inspector found evidence of small (1/8 - 1/4 inch) tube rubbing caused by engine vibration.
The inspector informed the licensee and requested information regarding actions taken in response to IE Information Notice 89-07 which addresses tube failures from rubbing on diesel generators. This is considered an Open Item. (295/89015-03(DRP); 304/89015-03(DRP)).
No violations or deviations were identified. One open item was identified.
9.
Licensee Event Reports (LERs) Followup (92700)
Through direct observations, discussions with licensee personnel, and review of records, the following event reports were reviewed to determine that deportability 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 N0.
DESCRIPTION 88020 Service Water Strainer Backwash Isolation Valve Nonconservative Failure 88021 Inadvertent Autostart of 00 Component Cooling Pump 89001 OBN Service Water Area Vent Fan Aircraft Damper Found Failed Open
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89002 Turbine and Reactor Trip While Troubleshooting Safeguards Test Circuit 89004 Shutdown Due to Inoperable Control Rod Position Indication Due to Regulator Failure UNIT 2 LER NO.
DESCRIPTION 88002-01 Unit 2 Steam Generator Safeties Inoperable 88009 Reactor Trip Due to Low Vacuum Turbine Trip During IM Surveillance 88012 Important Safeguards Actuation Due to Poor Communications 88017 Inoperable Reactor Cavity Vent Fan 2A Due to a Procedure Deficiency 89001 Failure to Post a Continuous Firewatch Due to Personnel Error Regarding LER 304/88009, reactor trip caused on October 12, 1988, during an instrument calibration of the control room alarm switch for condenser low vacuum.- The pneumatic sensing line was disconnected which also caused a low vacuum indication at the Turbine Protection Block causing a main turbine trip resulting in a reactor trip from 94% power.
The cause was attributed to an inadequate procedure which failed to direct the isolation of the alarm switch prior to disconnection.
The inspector reviewed the procedure used and the revised procedure 2P-TSS.63LV, LER 304/86019 and violation 295/86023-01; 304/86022-01.
LER 304/86019 reported a reactor trip caused by an error in isolating a turbine impulse pressure transmitter by an instrument mechanic (IM).
The violation was issued November 4,1986 for an inadequate procedure.
The LER issued October 20, 1986, identified the root cause as personnel error; however, committed to review, clarification, and addition of double verification of isolation to similar procedures.
When procedure 2P-TSS.63LV was revised, the revision was initiated September 29, 1988 and issued December 26, 1988, and included the
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clarifications committed to in LER 304/88019 and described as needed in Inspection Report 295/86023-01; 304/86022-01.
It is noted that the equipment and procedures associated with both LERs are classified as balance of plant (00P) and as such are not safety-related; however, as the root cause of two reactor trips their ability to adversely effect reactor operations has been demonstrated.
l Regarding the October 12, 1988 reactor trip, LER 304/88009 identifies l
the root cause as an inadequate procedure. The corrective actions are reported as a continuation of the ongoing effort to upgrade the IM
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procedures as identified during use.
Failure to promptly complete corrective actions committed to in LER 304/86019 resulting in a reoccurrence of a similar event, as well as, failure to establish adequate corrective action in LER 304/88009 to preclude repetition are examples of violations of 10 CFR Part 50, Appendix B, Section XVI as implemented by the Commonwealth Edison Quality Assurance Manual, Section 16, which states that a corrective action system will be used to assure that deficiencies which might affect safe operations are promptly identified and corrected.
(295/89015-04(DRP); 304/89015-04(DRP)).
Regarding LER 304/88017, Reactor Cavity Vent Fan 2A running backwards, the apparent cause was attributed to personnel error and procedural weaknesses during the rebuilding of the fan breaker. Several deficiencies in the LER were identified. The Description and Analysis section did not provide enough information to provide a basis for the conclusion that there was no significant impact on safety.
