IR 05000295/1989018

Insp Repts 50-295/89-18 & 50-304/89-17 on 890619-23 & 0717-21 & 24.Violations Noted.Major Areas Inspected:Maint, Support of Maint & Related Mgt Activities

ML20247A841
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	08/30/1989
From:	Eick S, Falevits Z, Gill C, Jablonski F, Tella T, Walker H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20247A796	List: IR 05000295/1989018 ML20247A792 ML20247A822
References
50-295-89-18, 50-304-89-17, IEIN-88-067, IEIN-88-67, NUDOCS 8909120222
Download: ML20247A841 (45)

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[< U.S.' NUCLEAR REGULATORY' COMMISSION

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REGION III

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Reports.No. 50-295/89018(DRS); 50-304/89017(DRS)-

Dockst Nos. 50-295; 50-304 Licenses No. OPR-39; DPR-48 Licensee: Commonwealth Edison Company Post Office Box 767 Chicago, IL 60690 Facility.Name: Zion Nuclear Generating Station Units 1-and 2 Inspection At: Zion Site,-Zion, Illinois Inspection Conducted: June.19-23, July 17-21 and 24, 1989 s'.D.&A. Inspectors: 2. Falevits, Team Leader e/s./,3 Date '

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S. D. Eic /30/89 Date Osb Y C. F. Gill I k)7

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Da'te . T. Tella 3l3 E' T Date

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H. A. Walker Mv hfo[# f

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Contractors: F. L. McManus G. T. Wasenius Approved By:

h J M CAL N onski, hief 8/30/f 9 Mainte nce and Outages Section Date '

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I s90912o222 890901 DR ADOCK c500 {

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Inspection Summary i

~ Inspection on June 19-23, July 17-21 and 24, 1989 (Reports No. 50-295/89018(DRS);

> No 50-304/89017(DRS)) _

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Areas Inspected: Special announced. team inspection of maintenance,. support of maintenance, and related management activities. The inspection was conducted 3

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utilizing Temporary Instruction 2515/97, the attached Maintenance Inspection .

Tree, and selected portions of Inspection Modules 62700, 62702, 62704,.62705, and 92702 to ascertain whether malatenance was effectively accomplbhed and assessed by_the. license Results: Areas of. strengths and. weaknesses were identified as discussed in the Executive Summary. Overall implementation of the licensee's maintenance program is synopsized in Section 4.0 and was determined to be satisfactor There were two violations: four examples of failure to follow procedures or inadequate procedures; and four examples of failure-to take timely corrective action on numerous identified maintenance deficiencies including lack of adequate and timely' corrective action concerning the testing of the Auxiliary Feedwater pump turbines.overspeed mechanism. One open item was identified that pertained to an inadequate' preventive maintenance program for the Radiation ~'

Monitoring Syste . . - -

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' DETAILS

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' Persons; Contacted ~ ' .~ . .

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Commonwealth. Edison Company!(CECO)

• T. Maiman,lVice President,'PWR Operations

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'*L. De1 George, Assistant Vice. President, Quality Program and Assessment

• P. Fay, Maintenance. Staff Supervisor

• K. Graesser, General Manager;'PWR Operations-

• Johnson, Assistant Superintendent, Maintenance

• T. Joyce, Station Manage .. .

• Kurth, Production: Superintendent'

• P. LeBlond, Assistant Superintendent, Operations-

• T. Rieck, Technical Staff Superintendent

• W. Stone,-Regulatory Assurance Supervisor U.S. Nuclear Regulatory Commission'(NRC)

'*H. Miller, Director, Division of Reactor Safety

• A..Bongiovanni, Resident Inspector

• F; ~Jablonski,' Chief, Maintenance and Outages Section

• R; Leemon, Resident Inspector

• J. Neisler,. Reactor Inspector

• J. Smith, Senior Resident ~ Inspector

• Denotes those present at the exit meeting on July 24, 1989.

Other licensee personnel were contacted as a matter of routine during the inspectio .0 Licensee Action on Previous Inspection Findings .(0 pen) Violation-(295/86026-01A): This vielation addressed inadequate work instructions in nuclear work requests (NWRs) for performing maintenance work. Licensee action to resolve this issue is described in the licensee's letter to the NRC dated March 20, 1987. This response was supplemented by NRC letter dated April 14, 198 The inspector reviewed 27 completed electrical NWRs and noted that 14 of the NWRs contained the statement " Investigate and Repair as Necessary" or a similar statement such as " Trouble Shoot and Repair."

No specific instructions for performing the work were included in the NWR package. Based on this review, many work instructions were not adequate to provide satisfactory control of maintenance. This item remains open pending additional management action to ensure that adeq~uate work instructions are provided. The failure to take timely and effective corrective action to ensure that adequate work instructions are provided for maintenance activities is considered to be an example of a violation of 10 CFR 50, Appendix B, Criterion XVI (295/89018-01A; 304/89017-01A).

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- M~ _* ~2. 2 (Clos'ed): Violation'(295/86026-01B): This violation documented 1 the

, Lfailure of maintenance. mechanics to sign off steps'in the work

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packages and procedures' Licensee action to resolve this issue i . ~

> n , , idescribed.in the licensee's letter,to the NRC dated March 20,c198 Thisresponsejas'supplementedbyanNRCletterdatedApril14,'198 There was no Ebjective evidence that work required by a number of job '

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steps had been completed. The_ inspector reviewed 27 completed,

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electrical NWRs4 andi tive electrical: NWRs.for which work was'in

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'progressfand.found that'all steps'were appropriately signed as

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, compi tel This, item is close '" 1 ' (0 pen)' Violation"(295/86026-02A): This' violation documented.13

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instances where work proceeded past'QC"" hold points" without:

sign-offs or appropriate. releases. Licensee action to resolve this:

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. issue is. described in the licensee's. letter to the NRC dated-

'. March 20,;1987. -This response was supplemented by an NRCe l'tter^

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Ldated April 14,'1987; The inspector reviewed 27'complet'ed. electrical NWRs and not'ed no problems,with QC hold point signatures. 'However, in reviewing work

.,; in progress the inspectors noted that a QC hold point was bypassed on NWR Z83483. In~ discussions with the licensee on this matter and

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detailed findings from this inspection, adequate emphasis was notl placed on.the responsibility of. maintenance personnel to adhere to QC hold points. This item remains open pending further mar.agement

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action to ensure strict complianct to QC hold point s

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2. '4 ' (Closed) Violation (295/86026-028): This violatio~n documented the tallure to obtain QC release for completed maintenance work prior to a-performing post maintenance testing. Licensee action to resolve this issuelis' described in the licensee s letter to the NRC' dated

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March 20, 1987. This response was supplemented by an NRC lette dated April _14, 198 The inspector reviewed 27 completed electrical NWRs and 5 electrica NWRs for which work was in progress and did not identify c'ases where-the QC release block had not been signed if appropriate. This item is close ~ Introduction to the Evaluation and Assessment of Maintenance This inspection was conducted during normal plant operations to

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evaluate the extent that a maintenance program had been developed and implemented at the Zion Nuclear Generating Station. Three major areas were evaluated: (1) overall plant performance as affected by maintenance;-(2) management support of maintenance; and (3) maintenance implementation. This inspection was based on the guidance provided in NRC Temporary Instruction 2515/97; " Maintenance Inspection," and Drawing 425767-C, " Maintenance Inspection Tree."

The drawing, which is attached to this report, was used as a visual aid during the exit meeting to depict the results of the inspection.

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U LT N goals of this inspection were;to evaluate maintenance activitie to fdetermineJif mairitenanceLwas. accomplished, effective, and. assessed:

by the. licensee-to assure the preservation or, restoration of the-

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availability andireliability of. plant' structures,' systems, and components-to operate on deman .

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Results of'this inspection were: derived from data obtained by

. observation (,f- current plant conditions and work in progress, by1 1<

q Lreview of completed work and by evaluation <of the licensee's self

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assessment and~ correction of weaknesses. : Major areas of ? interest ' .

included maintenance associated with electrical, mechanical, .

instrument and controlL(I&C) and the support areas;of radiological

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control, engineering;-quality control, training, procurement, and. .. o operation Problems identified by,the NRC. inspectors.were ~ evaluated:

for'effect on Technical Specification operability and technical ore managerial weaknes '

2 Performance Data and System Selection

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c LH istoric Dat'a-The inspectors reviewed plant operations history data for 1988 and the' available data for 1989, to assess the licensee's performance i meeting established goals.. The data pertained to'fcrced' outage rate,'

, unplanned. reactor' trips, Engineered--Safety Feature (ESF) actuations,,

safety system actuations,: Licensee' Event Reports (LERs), and the

available performance ~ data;for systems. selecte As of' June-1989,

.results were:

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• Forced outage rate for 1989 for Unit I was'15.6% and for Unit'2 was 11.3%; the' goal.was.less than'4%. -(The 1988 goal was-not met.for Unit 1.)-

• - One unplanned reactor' trip occurred on Unit 1, which was maintenance related; the. goal was'less than three per unit.-

(Six reactor trips occurred in 1988;' the goal was six for. both

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units.)

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• Two ESF actuations occurred on Unit.1; the goal for 1989 was zero. (A total'of 14 ESF actuations occurred in 1988 for both units;.no goalJfor 1988 h'ad been established.)

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1 * No unplanned safety system actuations occurred; the goal was ze ro (One safety system actuation occurred in 1988 on Unit 1;

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'the, goal was zero.)

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• Fifteen LERs were issued,+four due to equipment failures; the-goal for.1989 was 28. (Forty-one LERs were written in' 1988; 13 due to. equipment failure; the goal was 30 (15/ unit).)

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• Equivalent Availability for Unit 1 was 82.4% and for Unit 2

, 84.1%. The goal for Unit 1 was 72% and for Unit 2, 85%. The licensee. expected to meet the Unit 2 goal but not the Unit 1-

. goal. In 1988, the Equivalent Availability for Unit 1 was 72.3%

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fand for Unit 2 was 74.2%. Both units exceeded.the goal'ofL ,

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( ., :72.0%. (INPO best Quartile was set at'74.7%.)' ,

d'.J *- Cumulative Whole Body. Dose for 1988 was .1259. Man-Re The l M~

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i original ' goal wasl680 Man-Rem; however, the goal was; revised to 1260 Man-Rem. .The average Cumulative-Whole Body Dose for 1986,.

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1987;.and 1988 was 398 Man-Rem wh_ile the industry average median'

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Overall,2 performance in,the above areas did not meet the' established- l goals-set.by station management in most categories assessed.

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> Thelinspect' ors also assessed other data furnished by~ t'h e-licenseef to I

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- n ascertain'the availability and operability of_ selected systems sinc .

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Results of.this-review indicated that except,for the

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J , January 198 Auxiliary Feedwater (AFW)' System, no' plant goals were. established in

,these areastfor;the selected' systems. The 1989 safety performance a goalifor AFW' system was less. than 0.02 and actual was 0.041. In-addition,:for the first quarteriof 1989,,the'AFW system on' Unit 1 contributed to-all'of_ the; unavailable hours'due to a leaking valv In 1988;fthe safety system performance indicator for AFW was.les l than the INP0:1991 target. No performance data or goals wer i

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available for the: Reactor: Coolant Systemi(RC), Auxiliary Building  ;

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HVAC (AV), and control Room'HVAC (PV)fselected system !

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The' license'e es'tablishe'd goals to' determine.if maintenance was j

') accomplished.. The goals included maintenance backlog, and preventive .

