IR 05000295/1994013
| ML20149D864 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 05/18/1994 |
| From: | Jorgensen B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Tuetken R COMMONWEALTH EDISON CO. |
| References | |
| EA-94-079, NUDOCS 9405240018 | |
| Download: ML20149D864 (2) | |
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M MAY l 8 994 Docket Nos. 50-295; 50-304 License Nos. DPR-39; DPR-48 EA No.94-079 Commonwealth Edison Company ATTN: R. Tuetken, Site Vice President Zion Station 101 Shiloh Boulevard Zion, IL 60099
Dear Mr. Tuetken:
SUBJECT: NRC ENFORCEMENT CONFERENCE, REPORT NUMBER 50-295/94013; 50-304/94013 (DRP)
This refers to an Enforcement Conference conducted by Mr. J. B. Martin and other members of the Region III staff on May 11, 1994, of activities at your Zion Nuclear Generating Station authorized by NRC License No. DPR-39; DPR-48 and to the discussion of our findings with you and your staff. We have enclosed a report summarizing the discussion.
You will be notified by separate correspondence of our decision regarding enforcement action based on the information presented and discussed at the Enforcement Conference. No response is required until you are notified of the proposed enforcement action.
In accordance with 10 CFR 2.790 of the Commission's regulations, a copy of this letter and the enclosed enforcement conference report will be placed in the NRC Public Document Room.
We will gladly discuss any questions you may have concerning this Enforcement Conference.
Sincerely, lftyMY kt!
Bruch L. Jorgensen, Chie Reactor Projects Section lA
Enclosure:
Enforcement Conference Report 50-295/304-94013(DRP)
See Attached Distribution 0.
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Commonwealth Edison Company 2 MAY 1:8 Kfg4
REGION Ill Report Number: 50-295/304-94013(DRP) EA 94-079 Docket Numbers: 50-295 50-304 License Numbers: DPR-39; DPR-48 Licensee: Commonwealth Edison Company Opus West III 1400 Opus Place - Suite 300 Downers Grove, IL 60515 Meeting Conducted: May 11, 1994 Meeting Location: Region III Office 801 Warrenville Road Lisle, Illinois 60532-4351 Type of Meeting: Enforcement Conference Inspection Conducted: Zion Nuclear Generating Station March 24, 1994 through April 26, 1994 Inspectors: J. D. Smith M. J. Miller V. P. Lougheed Approved By: $b!*PW B. L. J6rdensin, Chief
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s-W P4 Date Reactor Projects Section lA Meetina Summary Enforcement Conference on May 11. 1994 (Report No. 50-295/304/94013(DRP)
Areas Discussed: Four apparent violations, identified in special inspection report 295/304-94010, were discussed, along with the corrective actions taken or planned by the licensee. The apparent violations involved (1)' low flow rates through the high-head safety injection throttle valves, (2) the missed >
limiting condition for operation action requirements 'when two trains of auxiliary feedwater were inoperable, (3) the inadvertent capping of all four containment pressure sensing lines, and (4) the inoperability of the high-head
. safety injection suction valves due to lifted electrical leads.
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DETAILS 1. Persons Present at Conference Commonwealth Edison Company (Ceco)
K. Strahm, Vice President, Pressurized Water Reactor Operation R. Tuetken,~ Site Vice President A. Broccolo, Station Manager -
D. Bump, Maintenance Staff Supervisor T. Cook, Mechanical Maintenance Master R. Cooper, Electrical Maintenance W. Demo, Electrical Maintenance Master K. Depperschmidt, Instrument Maintenance Master K. Dickerson, Regulatory Assurance Compliance Engineer G. Grabins, Work Control Center Supervisor K. Hansing, Site Quality Verification Director R. Huber, Mechanical Maintenance J. January, Electrical Maintenance .
S. Kaplan, Regulatory Assurance Supervisor .
W. Kurth, Long Range Work Control Superintendent ;
J. Madden, Assistant System-Engineering Supervisor D. Main, Unit Supervisor .
H. Neale, Instrument Maintenance L. Oberembt, Shift Engineer ,
T. O'Connor, Safety Analysis Engineer, Nuclear Fuels Services A. Orawiec, Nuclear Station Operator T. Poindexter, Attorney, Winston & Strawn G. Ponce, Quality Control Supervisor T. Printz, Assistant Superintendent of Operations K. Ramsden, Reactor Systems' Engineer L. .iimon, Maintenance Superintendent-T. Sinpkin, Nuclear Licensing Administrator G. Stojkovich, Regulatory Assurance Staff J. Tiemann, System Engineering Primary Group Leader D. Wozniak, Operations Manager J. Zura, Nuclear Station Operator U. S. Nuclear Regulatory Commission J Martin, Regional Administrator, RIII
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T. Martin, Deputy Director, Division of Reactor Projects (DRP)
R. DeFayette, Enforcement and Investigation Coordination Staff (EICS) '
B. Jorgensen, Chief, Section lA, DRP J. Smith, Senior Resident. Inspector, Zion P. Lougheed, Resident Inspector, Zion
'M. Miller, Resident Inspector, Zion P. Pelke, Enforcement Specialist, EICS D. Wiedeman, Enforcement Specialist, EICS J. Beale, Senior Enforcement Specialist, Office of Enforcement
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I NRC Attendees, continued l
- C. Shiraki, Project Manager, Nuclear Reactor Regulation ;
7 N. Hilton, Reactor Engineer, Section IA, DRP '
R. Bailey, Reactor Engineer, Division of Reactor Safety
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- Participated via telephone 2. Enforcement Conference ,
An enforcement conference was held in the NRC Region III Office on .;
May 11, 1994. This conference was conducted as a result of the findings of an inspection conducted March 24, 1994 through April 26, 1994, in which apparent violations of NRC regulations were identified. The +
inspection findings are documented in Inspection Report 295/304-94010, 1 transmitted to the licensee by letter dated May 4, 1994.-
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The purpose of this conference was to discuss the apparent violations, their root causes, any contributing factors, and the licensee's ,
corrective actions. '
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During the enforcement conference, the licensee acknowledged thel .
violations. For each violation, the licensee's presentation covered the- 't event investigation, including an event synopsis, the investigation the *
safety significance, and their corrective actions. A copy of the -,
licensee's handout is attached to this report.