It was not clear that the 2A fan run times given were for the 2A fan only and did not include the 28 fan, that the unit was in a refueling outage during the period of reverse operation, or how the statement that there were no abnormal temperature excursions determined.
In addition, the LER did not address post-maintenance verification of the work which should detect a problem such as this.
In discussions with the technical staff engineer and an electrical maintenance shop supervisor, it was determined that temperature alarm data was available to support the temperature conclusions and that the procedure change committed to is in progress and includes an appropriate post-maintenance polarity check. The failure of the LER to address these issues does not meet the reporting requirements of 10 CFR 50.73 and are examples of a violation of 10 CFR Part 50, Appendix B, Section XVI, as implemented by the Commonwealth Edison Company Quality Assurance Manual, which states that the identification and cause of conditions adverse to quality and the corrective action taken shall be documented and reported to appropriate levels of management.
(295/89015-05(DRp);304/89015-05(DRP)).
Regarding LER 295/89001, OBN Service Water Area Vent Fan Aircraft Damper found open. This LER identified a sticking control air valve which was replaced along with a solenoid valve which then allowed the damper to be closed. Another root cause was identified, however, for which no corrective actions were provided in the LER. This was the Technical Staff Surveillance procedure which removed power from Bus 248 for testing not related to this damper.
Restoring power was expected to reclose the damper, however, the sticking valve prevented it. The mispositioned damper was found the next day. The LER fails to address why a procedure that is responsible for the manipulation of safety-related equipment did not verify the results.
In addition, it was identified
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that a Deviation Report (DVR) was not written at the time of discovery.
This was not addressed, nor was the fact that this resulted in late submittal of this LER. These deficiencies in the LER are examples of
l violations of 10 CFR Part 50, Appendix B, Section XVI as implemented by the Commonwealth Edison Quality Assurance Manual, Section 16, which states that a corrective action system will be used to assure that deficiencies
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which might affect the safe operation of a nuclear generating station are promptly identified and corrected.
(295/89015-06(DRP);
304/89015-05(DRP)).
l Regarding LER 295/88020, this report concerns an event in which the j
l service water strainer common backwash isolation valve, 0FCV-SWO54, was not in its nonnal position (fully open). Two days before 0FCV-SWO54 was found out of position, the solenoid valve which supplies instrument air to 0FCV-SWO54 had not been reset following a surveillance test. The solenoid valve had been deenergized to shut 0FCV-SWO54; however, 0FCV-SW054 was not fully shut because of foreign material in the solenoid valve. The full closure of 0FCV-SW054 would have initiated an alarm light in the control room.
The safety significance of this event was minimal. Although the automatic closure of 0FCV-SWO54 upon receipt of a safety injection (SI)
signal was defeated in this case, the reduction in essential service water flow during a safety injection would have been very small.
(0FCV-SW054 is automatically shut with an SI signal to isolate strainer
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backwash flow.) During the time OFCV-SWO54 was out of position, a minimum of two service water pumps per unit were available; only one is
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required during an SI. Further, 0FCV-SWO54 would only admit backwash flow on an intermittent basis (when called for by high service water strainer differential pressure).
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The solenoid valve was replaced and reset to its proper position.
Surveillance procedures 15.6.35 and 15.6.43 are being revised to explicitly require resetting of 0FCV-SWO54 following deenergization of its solenoid valve. This LER is considered closed.
Regarding LER 295/88021, Inadvertent Auto-start of 00 Component Cooling Pump, Auto-start of a component cooling pump caused by a small metal filing shorting out contacts. The source of the filing could not be identified. The licensee reported inspecting and cleaning all similar safety-related contacts; no further action appears necessary. This LER is considered closed.
Regarding LER 295/89002, this event concerned a turbine trip / reactor trip which resulted from personnel error; a technician placed test leads across the wrong terminal paints during troubleshooting of a test light associated with safeguards circuitry. The light fixture and bulb for the test light were replaced. Carefulness in the performance of troubleshooting was stressed with station personnel. This LEP,is considered closed.