-maintenance (PM) and corrective maintenance (CM) ratio. .However, the licensee had not. established goals for measuring effectiveness-'of maintenance such as the number of limiting conditions for operations -1 due to equipment problems and number of power reductions due to j equipment' problem In addition, the inspectors determined that'  ;

several goals originally set for 1988 had been subsequently raised R

,'when the licensee realized that the goals would not be met. 'For

example, the original goal set for reactor. trips for 1988 was two per unit; subsequently, it was changed to three per unit. The actual was i four trips for' Unit 1 and two trips for Unit 2. 'The goal for- 1 e Cumulative Whole Body >Doce (Man-Rem) was' originally set at j 680 Man-Rem, but was subsequently changed to.1260. The actual  !

Man-Rem dose for 1988 was 1259. The inspectors concluded that a l moving target was not an effective mechanism for achieving set goal '

Lc The inspectors determined that the' forced outage rate for 1989 had i been significantly worse than the set goal. Three of the six  !

$ 'e - equipment forced outage reductions were greater than 25% power; all ,i due to equipment leaks. Also, the equipment ftilure per 1000  ;

critical hours during the first quarter of 1989 was 1.24 while the- l

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goal was less than 0.35. As a result, the exposure and contamination levels for 1988 were higher than expected and the licensee determined that the goals for this year would probably not be me In addition, the forced outages diverted manpower from non-outage work requests which resulted in a rise in the number of backlogged non-outage work requests. The inspectors concluded that equipment failures appeared to be a key contributor to the problems that resulted in large forced 6 1 i

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outag'es in. late 1988 and early 1989. . ' Increased management attention is needed to. reverse this. adverse tren . System Selection The systems and component'sJselected for this inspection were based on a Probabilistic Risk Assessment.(PRA).stuoy furnished ~to the team by the.Rel.iability Applications Section of-the Office of Nuclear Reactor Regulation and review of recent component failures, LERs, Nuclear Power Reliability Data System (NPRDS), and Deviation Reports. The systems. selected were:

, Auxiliary Feedwater System (AFW)

iAuxiliary Building HVAC (AV)

Control Room HVAC (PV)

Reactor Coolant' System (RC)

, . Description of Maintenance Philosophy The inspectors reviewed site policy statements, administrative

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procedures, organization charts, established goals, and document that described improvement programs for the maintenance process. The licensee did have a documented comprehensive maintenance plan, Conduct'of Maintenance, that included milestones and completion dates for improvement programs and goals. Discussions by the inspectors with selected managers indicated that those personnel were knowledgeable and aware of established performance goal The inspectors determined that the licensee's maintenance program was appropriately balanced with CM and PM. The licensee's predictive maintenance program was at the early stages of implementation in areas of performance monitoring of heat exchangers, erosion / corrosion pipe monitoring, vibration analysis and oil samplin A thermography program was in the planning stages with implementation sometime late in 1989. Because of the relative newness of the program, no overall

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evaluation of the effectiveness of the predictive maintenance program and its' implementation was made. The licensee's philosophy of maintenance included limited principles of reliability centered maintenance (RCM).

Zion did not perform stem thrust diagnostic testing of any motor operated valves (MOV); however, current signature measurements were utilized to determine relative condition of the MOVs. The licensee's MOV diagnostic program was considered behind the industr .3 Observations of Current Plant Conditions and Ongoing Work Activities 3. Current Material Condition The inspectors performed general plant as well as selected system and component walkdowns to assess the general and specific material condition of the plant to verify that NWRs had been initiated for identified equipment problems, and to evaluate housekeeping. The selected systems and components, which were selected, based on a PRA

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study for Zibn perform'ed by the Reliability ~ Applications Section of'

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the Office Nuclear.ReactorLRegulation, are identified in Sectionc3.1.2 of this~ repor Walkdowns included an assessment of the buildings, components, and systems for proper identification and tagging, accessibility, fire and security; door integrity, scaffolding, radiological controls, and any unusual ' condition Unusual conditions included but were not limited to water, oil'or other liquids on the floor or equipment; 4 indications of leakage through ceiling, walls or floors; loos I insulation;~ corrosion; excessive noise; unusual temperatures; and

- abnormal ventilation and lighting. Results are as follows:

• Housekeeping appeared to be very good. Generally, the plant was clean and many areas appeared to have been recently painte Although small water and oil leaks were noted in some areas, none appeared to be excessive. An oil absorbing material was used in most areas to absorb oil from small leaks. This appeared to be a good method for removing the oil; however, in at least one area (on top of IB diesel) this material was saturated with oil and appeared to be a fire hazard due to potential high temperatures. Licensee personnel immediately removed the oil saturated material from this are * The inspector selected 12 tags from equipment in the plant to evaluate the effectiveness of the licensee's tag out progra None of the tags noted appeared to be excessively old. Open NWRs existed for 11 of the tags. The remaining NWR,'for Tag M9528, had been closed on February 26, 1989, and the tag had not been removed. Two instances were ioentified where deficiencies existed and no NWR had been written. It appeared that the licensee's program for the identification of maintenance was goo * The inspectors noted two of three leads (tag L932 and L001) that were lifted since August 8, 1979, and March 3, 1980, which were still controlled by the temporary alteration procedure. The inspectors were concerned that items almost ten years old were considered temporary and not given the reviews and control required for permanent modifications. The inspector reviewed Procedure ZAP 3-51-4, " Temporary Alteration Program,'"

Revision 13, and noted that a temporary alteration was defined as " changes made to plant equipment intended to be temporary."

No discussion of requirements were provided as to the length of time that an alteration can be in place and still be considered temporary. During discussions with the licensee on this matter, the inspectors were informed that the control of temporary alterations had been previously identified as a problem and that the number of temporary alterations had been substantially reduce In addition, a review of all open temporary alterations was performed every six months to determine if the temporary alteration should be removed or made a permanent modificatio The inspectors were told that a modification had been issued to eliminate the need for the two noted temporary

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yS ' alterations and.that this modification would be implemented in ~ "

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l*; -The ini;pectors; nd ted that some of the spare. breaker cubicles.in j c

the 4.16kV essential switchgearirooms did.not.contain breaker j-The inspectors were informed that present practice kept a- l JM

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z breaker,in the- same location until maintenance was neede A .j

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J spare was temporarily.used and.the assigned breaker would be-  !

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reinstalled as soon.as-possible after repair. The inspectors d

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i were provided with:a list that.ident_ified breaker location by cubicle number in the' essential switchgear: rooms. A sample,

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. review of breaker locations indicated several inaccuracie /l Since PMs were performed by cubicle. number,, there did not appear

@ to be a positive' method in place to ensure that required PMs were performed.on all breakers. Subsequently; licensee ..

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. personnel' verified using completed NWRs, that the.. required PMs . 1

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'on Unit 1 bre?kers had'been completed and that the same'-

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verification of breaker PMs would be completed for Unit 2 . .

breakers. The licensee' stated that a system would be developed

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~PM This problem had been noted at other CECO plants and 1-appeared to beta problem generic to CECO plantsc

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e Manyfelectrical panels, equipment control panels and switchgea , , breaker enclosures, contained loose conductive. material such as

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screws, '~ spare fuses, spare light bulbs, nuts, wire lugs,: and

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metal marking tags. A review of LERs revealed'that the. licensee .,

had experienced an inadvertent autostart of safe due toLloose conductive material (LER 88-021:00)onguards November equi,pment 2,

1988. 'Following that event, the' licensee inspected all Safeguards and Reactor Protection cabinets in Unit 1 a committed to inspection of Unit 2 prior to restart following'the

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• A large number of 4.16kV breaker indicating lights were not u illuminated or were broken, and some lens caps were missing.

' , ' The licensee provided a list of .21 NWRs for repair of damaged-switchgear indicating lights during the next switchgear overhaul perio ,

• The inspectors observed 83 caution cards attached to control room panels s Of these, 42 were the result of pending maintenance. The NWRs for 17 caution carur had datet, greater than oneLyear"old. The~ licensee identisiest two caution cards that were no longer applicable because. maintenance had been completed and three caution cards for which no NWRs could be identified. "The correlation' of' caution cards that related to

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maintenance, and the NWR for the maintenance was difficult-because the caution card-log did not contain the out of service number nor the NWR number related to the maintenance. A sample of NWRs~was reviewed and no safety or operability concerns were noted.

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• The inspect' ors observed that humidity meter indications for the main control room were out of specification. The readings noted were between 0% and 80% for.the four device The FSAR

. specifies control room humidity limits of'35-45L No NWRs had been written to investigate these indications. The last documented observation of the humidity indication for the control room was February 1987, when repairs were made to the system. Routine logging of the control room humidity was not required by licensee procedures and operations failed to notice these erroneous indications when conducting routine walkdown Control room humidity was immediately checked and found to be within specification limit NWRs were written to repair the humidity indicating system for the control room. No maintenance problems related to control room humidity were noted by the inspector * Service water lines and-associated flanges, bolts aid nuts inside-Unit 2 containment appeared to.be badly corroded. These pipes and fittings' appeared to have never been painted. The inspectors determined that plant management did perform periodic walkdowns of the plant and results or deficiencies were documented on a " yellow card." However, a formal followup

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system was not establishe Generally, equipment problems identified by the inspectors during plant and system walkdowns had already been identified by the licensee's WR system, or were otherwise corrected. The material condition was considered satisfactory to maintain operability of components at a' level commensurate with the components' functio . Ongoing Work Activities

.The inspectors observed ongoing work in electrical, I&C, and mechanical maintenance areas. The inspectors selected these activities from the plan of the day listings, work assignments in individual maintenance shops and through discussions with individual foremen. W,v.re possible, safety significant activities were chosen for revie Maintenance activities were witnessed / observed to determine if those activities were performed in accordance with required administrative and technical requirements. Work activities were assessed in the following areas:

Administrative approval prior to start of wor Equipment properly tagge Replacement parts acceptabl Adequate work instruction Approved procedures available and properly implemente Work accomplished by experienced and knowledgeable personne Appropriate post maintenance testing included and conducte .3. Ongoing Electrical Maintenance

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bl The inspectors observed portions of seven routine electrical

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NWR Z80026c Inspcct 18 Safety. Injection (SI)' ' imp cubicle ;

cooler fan motor and cubicle tet ation boxes for '

undocumented wire and splices NWI Z82380 Inspect MOV for melamine torque twitch  ;

NWR Z82685 Inspect cubicle cooler fan motor for EQ

.c wiring and splices NWR Z82875 Replace Unit 2 governor valve limit switch actuating arm linkage:

NWR Z83034 Failure of IB AFW pump'to stop following inadvertent start from the remote shutdown panel C Z83134 Troublest. cot dc Bus 112 ground alarm

. Surveillance PT-30 Monthly battery surveillance on battery 212-The inspectors concluded that electrical maintenance activities were satisfntorily accomplished by skilled maintenance' personne Maint wice personnel appeared competent and were knowledgeable of the work performed. However, concerns were identified in the observation of the following work:

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• NWR Z80026 Procedure E 028-1, " Cubicle Cooler Fan Motor EQ Inspection / Maintenance," Revision 1, allowed work steps to be

, completed in consequential-order. Step 8 rcquired replacement of the junction box covers and Steps 9 and 10 required performance of electrical insulation resistance tests to ground and measured phase'to phase resistance'. If these steps were not performed in sequence, a wire could be pinched or damaged during cover replacement and not be decected by the electrical checks performed in Steps 9 and 10. The shop foreman discussed the inspector's concern at a shop meeting with Electrical Maintenance personnel. A change to the procedure had been submitted that required workers to close terminal / junction boxes before conducting thi, resistance and electrical insulation check No other concerns were note * NWh Z82875 - Repair of the non safety-related governor valve limit switch involved replacement of the actuating arm linkage to the limit switch. No concerns were noted during the field work observed by the inspectors. However, the inspectors were concerned that the NWR lacked detail and did not completely describe the problem, testing required, or accurately describe the part required. The " test required" block of the NWR was checked "No"; however, .the work instructions required that a post maintenance verification be performed to verify proper actuatio The'NQ " parts" block was L.rked "NA"; however, an

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incorrect replacement part'was supplied from the station warehouse. The part. supplied was right hand threaded, while the necessary replacement part' required.left hand threads. The

. maintenance electricians fabricated a temporary repair.using the ;

.old connecting linkage part * NWR Z83034 - Initial conditions for the surveillance transferred-control of_the IB AFW pump from the control board to the remote shutdown panel.in preparation for starting the IB AFW Lube Oil Pum TheLoperator became distracted and turned the switch for the AFW pump to what was believed to be the start position, but

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actually positioned the switch (clockwise) to the labeled "stop" position; however, the AFW pump starte The operator was directed to stop the pump. When the switch was placed in the labeled "stop" position (clockwise) the. pump failed to sto Control was transferred back to the centrol room and the pump was secured. The technical staff engineer concluded, and later ;

verified by testing, that the switch was wired correctly and the '

label plate wcs incorrect (start /stop positions reversed).