Regarding LER 295/89004, this event concerned a shutdown necessitated by the inoperability of all rod position indication (RPI) channels.
The licensee took all appropriate action to expeditiously shut down the unit and replaced the failed RPI regulator prior to resuming operation. This LER is considered closed.
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Regarding LER 304/88002-01, this event concerned three as-left main stearr safety valves. (MSSVs) with setpoints exceeding the:1% tolerance specified in the Technical Specifications._ The valves had been tested with a i
maintenance procedure.which included a set pressure tolerance of 12%.
.This LER revision amends the event analysis to state that even with
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out-of-tolerance set pressures, the three valves would reach full
' accumulation and pass their designated flows during.the most. demanding accident analyzed in the Final Safety Analysis Report'(FSAR).. The event analysis also points out that earlier cases of out-of-tolerance MSSVs found.during the review of records would not have prevented the MSSVs.
from providing'the necessary relief flow cited in the FSAR. This LER is~ considered closed.. MSSV testing concerns and regulatory findings are detailed in Inspection Reports 295/88009; 304/88010, 295/88012; 304/88013,'295/88015, and 295/88021; 304/88021.
Regarding LER 304/88012, this event was described in detail in Inspection-Report 295/88023; 304/88023.
Final implementation of the licensee's corrective actions'is.being tracked as Open Item 304/88023-03.
Therefore,.this LER is considered closed.
Regarding LER 304/89001, a Shift Control Room Engineer (SCRE) invoked incorrect action requirements for an inoperable fire suppression system.
With the sprinkler system for the' 2A diesel generator fuel oil storage room out of service, the'SCRE mistakenly instituted an hourly firewatch, instead of the continuous firewatch required by Technical Specification (TS) 3.21.3.
The SCRE failed to refer to TS in accordance with PT-14,
" Inoperable Equipment Surveillance Tests." The mistake was discovered.
during,a review of PT-14 surveillance during the following shift; the continuous firewatch was not posted for approximately seven hours. The safety significance was minimal in that the area's fire detection instrumentation was operable, a temporary fire hose was located in the area, and an hourly firewatch was in fact provided. The SCRE was counseled concerning his mistake and Technical Specifications. This
.LER is considered closed.
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.No violations or deviations were identified.
10. Training (41400)
During the inspection period, the inspectors reviewed abnormal events and unusual occurrences which may have resulted, in part, frr?a training deficiencies. Selected events were evaluated to determine whether the classroom, simulator, or on-the-job training received before the event was sufficient to have either prevented the occurrence or to have mitigated its effects by recognition and proper operator action.
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Personnel qualifications were also evaluated.
In addition, the inspectors determined whether lessons learned from the events were incorporated into the training program.
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Events reviewed included the events discussed in this report.
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v 11. Q uality Program Effectiveness
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l Temporary Instruction 2515/93 - Inspection 'for Verification of Quality
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Assurance Request Regarding Diesel Generator Fuel Oil - SIMS Item MPA-A-15 (25593)-
'The subject temporary instruction required the inspectors to verify that the licensee had included emergency diesel generator (EDG) fuel oil (FO)
l in its Quality Assurance (QA) program. The inspectors reviewed Zion's Quality Assurance Manual, Quality Procedure 4-51. Section 3.10. " Diesel Fuel", where it states that the F0 for the EDG is considered safety-related and shall be procured commercial grade.
It further states that a certifi-cate of conformance to ASTM is required. The inspectors verified that the licensee has procedvres in place for receipt inspection. Ceco Nuclear Operations Directive N00-CY>.6, " Sampling Diesel Generator Fuel Oil", and Zion Station Administrative Procedure ZAP 13-52-9," Visual Inspection for Receiving Diesel Fuel 011" were reviewed and found to meet the QA program requirements.