Corrective action consisted of a caution tag placed on the Remote Shutdown Panel that indicated the switch label discrepancy. Licensee personnel stated that a label with correct markings would replace the incorrect label. The inspectors evaluated the licensee's label improvement program to ascertain the extent of potential mislabeled plant component The inspectors concluded that this mislabeled switch was an isolated case and not symptomatic of a widespread proble * Surveillance PT-30 - The monthly battery surveillance on station battery 212 was performed per Procedure PT-30, " Station Battery Records Monthly Quarterly Equalizing Charge," dated April 20, 1988. Paragraph 5.2 stated " Verify all electrolyte levels are between 1/4 inch below the full line and the low level line."

Maintenance personnel indicated that electrolyte levels were acceptable even though most levels appeared to be at or very close to the full line. When questioned about this matter, maintenance personnel decided that the levels did not appear to be acceptable and stated that the procedure was not clear in this area. The individuals had performed this battery surveillance several times before. This portion of the procedure had been revised at the last revision. The high electrolyte levels were documented and the surveillance was complete This failure to follow required procedures in performing the battery surveillance is an example of a violation of 10 CFR 50, Appendix B, Criterion V (295/89018-02A; 304/89017-02A).

This matter was discussed with both the cognizant systems engineer and the master electrician. Based on discussions with the systems engineer, there did not appear to be a problem with-the battery.. The level requirement had been incorporated into the procedure to prevent over filling of the cell Licensee personnel stated that Paragraph 5.2 of the procedure would be rewritten for clarification. The failure to follow procedures

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was discussed with the electricians as well as the individual's responsibility to understand each procedure step, especially where recent changes are involve This matter appeared to have been satisfactorily resolve .3.2.2- Ongoing Mechanical Maintenance The inspectors. observed portions of eight mechanical maintenance activities as discussed below

NWR Z76089 Installation of a viewing window on AFW pump 2C shield NWR Z77209 Overhaul of condensate booster pump 1A NWR Z78406 Modification of heater drain lines, including welding NWR Z79909 Rebuild and repair of PHR snubbers NWR Z80465 Modifications, including welding of bul.k acid

. transfer pipe NWR Z81872 Rerouting of piping and supports NWR Z82855 Maintenance on Instrument Air Compressor 1A NWR Z83483 Troubleshoot and repair MOV 2M5006 The inspectors concluded that mechanical activities were adequate and accomplished by skilled maintenance personnel. Maintenance personnel appeared to be knowledgeable and adequately trained in the work performed. However, concerns were identified during the observation of the following work:

• NWR Z83483 - Tho' inspectors reviewed the open NWR package after maintenance had recently completed two repairs to the valv Numerous deficiencies were found during the repairs that were not identified in the " work performed" section of the NWR, such as: gear teeth for handwheel were broken, handwheel shaft was bent; an unusual amount of grease was found in the bellville spring pack; the torque switch was replaced and wired backwards causing the thermal overloads to trip; the new torque switch did not have a limiter plate installed and no NWR was written to order and install one. These deficiencies were discovered after discussion with workers and after a review of loose notebook papers that had been added to the NWR package documenting noted ;

deficiencies. Also,' the NWR maintenance cause code incorrectly i listed the root cause of the valve failure as "AM", defined as previous repair / installation status, and identified the valve as both EQ and non-EQ. Failui_ to fully document as-found conditions and work performed could result in poor work history input to the Total Job Management (TJM) system, and inaccurate failure and root cause analysis. The licensee had yet to review l this NWR for root cause and corrective actio _ _ _ _ _ _ b

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% LThe first repair of the. valve incorrectly used procedure

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P/M016-5N, " Removal and Installation of Limitorque Operator Site SMB-0-Through 4", Revision 5. Valve 2MS006 was an SMB-00 (

model and required a different procedure to assure correct

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' disassembly and reassembly. Failure to use a procedure

'

- appropriate to the valve model type is an example of a violation of.10 CFR 50, Appendix B,. Criterion V (295/89018-02B; 304/89017-02B). j u . . 1 The procedure used'to install the new torque switch, E022-l',

" Inspection'and Maintenance of'Limitorque Valve Motor Operators," Revision 1, did.not' provide adequate guidance to

_ prevent:miswiring. reattachment F of the procedure showed diagrams of the torque switch without contact numbers and did not. require the. craft to document the wires removed from the old

' torque switch for: reference when' wiring the new torque switc Also, double verification'of. proper wiring was not required by the' procedure.~ Miswiring of the torque switch caused the valv thermal overloads to trip during post-maintenance testin Failure to include adequate' procedure steps to prevent miswiring of Limitorque; torque switches is an example of a violation of 10 CFR 50 Appendix B, Criterion V (295/89018-02C; 304/89017-02C).

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Deviation Report DVR-22-2-87 was written and stated'that an operations B man tried to open the stuck closed valve'with a

" medium. size valve bar." The Limito que vendor manual clearly -

advised not to use a cheater bar on the handwheel. Use of the che'ater bar could have resulted in the broken teeth on the handwheel gear and the bent handwheel shaft. Use of a cheater bar was not' listed in any operations procedure; however, the inspectors were told that operators received training consistent

~

with the vendor's manual. The inspectors concluded this was a poor maintenance practice that warranted a review for pervasiveness and appropriate management attention to ensure its correctio j 3.3. Ongoing Instrumentation and Control Maintenance

The inspector observed portions of three I&C maintenance activities as discussed belo NWR Z82702 Investigate Low Lube Oil Alarm on IB EDG NWR Z83033 Investigate Low Lube Oil Alarm on Loop 2A NWR Z82111 Change Scaling of Flow Transmitter on Loop 2A  !

The inspectors concluded that I&C maintenance activities were accomplished by skilled maintenance personnel. The maintenance personnel appeared very conscientious and knowledgeable with an 4

'

average of 5.2 years experience at Zion. However, concerns in the areas of job planning and procedures were identified during the observation of the following work: j

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• . NWR Z82702 The work package for the repair of 1B Emergency Diesel Generator (EDG) lube oil level alarm was inaccurate and incomplete becaus'e it contained an incorrect calibration sheet and'no disconnect / reconnect sheet. The work package incorrectly contained the calibration sheet for~the lube oil alarm on IA EDG. This error'was not detected during the job plannin process; however, it was noted prior to work authorization. The NWR required the, disconnecting of leads. The technician failed

'to document disconnecting and reconnecting of leads as required by ZAP 3-51-1, " Temporary Alteration Program", Revision 26. A disconnect / reconnect sheet was not included in the work packag In response to.this-issue, the I&C department was developing a troubleshooting procedure that amplifies ZAP 3-51-1 and contains improved discormect/ reconnect forms and procedures. Failure to follow procedures is an example of a violation of 10 CFR 50, Appendix B, Criterion V (295/89018-02D; 304/89017-02D).

Documentation of IB EDG lube oil level during the period where the lube oil level low alarm was inoperative was not in accordance with Procedure PT-0, App. J-2, Revision 3, which required "a check mark in the appropriate space" when logs were taken. Five of eleven logs for 18 EDG had no check mark in the space indicating '! Crankcase Lube Oil Level at mark." These-logs contained a single check mark in the space for the top item on the log and a single lire drawn through the remaining spaces of the log. Not marking an item on the log at the time it is performed and leaving the marking until.all items in the log have been completed increased the potential for error and was not in compliance with procedure. The other'6 of 11 logs contained check marks or accurately documented lube oil level Management attention is needed in this area to ensure that appropriate checks are performed and documentation of those checks is per procedures and acceptable practices.

,

Two procedures wepe included in the work package; however, the

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reason and sequence for use was not specified in the work instructions. Procedure IMP-MI-4, " Determining Static Shift" had no correlation with the work instructions and appeared to be l incorporated as a contingency. Calibration Procedure 2F-414T, l' " Loop 2A Reactor Coolant Flow Channel Transmitter" was included 1-to " enter / exit the loop." The apparent task sequencing of the work instructions was to " enter / exit the loop" under NWR 82111 and perform Procedure IMP-MI-2 if necessary. The requirement and sequence for the use of Procedure 2F-414T was not clearly specified in the work instruction * NWR Z82111 - Technicians used reference data which had been l

deleted in Calibration Procedure 2F-414T. SPCR B707,

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" Instrument Setpoint/ Scaling Change Form," authorized changes to Procedure 2F-414T. These changes included the deletion and insertion of new data for zero shift, static shift, reference, and required data. This was accomplished by crossing out the old number with a single line and writing the new number abov The technician who performed the work used the crossed out

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reference numbers' wh'en taking as-found data for the transmitte A QC inspector-observed this work and did not identify the error. The as-found data was incorrect but did not have a j'

safety significance. In addition, the work package did.not contain all required' procedures. Procedure 2F-414T required the technician to " Refer to IMP-MI-9 for wet / dry transmitter calibration method." Procedure IMP-MI-9 was not included in the work' package; however, it was obtained and use . Radiological Controls

, . Maintenance work was observed in contamination and radiation areas as were' movements of tools / equipment to arid from these areas, and

interactions of workers with radiological control personnel were also observe No apparent problems were noted with health physics support of ongoing work or with ALARA review of specific task Radiological controls, post 4g and labeling were good. From a-radiological standpoint, cleanliness and housekeeping appeared ,

generally good for the non-outage condition '

Through observation of work in progress and discussion with licensee personnel, the inspectors determined that radiological controls were integrated into the maintenance process as evidenced by:

• The ALARA staff included personnel with backgrounds in maintenance and radiation protection (RP). The ALARA staff appeared to have the necessary size, expertise, experience, and dedication to implement effective ALARA oversight of maintenance activitie * Experienced RP-ALARA planners provided input to maintenance planning and assured that good RP practices were incorporated into planned work activities as early as possibl * Members of the ALARA staff attended planning meetings, performed daily' review of RWPs, supervised decontamination crews, administered the shie_lding program, conducted pre and post-job meetings, and collated and tracked the station's person-rem performanc * Proposed facility changes were reviewed by the ALARA staf * The licensee had developed extensive job history files and generally effectively used a review of these files and previous work packages to factor lessons learned into the planning proces * Dose savings were achieved through extensive use of shielding, mockups during pre-job training, videotapes of selected jobs, and an extensive photo-librar !

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*r The; station'sALARhgrou~pprovidedALARAawarenesstraining

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• - ' Audits by;the onsite QA organization and the corporat'e office:of

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. Jthe radiatipn protection program including ALARA were performed

and findings appeared to be'well addressed by appropriate'

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[ * 1 The formal ALARA: review program, management. support, ~

consideration of ALARA principles by other' station groups and

% the working relationship with the ALARA group appeared conducive; y

$ ,'to.the continuation;of a good ALARA program. ' ,

, , , The' inspectors notedLsome'weakn'ess in maintenance / radiological y, , controlcinterface as follows: t m ,

• "AlthoughIthestation'sradiologicalcontrol/ALARAprogram ,

functioned well. for' large outage maintenance projects, more '

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emphasis on routine: maintenance tasks was desirablec The ae licensee did not maintain the cumulative dose to maintenance personnel within the. station goal.,

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• , Radiological control /ALARA personne1~should be more cognizant cf

'systemioperations'and work more) closely with operations and

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maintenance personnel on? routine and special system maintenance activities to' reduce dose to station personnel and the potential

< of radiological effluent releases to the environ Theinspectorsalsoidentified/maintenanceweaknessesregarding

. radiation. monitoring ~ system (RMS) reliabilit *- 'Proces's' and effluent RMS. reliability problems were identifie'd i f Inspection' Reports'No.'50-295/87022(DRSS); 50-304/87023(DRSS).

The' lice'nsee established a RMS reliability task force (Radiation Mo'nitor: Committee) which met weekly until about two months prior

< . to the maintenance tea'm, inspection. .This-task force consisted "

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of ' technical staff,1 radiation protection, instrument

' maintenance, and operations representatives and was charged wit correction 1of recurrent RMS problems and timeliness of

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c'ompletion_of maintenance work requests. The committee was able

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-to resolve some recurrent problems and significantly improved

$. workLrequestetimeliness; however, licensee representatives n' stated that since the committee's last meeting, work requests were no longer processed in a timely manner, RMS reliability

- decreased, and management involvement significantly decrease .j

>

The day after inspector concerns were expressed to station  ;

& management, committee members were appointe The Technical

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Superintendent was designated as the committee chairman and the  !

A first weekly meeting was scheduled for June 27, 1989, to review current radiation monitor problems, proposed RMS Technical

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1. Specification amendments, and a recent consultant's report which

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. included numerous RMS' recommendation This is' indicative of the need to provide adequate management oversight and/or convey y management expectations to the staff to ensure the continued high reliability of the' process and effluent RM * The licensee had an' ineffective system for review of Instrument Maintenance Radiation Surveillance (IMRS) procedures and g' associated work packages. During the review of the assembled

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work package for WR'Z8301, prior to observation by an NRC inspector, the RMS system' engineer noted that IMRS No. 31 had~a procedural deficiency. The system engineer stated that he usually did not' conduct reviews of this type. IMRS No. 31 had correction tables for decay of the radiation sources for a three year period; however, the referenced source calibration was three years and three months ago. Thus, the scheduled maintenance. activity could not have been accomplished with this procedure. The IMRS procedures were reviewed every two years, the primary calibration-for IMRS No. 31 was approximately two years old when IMRS No. 31 was approved; therefore, the

. procedure was scheduled for review approximately one year after the procedure would have become inadequate. On June 22, 1989, a fourth year correction table was added to IMRS No. 31 and the procedural revision was submitted for approval' review. The licensee stated that other IMRS procedures would be reviewed for errors and the approval process would also be reviewe * Tagging of out-of-service (005) RMS'on the control room status / operation panels appeared inadequate. On June 22, 1989, ,

an NRC inspector observed that, although radiation monitor ORT '

PR-18A was 005, it was not tagged as such on the RMS control room status panel. The inspector was informed by the RMS system engineer that 005 RMS had a label, which listed the NWR number, placed on the appropriate panel and when the NWR was completed, the label was removed and placed on the NWR. In the case of the subject monitor, the NWR was completed but the IM technicians were waiting for approximately one day to assure instrument failure did not recur before having the monitor declared back in service. Control room operators keep track by the PT-14 records (Inoperable Equipment Surveillance Tests); however, it appeared desirable for 00S tags to be placed on the RMS panels until the instruments are back in service so that-the personnel who operate the RMS or check monitor status would know which instruments are 005. The licensee stated that a review of the current tagging procedure would be done and revised if necessar * The PM program for the P.MS appeared ineffective based on a study completed by a licensee consultant in early 198 The RMS blower PM did not make an improvement in blower performance in that 100 NWRs were issued for this problem in 1987-1988, of which 39 NWRs were during the last half of 1988. The blower manufacturer specified that the blowers should last for 30,000 hours0 days <br />0 hours <br />0 weeks <br />0 months <br /> of operation with a PM program that addressed fan

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"r ,.- consultantreported;amean' time'to'failurelof:7,000.h'ours. The

,W ' ' consultant also reported that the sample. canister PM progra , Jappeared to be-ineffective. A more effective and' thorough RMS

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PM program should beHaddressed by thejlicense ynf

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Maintenance' weaknesses jegarding RMS reliability were discus' sed with Nh

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,. Estation.managemeni. and will be reviewed further'during a future A inspection (0 pen Item 295/89018-03; 304/89017-03).

h 3.3.41 : Maintenance Facilities, Material Controlf and Control of-Tools and Measuring Equipment '

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i T, The inspectors. reviewed the licensee's.' activities in the areas of-facilities, equipment,fand material control to; assess support'given.

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to the. maintenance process. Interviews were conducted with various' ,

. maintenance management and craft personnel to determine.the poli'cies,

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goals, and objectives;;and followup observations were. performed to determine the extent to which the' plant practices, procedures,<

equipment, and layout supported the maintenance. proces .

1 3j ' Facilitie The electrical maintenance workshop areas appeared to be adequat ,

Noicongested or crowded conditions were note Mecha'nical' maintenance facilities were generally adequate; however, Lthe ~ inspectors noted that the " Hot Tool- Room," located in the Auxiliary Building, did not have a list of hot tools contained there, and did not maintain any control.on'the tools issued or receive :

However, no. evidence of contamination of plant areas or personnel:due-to the lack of' positive control of hot tools was noted'during the inspection. The licensee stated that~a program for control of hot

' tools-was still in the: developmental, stag I&C maintenance facilities were adequate. The_ instrument maintenance workshop was located on the turbine deck and.provided easy; access to the control: room and auxiliary electrical areas. The master

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instrument mechanic, foreman,. work analysts, and scheduler's offices and the tool issue room were adjacent to the work sho _

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3.3. Material. !quipment, and-Tool Control Warehouse facilities at Zion-included two warehouses, one inside the m controlled area and one outside. -Neither warehouse had a Level A H storage area; however, the inspector was told there were no items H specified as requiring Level.A storage. Physical control of access to the warehouse facilities was good, environmental controls were

< acceptable, and cleanliness'and housekeeping aspects were good. A system was.in place for control of limited life material; however, some problems were noted in this area, which are addressed later in this section. ' Control-for consumable materials such as solvents and cleaners, thinners, paints, oil, grease, and gasket materials appeared to be acceptabl A separate storage area had been m .

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established (foreflammable ' materials'and th'ose that required special 7 '. handling,1such "as;hazardousimaterials, and those requiring specific-4. safety precautions 1<

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, parts; Most'of.the items'were ordered for the upcoming outage and no

safety significant non-outage items'were noted. ,. None of the NWRs .had

@* 1 . a high working priority.-

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1; h * . . r i Thetlicensee utilized a computerized system for tracking and

+ Jcontroliing stock quantities, stock locations,1and to: initiate .

procurement of stock parts. ' This system automatically included the.-

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appropriate specifications, documentation requirements,l testing,

inspections,' acceptance, records, acceptable sources,' stock quantities,- reorder. points, and ; reorder quantities aslwell

as y L - m , indicating lead. times. .The'. computer;information was, updated as

, lne'eded by . engineering, procurement, or stores, as appropriat ,

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During the review ofethe procurement and stores area, the1followin '

concerns were identified:

• Three different items of-limited life material were found'in-

. stores without~being identified as limited life material and with no expiration date.specified.- Items noted were as follows:

• '

Item 350076,-RTV Silicone Sealant

-- two boxes not

' identified ^as limited. life' material and no expiration dat .

b.' Item 709207; White Adhesive Sealant --217 tubes not -

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identified asilimited life material and no expiration dat , ,  ; Item 709174, RTV Red Heat Resistant Sealant -- 158 tubes; of these,1.' box of s36' tubes was identified as limited life e material on the box. Individual tubes were not' identifie None of the other 122' tubes'was identified on the box or.

, , , the tubes. Loose tubes were on the shelf available for-issue:

All of- the above items were non safety-related material. .During

,

the review of ZAP-13-52-2,. " Preventative Maintenance and Limited

%0 Shelf Life of safety-Related, ASME Code, Regulatory Related, and Non Safety-Related Items," Revision 7, the inspector noted that Paragraph 1.b. required the labeling of limited life material which must include the' discard dat Significant management attention isurequired in this area to assure adequate control of-limited life materia * In reviewing welding materials in stores, the, inspectors noted '

that.a number of welding backing rings had significant surface

, rust. This rust made the backing rings unusable without extensive cleaning. The inspector was told that most of.the welding material was old and had been transferred to stores from constructio .

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'the' warehouse in the controlled area. L ThjM[in'; cpndition items did not. stored in

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$*, , / i appear to exist in the other warehous ;

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• ZIn the electrical maintenance areas,ithe' inspectors note'd a '

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, ,significantiamount of material. stored in the. shop area. . Some of

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this material appeared'to be used and was stored.in'open bins'

r but not' marked by part number or other identifier. The,.

inspector;was told this' material"was material? to be used for:

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A partsyin non safety-related. applications; The inspectors were- 'j<

also told.there was no.procedurefforTcontrol of these part '

This did not appear to'be appropriate coritrol-even for non v <

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. safety-related parts; . Another storage area' in electrical .

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i s , ' maintenance was lockedTand was marked " Safety-Related." This ,

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l storage _ area contained new expendable parts such as lugs and

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splices'.that were ' appropriately identified.by both part numbe ff

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Overall, this area was considered to be satisfactory. Managemen l t attention is'needed in;the control of limited life' material and non safety-related electrical component ,

d 3.3. Control and Calibration of Measuring and Test Equipment (M&TE)

Control of MT&E was~ satisfactory in that defective or " calibration i

'due" instruments were. segregated from those in calibration and -

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acceptable for use. Procedures were developed.for the issue,. return,

- and recall of M&TE. lThe individual checking out an instrument; the ,

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. work order, procedure,;orl location used;.date out, and date' returned-

were recorded'for permanent, record All-three maintenance disciplines maintained their own-M&TE issue room. ' A; strength noted by the inspectors was' that the mechanical ~

tool room' attendants noted the pre-use" and post-use test reading fo '

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. torque wrenches and' micrometers. This practice precluded the-issuance'of equipment:that was'out of calibration. If a tool was found to be out of calibration after use, the work crew was issued another too1L for the verification of the work done with the faulty

_ ,

tool. This method prevented multiple _ usage of a defective too LMuch of;the certified equipment onsite~was sent off-site to' Systems Operations Analysis Department (SOAD1<for calibratio .'4' Review and Evaluation of Maintenance Accomplished

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3. Backlog Assessm'ent and Evaluation ,

,

The inspectors reviewed the amount of' work accomplished compared to the amount of work-scheduled. Emphasis was placed on work that could

e affect the operability of safety-related equipment or equipment

'L_ considered important to safety, which included some balance of plant component Maintenance" work item backlogs were evaluated for safety impact of deferrals and deferral cause U

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The majority'(61.5%):ofinon-outage' corrective maintenance NWRs were;

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-prioritized B2; which was defined i in the COM as work.that must be;

.,f  : sch'eduled' within five da'ys'. ? AlsoT priority B1 non7 outage NWRs,y ,

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(defined las work to be schedulsd wishin 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, constituted;' .. .i '

.'a' approximately 10% of the backlog. As a result /of discussions with L

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the . licensee,0 the' entire, backlog of NWRs .was reviewed to, determine if=

any, affect plant operabil.ity oroshould be. immediately completed.' The - 1, 11icensee determined thatinone 'of thelbacklogged'NWRs needed=to be:.