Zion Station purchases commercial grade F0 from an approved vendor with a certificate of conformance. Upon arrival'of the EDG F0 on site, prior to adding new F0 to the storage tanks, two samples are drawn from the bottom of each compartment of the tanker. One sample is stored on-site for visual comparison with future shipments. The other sample is sent to System Material Analysis Department (SMAD) for analysis of water, sediment, and viscosity to be completed within 2 weeks of delivery. A representative sample of F4 is then visually inspected for specific acceptance criteria.
If the visual sample fails any test or retest, the procedure calls for notificat%n of the Shift Engineer for resolution.
If the SMAD results exceed any of the acceptance limits, the Operating Department shall take appropriate action to bring the F0 within limits or replace the F0 in a week. Procedural provisions exist for F0 supplied by non-approved bidders.
12. Temporary Instruction 2515/100 -
Emergency Diesel Generator (EDG) Fuel Oil (FO) (255100ProperReceipt.Storag)e The purpose of the subject temporary instruction was to survey licensee's results to selected EDG F0 issues on a questionnaire supplied with the Temporary Instruction. The inspectors reviewed the licensee's QA
program, FSAR and Technical Specifications, to determine the licensee's i
requirements and' commitments in this area. Once the requirements were determined..the inspectors compared the licensee's implementing procedures against these requirements and commitments to ascertain program compliance.
The inspectors filled out the required information on the questionnaire and forwarded it to NRR.
Currently, the licensee's Technical Specifications (TS) do not include requirements for EDG FO quality. The licensee is planning on requesting a TS amendment to include such a requirement. On March 15, 1988, Nuclear
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Operations Directive (NOD)-CY.6, Revision 0, was issued which stated that
all stations shall include in station procedures a procedure for the sampling of EDG F0 as a safety-related item. The station failed to write
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this specific procedure.
In general, they had been sampling the F0 storage tanks on a quarterly basis, as part of the lube and fuel oil sampling schedule. This is not a controlled procedure.
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Appendix B, as implemented by Commonwealth Edison's Quality Assurance (QA)
Topical Report, CE-1-A, requires that activities shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances. Maintenance of the EDG F0 quality is essential
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to the operability of the EDGs.
EDG F0 is safety-related and should be
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sampled in accordance with approved station procedures. Sampling the storage tanks without approved procedures is a violation of Appendix B as set forth in the Notice of Violation (295/89015-07; 304/89015-07).
Zion QA Audit 22-89-42 documents an audit which was planned before but i
conducted after the start of this EDG F0 inspection. QA also concluded
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that the station did not have an appropriate procedure and that four quarterly F0 storage tank samples were missed. There was no indication that the F0 was degraded when subsequently sampled.
It was also noted that the storage tank samples did not include a bottom sample as requested by the N03.
The licensee has established a Total Job Maintenance activity to inspect and clean the storage tanks. However, it was noted that EDG //0 had not been inspected and cleaned by their due date of February 1988. The licensee intends to inspect and clean this tank during the upcoming outage.
The licensee has written a revision to ZAP-10-52-9 which included adding quarterly samples of the EDG F0 storage tanks. This revision was issued 6/29/89 and also int bded provisions to take a bottom sample. Conse-quently, no response to this violation is required.
13. Open Items 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. One Open Item disclosed during this inspection is siiscussed in Paragraph 8.
14. Unresolved Items Unresolved items are matters about which more information is required in order to ascertain whether they are acceptable items, items of noncompliance or deviations. Two Unresolved Item disclosed during this inspection are discussed in Paragraphs 2 and 5.
16. Exit Interview (30703)
The inspectors met with licensee representatives (denoted in Paragraoh 1)
throughout the inspection period and at the conclusior, of the inspection on June 29, 1989, to summarize the scope and findings of the inspection activities.
The licensee acknowledged the inspectors' comments. The inspectors also discussed the likely informational content of the inspection report with regard to documents or processes reviewed by the inspectors during the inspection. The licensee did not identify any such documents or processes as proprietary.
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