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reclassified:to.a higher pr,iority; howevers the majority were ' . . . ^l

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' reclassified-i6?accordance with: the COMA As a result,'the percentage .!

$ x of!B2 NWRs' dropped from 61.5% to:7.5% and B3fNWRs (schedule work asi j time permits) increased from?24% to 86%. :Th'e inspectors reviewed a

'

Q sample of;.reprioritized NWRsia~nd no concerns were noted. 'The . j

licensee ~ stated that changes 'were.needed in. Zion's NWR prioritization  ;

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,l-17

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process to agree with'the COM.,

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The ~ backlog'of bot _h outage _ and 'non-outage NWRc"was: tracked by the' l maintenance, department by use of a computerized syste Backlog , ll '

information could be obtained from the computer at any time. . .

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tracking report was issued monthly 1to' management on the status of the backlogs.7 ~ The1 current as well as previous month's backlogs were j

, listed so changes were readily apparent. 'The report also indicated 1'

the percentage of'NWRs open more than three months. At the time of

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the;inspe'ction', Zion was meeting the goal.of less than 50% NWRs greater than three months ol j

Approximately.130NWRswereidentif.iedbythecomputerasawaiting'.

parts;~however, the majority were outage related. The inspectors'

j i

reviewed several non-outage and outage; backlogged NWRs' and determined  !

that noneshad' impact:on operabilit ,,

The inspectors determined that on' July 118,'1989, the non-outage NWR

~

' backlog:was.901 for mechanical maintenance (MM),148 for electrical '

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maintenance -(EM), and 144 for instrumentation maintenanc'e-(IM). The '

-1 CM backlog was low and within the capabilities of current staff.; ,

however, pending NWRs were still above the station goal of 85 ~

l Based on the number of craftsmen and an average manhours per MWR  ;

co'mpletion, there was approximately eight weeks work for.MM,- and.tw '

weeks for. EM and I .4. Preventive Maintenance Backlo i

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Preventive maintenance NWRs were also tracked by a computerized  !

syste PM was accomplished by nonscheduled NWRs and by scheduled

, PMs, which were mostly acenmplished using procedures rather than work requests. The scheduled PMs were tracked by the. General Surveillance Program-(GSVR). Also included in the PM program were lubrications

>

that were tracked monthly. Based on review of licensee records, the inspectors determined that on July 18, 1989, the nonscheduled PM

'

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backlog was?498 and the scheduled PM backlog was 66. No scheduled PMs were' deferred; all 66 were classified as past due. This backlog was low and represented a little more than one months work. The

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licenseb'sratioofPMhourstot'talmaintenancehoursaveraged-o about 46% which was higher than the~ industry average of 42%.

Review of the outage and non-outage backlog of PM NWRs-did not

identify any that could adversely affect operability.'

'

3.4.2- Review and Evaluation of Completed Maintenance

.

The inspectors selected the equipment and systems identified in Section 3.1.2 of this report for further review. The purpose of this-review was to determine if specified electrical, mechanical, and I&C 1 maintenance on those selected systems / components was accomplished as require This review included:

Application of risk-based priority to the performance and extent of-maintenanc Evaluation to determine the extent that RCM was factored into the established maintenance proces Evaluation of. the extent that vendor manual recommendations, 'IE Bulletins (IEB), IE Notices (IEN),' Service Information Letter (SILS),

Significant Operating Experience Record (50ERs), and other outside

,

source information was utilize Evaluation cf the extent that maintenance histories, NPRDS, information, LERs,= negative trends, rework, extended time for outage, frequency of maintenance, and results of diagnostic examinations was analyzed for trends and root causes for modification of the PM

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process to preclude recurrence of equipment or component failure Evaluation of completed CMWRs'and PMWRs for use of qualified personnel, proper prioritization, adequate work instructions, Quality Control (QC) involvement, quality of documentation for machinery history, description of problems and resolutions, and post maintenance testin Evaluation of work procedures for inclusion of QC hold points, acceptance criteria, ease of use, and general conformance to NUREG/CR-136 Backlogs for selected component .4. Past Electrical Maintenance The inspectors determined that the Electrical Department philosophy addressed elements of RCM, which included vibration analysi Equipment failure trending and analysis of maintenance problems was addressed in the licensee's TJM and Problem Analysis Data Program

,

(PADS) which is discussion in Section 3.6.2 of this repor The inspectors reviewed 65 completed NWRs in the electrical

,

maintenance area. Most of the NWRs did not describe the component l failure (Maintenance Code Block) or the reason for the failure l

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(Maintenarice Cause" Code) as required by ZAP -3-51-1, Revision 33. The

- reviewed NWRs contained the; appropriate approval . signatures and the

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required tests.were: signed as completed.' .A review of,the tests conducted revealed that the; tests properly' tested the corrective maintenance activities described'in the " work completed" section of

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the NWR. Approximately half of the NWRs contained brief work

. instructions which read "investigateLand repair-as necessary." The

. work description.s were not specific. The brevity'and latitude implied in these instructions caused the inspectars.some concer ,

However, no instance of failure to.use the appropriate procedu*e or to conduct work in accordance with established policy was noted during actual work observations' by the inspector ,

t On October 10, 1987, six NWRs (Z63523, Z63524, 263689, 263690, Z63691, and Z63692) were' written ~and described the failure of the dc battery to dc bus feed breakers to reliably close on the first m attempt. As of June 22, 1989, these NWRs were still open. An

. investigation by vendor representatives (undocumented) indicated that the problem appeared to be worn bearings. The licensee could not ,

describe with certainty which bearings were worn. Based'on . l discussions with the system engineer, the breakers have always closed :

on.the second attempt. No tracking system had been established to track the operation of these breakers to determine if the closure action' performance was' degraded. Replacement of the breakers required deenergizing the bus. The Technical Staff and the .

Electrical Department indicated that they would like to replace the '!

breakers; however, the Operations Department did not want to :

deenergize the bus. No action plan to replace or repair.these

.breakerswaspresentedtothel inspectors. The inspectors ~were  !

-concerned that the licensee was not pursuing an aggressive action plan to. return these safety related breakers to fully reliable i performance'. Failure to take timely corrective action to correct

'

breaker closure failures is an example of a violation of 10 CFR 50, Appendix B, Criterion XVI (295/89018-01B; 304/89017-01B).

.The inspectors reviewed Electrical Maintenance Procedures to verify ;

inclusions of vendor recommendations, IEBs, IENs, and other.outside source information. The procedures were reviewed to determine that ;

appropriate QC hold points were identified. The following procedures l were reviewed:

E000-1, " Motor Test or Disconnect / Connect' Data," Revision 0 i

'

E005-1, " Repair or Replacement of Logic Relays," Revision 7 E022-1, " Inspection and Maintenance of Limitorque Valve Motor j Operators," Revision 7 l E024-2, "ASCO Solenoid Valve Replacement and Installation,"

Revision 0 E028-1, " Cubicle Cooler Fan Motor EQ Inspection / Maintenance," i Revision 1 l

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.TSSP-139-89,l" Test'of:1BAFWPump. Control: Switch:at-Remote, Shutdown +

3 7 tPanel,"l Revision 0"

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.- The review indicated that the procedures'did contain information'or-references to outside source' documents such as IEBs,'IENs,~and' vendor.-

y _ notices. (QC hold' points were properly: identified in the procedures..

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-~ field workivhich could lead to an undetected' electrical proble ~

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Thisits' discussed in Section 3.3. .. .

The: inspectors reviewed the Vendor Manual upgrade program,; '

L ' 4 ._ ZAP 6-25-5, " Zion' Station Vendor Equipment Technical Information

,L Program'(VETIP)," Revision 8. The VETIP program began'inLlate 1988 U

,. , :and is expected to be completed in.midl1991. The' program insured'no; K .

J unreviewed Equipment Technical Information (ETI) was used in.the=

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performance of work'on the, equipment defined and to control Equipment Technical Information Manuals. The' defined equipment included Safety-Related, Regulatory.Related, Reliability Related, and other equipment, selected by the station. Information sources for the ETI-

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program: included Vendor Manuals / Bulletins / Notices', NRC-

. Bulletins / Notices / Generic Letters /Part 21 Notifications, Station Experience,.and Indust'ry Sources. Approximately 150 of an estimated 3,000 manuals have been completed. It:is. estimated that 45,000

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components and. equipment'will;be included _in this upgrade program

'

' when completed. Manuals _that have not been reviewed by the VETIP procedure are used'only with approval of the appropriate Maintenance ,

7, Department Head.' However, no: check was required to ensure existing maintenance procedures. agreed with the new controlled manual m

.A review of' selected vendor manuals"was conducted to ensure that

.

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-vendor recommended maintenance actions and frequency were accomplished. The inspectors were concerned that the licensee had not verified.that the PM program incorporated the' vendor recommendation for maintenance or provided justification, by analysis, for changes to the vendor rec' commendation For example:

'

• The essential switchgear. vendor recomm' ended an inspection interval of every 6 months; the: licensee schedule was every-18 month * The Buffalo-Forge manual for the Auxiliary Bui1 ding Ventilation Supply Fan could not be' located. However, the manual for the exhaust fan (same vendor) suggested a motor bearing lubrication  !

frequency of every nine months. The inspectors could not find I the supply fan equipment identification number in the Lubrication Program Auxiliary Building Ventilation record >

3.4. Past Mechanical Maintenance The inspectors, determined that the mechenical philosophy did include some concepts of RCM. The licensee used vibration analysis for predicting the reliability of pumps and fans. The licensee also measured the pipe wall thickness in steam extraction lines and l

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feedwater lines'to predict possible failure's based on reduction in wall thicknes "

The'licens'ee was in t'e h initial stages of a new MOV overhaul and

- diagnostic program'for all MOVs in the plant. The overhaul consisted of. a complete inspection and PM that included lubrication of: the main

- gear case,' limit switch compartment and valve stem, and proper setting.of torque and limit: switches. The program was scheduled to begin during the next refueling outag Zion experienced 26 MOV failures during'1988, which was down from 43' ,

failures in 1987. This downward trend was expected to continue i because.all safety-related/non safety-related MOVs had been recently added to the PM progra The licensee did not perform stem thrust' diagnostic testing on any MOV Current signature traces were used to determine the relative condition of the MO Current signature measurements are the simplest, but yield the least accurate result It was noted tnat Zion was implementing a M0V test program which would yield stem thrust measurements by yoke strain measurement. This measurement will provide the most accurate information in both the closed and open direction through the entire stroke. Zion was considered behind the industry in taking initiatives to improve valve diagnostic The inspectors reviewed the following Zion procedures used for maintenance activities for completeness, necessary approvals, adequacy of work instructions, inclusion of QC hold points, and acceptance criteria, when applicabl P/M017-1N, " Hydraulic Snubber Handling and Rebuilding Procedure,"

Revision 8 P/M017-3N, "ITT Grinnell Hydraulic Snubber Removal, Decontamination and Reinstallation," Revision 3 PT-7, " Auxiliary Feedwater System Checks and Tests," Revision 42 TSS 15.6.48, " Hydraulic and Mechanical Snubbers Survei'llance,"

Revision 21 ZAP 3-51-1, " Organization and Routing of Work Requests," Revision 33 ZAP 10-51-1, "Backseating Instructions," Revision 4 ZAP 10-52-10, " Vibration Monitoring / Analysis Program," Revision 12 The inspectors determined that the procedures reviewed were  ;

generally adequate. However, Zion Station Administrative j Procedure ZAP 10-52-10 included criteria for alert and action limits '

for vibration levels of the auxiliary feedwater turbines as 5.91 and 10.61 mils peak to peak, respectively. The station vibration coordinator stated that these limits were based on the Canadian government specification CDA/MS/NUSH 107 for small turbine The

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willoapply,iifjmore limiting than'CDA/MS/NUSH 107L The' inspectors reviewed theLturbi'ne' vendor. manual andifound that recommended 1 1"

vibration' levels wereT3;and 5 mils peak'to peak respectively, for-l- , ; ,

g operation and trip oflth' LAFW; e turbine. Therefore,. the vendor;

.

9 Recommendations would; appl Neither the< system: engineer nor the

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L vibration coordinator were. aware of the'more restrictive criteriai ,

Lfrom the{vendorc iThe inspectors: reviewed pastLvibration'

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' measurements and found no instances where vibration levels exceeded:

t3' mils. However, ; excessive unacceptable Vibration-levelse on(these > .

j-turbines could havelgone; unnotice The' inspectors evaluated the'extentLthat vondor recommendations, IE: <

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~ Bulletins,-IE Notices, and vendor'informatio'n bulletins lor letters,

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.were utilized in the' maintenance of.the components' selected,

.  ; including feedwater pumps:and turbine .

, DVendor manuals. reviewed were.as follows:

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ETI;000017,' " Terry Turbine Instruction' Manual,"' Revision 0'

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ETI:000082, " Pacific'(Dresser) Pumps Instruction Manual,"'datedf

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October:3, 1986-i ETI'000103,'"Trane' Reciprocating Compressors Manual," Revision O'

2 .ETI 00108, " Circulating Water Pumps Manual," dated October 1969 The inspectors verified that the vendor recommendations were-7 adequately addressed'in the licensee's PM program; however, the

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following was note <

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• J The. AFW' pump turbine manual included recommendations from

1. ' .

Woodward Governor'(Bulletin 36694D) that'the overspeed governor

• 'and trip mechanism be' tested regularly, preferably once a wee '

' Schutte Koerting Company, who supplied the throttle.and trip

'

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t valves, included a recommendation that the moving parts be

~. lubricated at-least once:a week, and thatNall parts be kept .

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clean. -Contrary to the vendor recommendations, thel licensee had

.

never tested _the overspeed trip' mechanism of Unit-2 AFW turbin The Unit 1 trip mechanism was tested once during April 1987, with limited succes '

The inspectors were concerned that lack of testing of the the

~ Zion Unit 2 AFW turbine overspeed trip mechanism could subject the_ downstream piping of the AFW system to~overpressurization should the turbine overspeed and the trip mechanism fail to o M function. Information Notice No. 88-67.was issued on August 22, i X 1988, and described a July 1988, failure of the AFW pump turbine overspeed trip mechanism at San Onofre Station. A failure of

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the overspeed trip mechanism at Rancho Seco Nuclear Plant occurred during January 1989, an incident in which the AFW system was overpressurize , y_ 27

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Thelicenseewasaware6f:the'FW'turbinet'esideficiencp"ast A -

nearly 'as July 1986, when General Electric (GE)' Memo G-EB0-6-225?

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M . e > , !was r'eceived and identified problems with the Terry Turbine trip -

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7 assemblie A similar finding was'ma~de again:by INP0 during

• nZion's February 1989 assessment. The licensee proposedL "

. corrective'actionito this finding jas.to'. test the linkage and- '

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valve mechanism monthly'and conduct the. actual 7overspeed tests

'

' periodically, typically during each' refueling outag ,

ua Subsequent to the inspection and NRC concerns, the licensee

"' tested the Unit 1 linkage and val ~ ve mechanism on_ July 22-23n ..

~

L1989, in accordance with Zion procedure TSSP 151-89, Revision'. ' "

During'the. test, the valve did not; actuate as.. required when the E i manua1{ trip ~ lever was depressed. Maintenance had to be'

performed to remove' paint and corrosion.from the mating surfaces and. lubricate part "

Subsequent to this maintenance', the' Unit 1 AFW' turbine'overspeed e trip mechanism was tested successfully; .The licensee-informed:

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the NRC.' inspectors that the linkage and valve _ mechanism tests on:  ;

l ,i the Unit 2 auxiliary feed' turbine were:successfully. completed o July 23,;1989;

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c Thefollowingareconcerns'r'egardingthelacklof'testingoftheAFW ,

< turbine"overspeed tripimechanism- 1

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• cThere werefno documented records available to demonstrate'that-

. the AFW turbine overspeed trip tests!were' conducted during'

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preop /startup'te's ting phase; * ,

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• - VendorrecommendationsfortestingtheoveEspeedtripmechanisms b weekly were never translatedfinto station PM procedure <

.* .' Actual overspeed trips were never performed on the AFW turbines .

. prior-to 1987 on.' Unit 1, 'and July 1989,: on the Unit 2 AFW turbine- .

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even though the licensee had knowledge of TIE Notice 88-6 Corrective action to test the overspeed trips from 1987 until 1989 was untimel * The licensee did not evaluate the safety significance of non-operability of the overspeed trip ,

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Based on the above, the inspectors concluded that the licensee did lv' not take timely _or adequate corrective actions to inspect, maintain, and test the overspeed trip mechanisms of the AFW turbines,'even'

though the licensee knew of the problem since at least July 1986.

c The. inspectors determined that if the Unit 1 AFW turbine overspeed trip had been required to operate during an ' actual event, the failure could.have overpressurized the Unit 1 AFW piping system. The failure of the overspeed trip mechanism was considered significant, as the

"

AFW: system is. designed to prevent or mitigate a serious safety even The licensee's inadequate and untimely corrective action of several years in dealing with this significant issue'is an example of a

.

.

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I violation of 10 CFR 50,' Appendix.B, Criterion XVI, (295/89018-01D;-

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,w' . 304/89017.-01D);  ;

3.4. .Past Instrumentation and Control Maintenance l

The inspectors determined that'the I&C maintenance philosophy  !

, included some concept of RCM. Maintenance was primarily based on l

', vendor manuals and previous maintenance histor !

)

The inspectors evaluated the extent-that vendor recommendations,. .

IEB's, IENs,: SILs, and other outside source information was ' utilized I

,. -in I&C maintenance. -The component selected for evaluation was the Rosemount,~Inc. pressure transmitters. The inspectors reviewed the

'

following. documentation- ]

10 CFR 21 Report from Rosemount, Inc., dated February 9, 198 j IEN 89-42, " Failure of Rosemount Models 1153 and 1154 Transmitters."

, Vendor Manual.4302, "Model 1153B Alphaline Pressure Transmitters for i Nuclear Service," Revision '

The 10 CFR 21 Report documented a problem with pressure transmitters

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'that manifests itself as degraded response time over full range i Jand/or overall increased response time. The licensee had reviewed the probles and had a testing procedure developed by Northeast Utilities that will be used to test all Rosemount transmitters during  !

routine outages. This testing should detect any degradation'of the l Rosemount transmitters installed at Zio The inspectors reviewed selected vendor. source documents to determine if. requirements'specified were incorporated into appropriate maintenance procedure The source documents reviewed were:

.

Heise Digital P_ressure Indicator, Model 710A L Heise Digital Pressure Gage, Model 901 A/B Hewlett Packard Digital' Multi-Meter, 3466A The inspectors verified that the vendor recommendations were L

adequately addressed in the appropriate calibration procedures with the exception of the temperature and humidity controls discussed in

~

I Section 3.3.4.3 of this repor The inspectors reviewed component history for the I&C components and systems selected to determine whether methods had been established and implemented for detecting repetitive failures and adverse quality trends, and whether appropriate corrective action had been taken to address adverse trends. The inspectors also utilized NPRDS and LERs in the review to ascertain the effectiveness'of the licensee's trend analysis and root cause analysis. Concerns were identified with the licensee's approach to,both trend and root cause analysis and are discussed in Section 3.6 of this repor _ _ _ _ _ -

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'1 personnel,iproper prioritization', QC involvement, quality of;

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documentation for the work-history and post-maintenance testing. Thel -l j ifollowing concerns were. identified:

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Post-maintenance t'ests' were insufficiently specified 'and poorly.' d documented as' discussed in Section 3.5 of.this repor '

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Work. history documentation was poor. -Simple, general statements-

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4 . were used to describe completed work's'uch ass" Completed' .

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- calibration" or " Repaired." = Cause codes were'not' .indicatediin 8 4 ft ap

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of,27.NWRs reviewe '

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• .QC-hold points were required in only'5 of 27 NWRs reviewe '

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TheiinspectorsreviewedI&CproceduresLfor'inclusionofQCholdl ~

J points,, acceptance criteria and ease of:use. The licensee ~was' ,

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_ aggressively updating I&C procedures at.a rate of approximately 60 rper wee New procedures were detailed, contained-vendor recommended-refurbishment,-required tools and 'necessary acceptance criteria; j

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however,~ QC hold: points were not included and, management attention.is needed to^ assure adequate QC coverage'. The' procedures were 'i considered user friendl '

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' Maintenance Work Control

< The inspectors reviewed:several maintenance activities to evaluate

. the effectiveness of the maintenance work control process;to assure  :; j f that plant safety, operability, and reliability were maintaine . Areas evaluated were control of maintenance work orders, equipment i v maintenance records, job planning, prioritization and. scheduling of 1 work,= control of maintenance backlog,, maintenance procedures,L post <

i maintenance testingi completed documentation, and revi_ew of work'in .I d, progres j

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Job planning Eas no't detaile Several$orkJpackageswereinaccurate- 1

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or incomplets, and contained insufficient'information to support l consistent quality work. . Work packages appeared to be developed to , l support any contingencies that-could develop from the problem / work , j

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requested in the'NWR and werei notitailored to the work instruction i The work instructions <were<often vague and contained general j

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directions- such 'as " repair / replace": or " investigate and repair."

iPre-job scoping wasifrequently'not' effectively performe ;

i In some instances, procedures required.for the work identified in the i work instructions were omitted from work package Other procedures, j

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.not related to the work instructions', were incorporated in the. work l

,y packages without indication of how or in what sequence the i 9; procedures were to be used. ' Examples of insufficient job planning are contained in Sections 3.3.2 and 3.4.2.1 of this repor r PMT requirements were insufficiently specified, and the results of post maintenance tests were; inadequately documented in work package Station procedures for PMT were drafted but had not been approved.

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i been-conducted on:PMT;ihowever, weaknesses still existed. Examples:

S ofL problemsfnoted include

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[L 4 *1 NWR '83200"-J Rehuire'd the rep 1'acementlof ?a filter in the system; idue to a high' differential pressure (delta-P); ;No'PMT was'

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specified to check'the' delta-PTunder normal system flow

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following? completion.of the maintenanc The delta-P was not" f ,

recorded at the completion of wor .

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.* ;NWR:78321 . Identified"arpr.oblem with Nuclear Instrument'

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indication. :The work instructions required the verification of: . Compensating voltage per Calibration Procedure'IN-35E. tThis X , procedure was not used to perform.the work-'andLPMT,was nota m q 'specifically specifie The " work performed" section.of the a

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work packageEstated. " comp. voltage read.- 40.98;vdc". .PMT -

E'- .should have included verification of the nuclear instruments N' s calibration per procedur o m ' ~

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.During-the inspe'ction, increased' emphasis on PMT was noted with.nine s of ten I&C work packages,cand four of five electrical work' package % .

/ - prepared by work analysts that clearly' indicated PMT.. However, most

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^ Lof the' completed work packages reviewed did not specify PMT after < 3

- ; ~ maintenance $ activities that'would require such testin "'

c . The i'spectors n reviewed the areas of. maintenance' work planning and

'

. scheduling. 4The" inspectors reviewed these items withsthe' mechanical

< . scheduler and the mechanical senior work analyst. Personnel appeared-

+'- to.be knowledgeable;in:the areas assigned. The inspectors were told-the mechanical maintenance department planned to ' increase the: current'

,

staff of four work' analysts'to.nine, in view of the; increased scop of work.1,The inspectors noted- concerns -in' prioritization of the maintenance work as discussed inLSection 3.4.1.1.

3.6: Engineering Support of Maintenance The'-inspectors evaluated the extent to which engineering principles

'and; evaluations were integrated into the maintenance process. This e, '

<was: accomplished by review of maintenance work orders,' activities n associated with. failure' analysis, and other maintenance activities to

'

evaluate the effect ofLengineering support. Areas reviewed were engineering support to PM, material qualifications, compliance with n codes and regulations, system engineering concepts, industrial-

,

< , initiatives and post-maintenance testin .

3. . Engineering Support

.) !

The " System Engineer" concept was.not fully functional at Zion P

Station. . Tech Staff engineers, inLgeneral, were given assignments on a functional basis such as erosion / corrosion program, plant life

. extension, vibration analysis, eddy current analysis, and pump and valve program. 'Some assignments in the thermal group were made on a

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Specific responsibilities for system engineers were not included in any specific. procedure; however, the position descriptions for engineers were. issued in a paper dated April 15,.1987. Minimum

.' qualifications for systems engineers were'not considered to be very demanding since requirements could be two years related experience or a high school diploma and one and one half years related experienc Discussions with several technical staff engineers indicated that the experience and expertise varied.widely. While some engineers appeared to be knowledgeable in the systems assigned to them, others were not. The inspectors noted that some engineers kept notes'on events in the assigned systems, but these were personal notes and were not considered to be comprehensive.-

The following additional problems in the system engineer area were noted:

• The assigned engineer received the " blue" copy of the NWR when initiated; however, completed NWRs were not received. This

-

prevented the system engineer from evaluating assigned system failures, detecting adverse trends, and determining root cause * 'As mentioned earlier, several responsibilities were assigned on a functional basis. The results obtained by the specialists were not routinely sent to the system engineers for review and analysis. For instance, the vibration coordinator did not inform the system engineer of vibration levels of a pump or a fan unless the vibration levels exceeded the alert or action limits. Similarly, the IST. coordinators did not inform a system engineer about deteriorating performance of a pump, unless the performance _was unacceptable as per the applicable code requirements. The assigned. system engineers were not aware of events or performance problems unless unacceptable levels of performance had been reache * The inspectors noted some weakness in resolving problems due to distribution of work to different sections of the technical staff. -When the inspector raised the issue of severe corrosion of service water piping inside the containment, the Service Water System engineer was not aware of the condition. The inspectors were referred to the Erosion / Corrosion Coordinato i The Erosion / Corrosion Engineer stated that the corrosion of service water piping inside the containment was handled by the corporate. offic * The inspectors discussed the silting problem in small heat exchangers, due to silt carried from the lake water. The system engineer for the Service Water System did not have a comprehensive understanding of these problems. The inspectors were informed that the silt problem would be handled by the corporate engineering staf . Technical Suppe $.

32

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4 4' ~ Component trending was provided by' Zion's TJM system. ! Station personnel were" alerted in the event'of an excessive number.of " hits" M, f * '

(two) for correctiv'e maintenance actions in a 12 month ~ period.' . Hits.

,

'

were based on Equipment Identification Numbers or Manufacturers'

}' ~.' t 'Model Numbers. Excessivel" hits" generated a report to. Corporate N- , Headquarters, which was forwarded.to the station' PADS Coordinator for" ','

evaluation.- In the' event the evaluation indicated the need for m further: analysis 'a PADS review was indicated and forwarded to the'-  %

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technical staff for' evaluation. Other problems'that could result in

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Y a' PADS-initiation included: (1) A safety related,. regulatory

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related, code,'or: reliability related component that caused the M, ' '

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equipment or

system to.be' declared" inoperable'or' required moreLthan

.

E, 80. man-hours uto ' repair; or' corrective maintenance was- the result. off fx unsatisfactory PMT orJ the Min-Max TJM report showed a trend of repeat l W_ ,or' rework; f (2) A; preventive maintenance or surveillance. test that

_

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L". 1 indicated a measure'd data point had~ deviated from itsiallowable band H ,

of operation.and was not covered by a DR/LER/DVR/IDR. :(3)'A surveillance or:a-preventative maintenance activity had failed resulting'in' corrective maintenanc The purpose;of.the PADS program was to provide a consistent method of

. performing' systematic' analysis of maintenance problems to determine 1 the root causesiand establish appropriate. corrective action

'

consistent.with'the importance of a given piece of equipment to x prevent future failures. When initiated, a PADS ' report . required the .

Work Analyst to review the TJM Maintenance History for failures. _ "

. ,s ooccurring on the same type of equip:nent, model number, or: components

, that Jiave previously failed at the: station'. : The analyst was also

, ' requi,ed to notify the, system engineer or. technical staff. The Work

" Analyst indicated the probable root'cause'and provided corrective-

~ action recomniendations with concurrence.from maintenanc The trending and Root 2Cause Analysis (RCA) programs for maintenanc activities were inconsistent.and fragmented. A RCA procedure was'in

. draft but had not been implemented. ADeviationReport(DVR) program

existed only for major maintenance problems. The Discrepancy Report

'(DR) instruction'had been in effect for only three months and the

~

'

effectiveness of the program could not,be: evaluated. Trending programs existed,Jbut were-inconsistent and uncoordinated, and

,

procedures were inadequate: Examples ofitrending' programs included, ;i L

, Instrument Discrepancy Reports (IDR), Certified Instrument 5 Discrepancy Reports'(CIDR),:TJM and~NPRD The primary document for initiation of RCA appeared to be DVRs. The )

DVR program had high thresholds for the initiation of a DVR, This

, . limited the program to a very narrow range of events. The program was limited further by the inconsistent application of these 7 thresholds. For' example, a DVR was required for a 10% derating. The

~

'

' : . licensee's Monthly ReportLData Forms for 1988 indicated 18 deratings of greater than 10% where no DVRs were initiated. Zion had 13

~ ' '

deratings in 1988/89 due to problems with steam generator chemistry  !

T on startup for which no DVRs were written. The DVR coordinator indicated that startup chemistry events were a perennial problem and

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that the pervasiveness and causal factors relating to startup

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s chemistry problems were known. However, RCA documentation for steam

. generator chemistry problems could not.be provided when requested by the_ inspector Other areas where RCA was considered a concern were:

'

• ConsistentinoperabilitylofRadiationMonitoringInstrument *- . Consistent failure of all dc Bus Tie to Battery breakers to close on the first attemp * Accelerated tube leakage of 2A steam generator with 212 tube plugged compared to 54, 40, and 40 tubes plugged in the other Unit 2 steam generator The licensee's long term programs for improving RCA were relatively new; therefore, the implementation and effectiveness were difficult to asses Trending programs were uncoordinated. TJM, NPRDS, and PADS had different cause codes for documenting the same maintenance proble Cause codes were insufficient. For example, TJM did not have cause codes for electrical / electronic component aging failures ,No guidance was provided to indicate what components were covered by individual' trending programs. This caused overlapping coverage and

.potentially.a lack of coverage for sone component The inspectors noted inconsistencies in'the collection and dissemination of trending data. Cause codes needed for trending were -

not documented in 8 of 27 completed NWRs reviewe No semiannual report for the IDR program has been issued for the past yea . Incomplete procedures existed for the IDR and CIDR programs. The reporting requirements for these programs were in ZIAP 5-51-12, Revision 26. This procedure required copies of IDRs to be forwarded to the Technical Staff; however, no procedure existed for the trending and reporting of IDR data by the Technical Staf ZAP 15-53-1, " Processing Discrepancy Reports," Revision 1, required the initiation of a DR for broken or out-of-tolerance M&TE. The I&C department did not use DRs for MT&E problems. CIDRs were written for broken or out-of-calibration MT&E and turned into the QA department in place of DRs. The QA department did not log CIDRs as required by the DR procedure and no formal procedure existed for the trending and reporting of CIDR dat .7 Maintenance and Support Personnel Control The inspectors reviewea the licensee's staffing control and staffing needs. Inspection activities included interviews with plant personnel, training facility observations, in plant observations, and review of documentatio The licensee had developed a comprehensive plan for personnel control, which was proceduralized and integrated into the maintenance

34

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iprocen. The rgani.zation chart was available and generally up' to: MJi p"~

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L interviewed and were found to be' knowledgeable of' responsibilities land accountability. jThe staffing requirements for the Mechanical,

.

nw ', __ Electrical ~,_and I&C departments appeared to be adequate for;

'

rnon-outage; work. The inspectors were told these departments were

' 6 supplemented with contractor services 1during heavy outage work load .

,

m  ! Contractor services could not be adequately assessed .duringLthis , ,,

4 non-outage inspection.

/ g_ The. maintenance training program wasfaccredite'd by INP0 on

,

,  ! November 25, 1987. . The inspectors observed'the licensee's trainin + ~ facilities and noted the use of mock-ups- for. all maintenance a discipline ((l D

'~ 3. 8 m " Review of Licensees Assessment of Maintenance

. .

The inspectors' evaluated the licensee's quality' verification process i in the maintenance area by the review'of audit reports, surveillance reports, corrective action documents, the' maintenance'selfl

' assessment, and the Auxiliary Feed Water. Safety System Functional,

,

'

q' ' ' . Inspection-(SSFI) report. The documents.were reviewed to assess n,. technical adequacy, root cause analysis, timeliness of corrective action, Land ~justificationfor;close'outof..correctiveaction-

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document '

, 13. ' Audits and Surveillance

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The: inspectors; reviewed records of five audits conducted during the last year,which covered portions of maintenance. ; A complete audit' of'

maintenance had not been performe maintenance audit coverage.was c

usually provided by specific product audits which'were very limited

~

in scope,- only addressed small portions Lof < maintenance, and did not-

_

appear.to be performance oriented However, two Lof the audits

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reviewed appeared-to provide good coverage of PM in' the mechanical

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'and' electrical disciplines. These audits:Gere-conducted.in December 1988, and March 1989, and resulted in thecidentification'of several

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significant PM prob 1_ em These included inadequate, equipmen T1ubrication and.PM activities not being completed as schedule 'Although'someLimprovement had been made, these same conditions still

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existed and were noted during this. inspection. The inspectors were told that' a complete maintenance audit was scheduled in July 198 ~

The inspectors reviewed the check' lists for this scheduled audit and noted that the methods of verification were not specified; therefore, it could not be determined if the audit would be performance oriented or no The inspector reviewed records of four QA surveillance conducted j during 1989.between January and March. These surveillance, although l

'

very limited in scope, included the observation of work and appeared to be performance oriented. No findings were identified during these surveillance. Based on the results above, it appeared that the QA

,

, surveillance program was performance oriented and provided a good supplement in the licensee's assessment of maintenance.

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, 3. Review of Maintenance Self Assessment and SSF1

, 3.8. Maintenance Self Assessment The inspectors reviewed the report of the licensee's_self assessment of maintenance performed by maintenance management personnel fro .other CECO nuclear power stations and corporate operations,

. maintenance, stores, and training staffs during September of 198 A copy of'this assessment was not sent to QA for utilization in QA followup audits of maintenance. Based on reviews and comparisons with other industry self assessments of maintenance and the results of this current NRC inspection, the inspectors concluded that the licensee's self assessment was effective in the identification of maintenance problems and concern However, many of-the problems and concerns identified during the self assessment in 1987 were noted by the inspectors during this inspection. This indicated inadequate or untimely corrective action. The following weaknesses were noted:

• AFW components including overspeed protection testing were not tested per vendor recommendations; discussed in Section 3.4. of this repor * Failure to follow procedures and inadequate procedures; noted in Sections 3.3.2.1, 3.3.2.2, and 3.3.2.3 of this repor * Post-Maintenance Testing; discussed in Sectinn 3.4.2.3 of this -

repor * Temporary Modifications; discussed in Section 3.3.1 of this repor * Work Control; discussed in Section 4.3.1 of this repor Failure to provide adequate and timely corrective action on known problems in post maintenance testing, temporary modifications and work control is considered to be a violation of 10 CFR 50, Appendix B, Criterion XVI (295/89018-01C; 304/89017-01C).

3.8. Safety System Functional Inspection (SSFI)

A self initiated SSF1 of the AFW system was conducted from June 1 to September 13, 198 No maintenance. deficiencies were identified during the SSFI; however, two maintenance concerns were identifie These concerns related to the failure of engineering to provide adequate documentation of torque switch settings to maintenance, and the failure to test the AFW turbine overspeed trip mechanism. The first concern was followed up by QA and was recently closed. The findings and concerns from the SSFI concerning the AFW turbine had not been addressed and again validated thc team's finding of untimely corrective cctio . Effectiveness of Corrective Action

L- _ _ _ . _ _ __ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ __ _ . __w

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Findings from the product audits associated with maintenance appeared to be adequately closed. The findings from the audits of PM conducted in December 1988 and March 1989, were still open; however, l

improvements appeared to have been made in the preventive maintenance are Overall, the licensee's self assessment of maintenance was not totally effective, primarily due to the lack of followup and corrective action on problems identified during the maintenance self'

assessment and'the lack of substance and depth in QA audit Recent improvements in the audit program including the scheduling of-specific audits to cover maintenance and;the current emphasis on performance based audits have the potential to substantially improve management's ability to adequately assess the maintenance proces .0 Synopsis 4. Overall Plant Performance 4. Performance Indicators The historical data indicated a trend of poor performance in maintenance. Failure to meet the safety performance goal for the Auxiliary Feedwater System due to a leaking valve was attributed to poor maintenance. In addition, five of the six forced outages in 1989 were due to equipment failures that indicated lack of or poor maintenanc The sixth forced outage was during maintenance related troubleshooting. Goals had not been set for all categories and system . Plant Walkdowns Housekeeping was considered-good. Overall, the material condition of the plant was considered satisfactory for a plant.in operatio .2 Management Support of' Maintenance 4. Management Commitment and Involvement Management was committed to improve maintenance activities at Zion as shown by the work in progress on assigned sections of the Conduct of Maintenance program; however, implementation of these programs appeared to be severely laggin Management was committed to the improvement of the maintenance process at Zion as evidenced by:

• Commitment for a more aggressive implementation of the numerous new maintenance related programs that were recently started at Zio * Aggressive involvement in upgrading housekeepin . _ - - - - - - - - - - . - - - - - - _ - - - - . - - _ -- _ _ _ ___--___ __.--- ---_ ___ ---- _ _ _ _ --- J

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• Commitment to a reliability. centered maintenance type study on:

the feedwater Syste ~ >

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-* More aggressive' approach to implement a multi-faceted predictive maintenance program at Zion; for example, use of. thermograph ' Based on weaknesses identified during this inspection, it was-apparent that continued involvement and strong commitment by management is necessary to improve maintenance activities to the level desired by Commonwealth Ediso Areas in need of management .

attention are:

• Lack of aggressive system engineering involvement in the maintenance proces * Lack of prompt corrective action to address recurring problems t identified previously by various maintenance assessments at Zion. In addition,-incomplete work packages, inadequate procedures, inadequate or non existent post maintenance testing and temporary modifications were also identified by the team and by various self assessments as recurring problem * Vendor recommendations were not incorporated into maintenance procedures nor assessed for a basis not to do so, and all components requiring preventive maintenance were not identified in the preventive maintenance program.-

• Lack of interim measurn, to address weaknesses that were not yet corrected by the maintenance pilot programs at Zio * Lack of QC involvement in corrective maintenance activitie * Limited diagnostic program for motor-operated valves as compared to other' sites that have been inspecte * Lack of personnel adherence to procedure requirements which appeared to be a recurring proble * Lack of a comprehensive trending program and aggressive failure analysis for corrective maintenanc . Management Organization and Administration _

The inspection indicated satisfactory performance of the management organization in the administration of the maintenance progra Although the forced outage goals were not met in 1988 and will probably not be met in 1989, the equivalent availability of Units 1 and 2 in 1988 exceeded the goal and will probably meet or exceed the goal for Unit 2 in 1989; however, increased management attention to address equipment failures is needed to meet the goal for Unit The following observations were made:

• A long range maintenance program had been established as specified in the Conduct of Maintenance Manua _ _ -

,

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.

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• Plant housekeeping improvements such as the. plant painting program had'made definite housekeeping upgrade e o Ongoing facilities improvement should also help consolidation of group However, based on the weaknesses noted below, it was apparent that the administration of the maintenance program needs increased-management attentio For example:

• Although thermography was not a part of Zion's current

,

predictive maintecan:e program, a program is being initiate * Increased management attention'was needed to implement the j various pilot and new program * Additional management attention was needed to repair equipnent leak l

• Performance indicators did not measure effectiveness of i maintenance such as the number of limiting conditions for i operation and power reductions due to equipment problem * . Goals and performance' data were not set'for three of the four systems selected for this inspection, and several set goals were changed (increased) during the yea * Prioritization process of. Nuclear Work Requests needs to be <:

assesse . Technical Support The licensee's.techn'ical support of maintenance was considered satisfactory; however, signif.icant weaknesses were identified that were caused by inadequate implementation of the " System Engineering" concept. These weaknesses, if left uncorrected, could lead to poor plant performance. -Some weaknesses were:

• No specific guidelines exist for the implementation of the

" System Engineering" progra * System engineers did not routinely receive the performance data on the components in the systems assigned unless the al2rt or code limits were exceede * System engineers did not appear to be taking an active role in

, failure analysis and trendin * System engineers aid not appear to have reviewed all assignod vendor mmals for preventive maintenance and periodic inspections to ensure recurring maintenance requirements were included in the maintenance progra . . . . . . . ~ .. -___ _ - _ _ _ _ _ _ - - _ _ _ _ _ _ _ . _ _ _ _

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L * Trending and root cause analysis of system and component problems was inconsistent and fragmente * A comprehensive evaluation was not performed for testing

. auxiliary feed turbine overspeed trips since the problem surfaced in 198 * Total Joe '.'danagement data base was not complete or accurate in the areas oi cause codes and as-found dat .3 Maintenance Implementat an 4.3.1 Work Control The licensee's work control activities were considered satisfactory with the following strength:

• - Although the pending non-outage corrective Nuclear Work. Request backlog did not meet the goal of 850, the backlog of corrective and preventive maintenance was low and within the working capabilities of the maintenance departmen The inspectors noted that weaknesses existed as follows:

• Poor' work request format, which included inadequate space for workers' notes and no space for post maintenance testinr, resulted in inadequate and inaccurate Total Job Manageit: 4 dat * Detailed work instructions on numerous work requests were not specifie * Deficiencies noted by workmen were documented in an uncontrolled manner, on loose notebook sheets, which tended to preclude use of the information in future maintenance activitie * The work request prioritization system was inadequate and not consistently followed. Instances were identified where high priority work requests were not completed for an extended time period without technical justificatio The present system allows for corrective work to continue indefinitel * Work request cause codes were incorrectly use In' addition, not all required blocks were filled in and data was not used for trendin .3.2 Plant Maintenance Organization The licensee's performance in this area was considered satisfactor Strengths and weaknesses were identified, such as:

• Instrument and Control maintenance department had aggressively upgraded procedure * Although plant system integrity was maintained and controls of maintenance activities were monitored, rework and

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4.3.3 .

Maintenance Facilities;' Equipment and Material Controll

%, . .. . The'iinspectors considered th'e licensee's-performance as satisfactor '

The following weaknesses were identified- -

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1. -Inadequate program to control; hot tool '

%' . ".' ,In plant storage was of a lower standard th'an:the standard warehouse.: storag ,

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3 Several examples were noted where limited life items were not

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-ManagementpErsonnelwereknowledgeableofresponsibilities'and

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. departments appeared adequate for non-outage wor .0' Open Items; Open' items are matters.which have been~ discussed with the. licensee,"

'

which will be reviewed further by the inspector, and whichtinvolve some action on the part of.the NRC or licensee or both.10 pen items

? disclosed during the inspection are discussed in Paragraph. 3. .0 Exit Meeting

. .. .-

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, The" inspectors met with licensee representatives (denoted in

" Paragraph 1) on July 24, 1989, at' Zion Nuclear Generating Station, .

d Units 1:and 2, and, summarized the purpose, scope, and findings of'the

. inspection. The> inspectors 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

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' APPENDIX A

! AC - Alternating Current AFW Auxiliary Feedwater, System ALARA- As' Low As Reasonably Achievabl AV Auxiliary Building HVAC BOP Balance of Plan Ceco Commonwealth Edison Company

'CIDR Certified Instrument' Discrepancy Report LCM, Corrective Maintenance CMWR Corrective' Maintenance Work Request COM Conduct'of Maintenance DC Direct Current DG LDiesel Generator DR' Discrepancy Report DV Deviation Report'

ECCS ' Emergency Core. Cooling System

'EDG Emergency' Diesel Generator EID Equipment. Identification EM Electrical Maintenance EPRI Electrical Power Research Institute ESF Engineered Safety Feature EQ Environmental Qualification

,

FCR Field Change Reques FSAR Final Safety Analysis Report GE- General Electric-GE SAL General Electric Engineering Service Advice Letter GE SIL General Electric Service Information Letter GSRV General Surveillance HP Health' Physics HVAC- Heating, Ventilation and Air Conditioning I&C Instrument and Control IDR Instrument Discrepancy Report IEB IE Bulletin IEN IE Notice IM Instrumentation Maintenance IMRS Instrument Maintenance Radiation Surveillance INP0- Institute for Nuclear Power Operations ISI/IST Inservice Inspection / Inservice Testing

.K ' Kilo LER Licensee Event Reports MCC Motor Control Center MM Mechanical Maintenance MOV Motor Operated Valve M&TE Measuring and Test Equipment NPRDS Nuclear Power Reliability Data System NRC Nuclear Regulatory Commission NWR Nuclear Work Regcest

.NUMARC Nuclear Utility Management and Human Resource Committee 005 Out of Service PADS Program Analysis Data Sheet  ;

PM Preventive Maintenance )

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PMT" . ,; . Post Maintenance Testing a. . PMWR/ . Preventive Maintenance Work Request

~ PRA~ Probabilistic Risk Assessment PV . - Control Room HVAC QA' Quality Assurance-

..QC Quality Control _ . . .

'

RC - Reactor Coolant System RCA- Root Causel Analysis .,

RCM Reliability Centered Maintenance RMS" Radiation Monitoring System'

RWP -- Radiation' Work Permit

- SALP

-

' Systematic Assessment of Licensee Performance-SER- Significant Event Report '

~ SOAD : System Operational-Analysis Department'

-

SOER- Significant Operating Experience Report-TJM

Total Job Management TS Technical Specification-

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