Attachment: As stated
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Attachment._
Page 1 of 19 Zion Enforcement-Conference Asrenda -
Opening Remarks K.A. Strahm
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Introduction Event Discussion E.A. Broccolo .i Analyses / Corrective Actions a
event description
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event causes
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safety significance
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corrective actions Aggregate Assessment of the Four Events
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broad-based corrective actions
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Summary Closing Remarks K.A. Strahm Attaciunent: Chronologies for Individual Events
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Attachment Page 2 of 19 Introduction '
E Acknowledge Violations
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Each violation was identified by CECO
E Event Causes have been identified
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Each event was characterized by unique contributors E Performed an aggregate assessment of the four events E Summary of CECO actions to address the need for both event-specific and broad-based corrective actions E Presentation will demonstrate that Zion has promptly and comprehensively responded to these events from both perspectives E Need to improve ability to utilize low-level event information to assist in preventing the occurrence of more significant events CD Will discuss the following issues and the focus management is placing on them:
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communications
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overly complicated processes
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critical path activities
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accountability
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ensuring / encouraging participation by all levels in assessing the need for and identification of appropriate corrective actions v
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Page 3.of 19
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Time Line '
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Issue 1 Issue 2. Issue 3 Issue 4
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\ 6/21/92 3/7/94 3/15/94
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3/19/94 4 :.
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Issue 1: HIGH HEAD SAFETY INJECTION LOW FLOW Issue 2: FAILURE TO TAKE ACTIONS REQUIRED BY TECHNICAL ,
SPECIFICATIONS WITHIN THE REQUIRED TIME PERIOD '
Issue 3: ECCS VALVES FOUND WITH LIFTED LEADS (MOV-VCl12D AND MOV-VC112E)
Issue 4: INADVERTENT CAPPING OF CONTAINMENT PRESSURE SENSING LINES l-3- )
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Attachment-Page 4 of 19.
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Event Discussion- '
Analyses and Corrective Actions :
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Issue 1: High Head Safety Injection Low Flow -
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Event Cause: Procedure Deficiency - flow verification was not required subsequent to installation of valve restraining devices Safety Signl/icance: The lowest total three loop flow (249 gpm) was 26 gpm less than the minimum .
acceptable flow of 275 gpm. *
Nuclear Fuel Services (NFS) reviewed the deviation for impact on worst case accidents (small and large break LOCA).
The evaluation revealed no additional peak clad temperature penalties associated with the as found flow anomalies.
Safety significance of this event was minimal.
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Corrective actions: Throttle valves were repositioned and stem measurements were made for future reference.
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Injection flows were verified after restraints were installed.
All injection flow paths for both units were found to be acceptable. .
The Zion Independent Safety Engiacering Group (ISEG) performed an indepen .
dent evaluation that also concluded that the rec uction in flow was the result of. '
inadvertent changes to the throttle valve positions.
Zion's ISEG group is performing an independent review of how control of throttle -
valves are maintamed in other systems.
A permanent procedure change to TSS 15.6.84 " Charging and Safety Injection Check Valve Test" will be made to ensure that flow measurements are verified -
following the installation of throttle valve restraints =
Zion's engine'ering organization will evaluate the' appropriateness of this applica-tion for this valve design. I i
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P. age 5 ofu19-Hiah Head Safetv inlection Low Flow Rate -
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Page 6 of 19 Issue 2: Failure to take actions required by Technical Specifications for two inoperable
trains of auxiliary feedwater (AFW) within the required time period.
Event Causes: Human Performance Deficiency
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Operators failed to recognize that inoperability of the 2B Emergency Diesel Generator (EDG)in conjunction with the inoperable 2A AFW pump resulted in the 2C AFW pump being inoperable.
Procedural Deficiency
Procedures did not direct operators to review the appropriate Technical Specifications Additionally, Zion's custom Technical Specifications were confusing.
Safety Significance: The AFW system provides a reliabie source of water to the steam generators for decay heat removal.
Either the turbine-driven AFW pump or one ofthe two motor-driven AFW pumps are capable ofmeeting the decay heat removal demands for the unit during acci-dent conditions.
However, one available motor-driven AFW pump does not meet the accident analysis assuming one active failure coincident with a Loss of Offsite Power (LOOP).
The unit had not yet been taken critical following a refueling outage. Decay heat was minimal. All four steam generators were filled with water and available for cooldown to Residual Heat Removal (RHR) conditions. One motor-driven AFW pump capable of providing 100% of required flow was operable.
Safety significance of this event was minimal.
Corrective Actions: Repaired the 2A AFW pump.
Repaired the 2B EDG.
PT-14 " Inoperable Equipment Surveillance Tests", was revised to require a li-censed shift supervisor review of Technical Specification 3.0.5. applicability and the Zion Operability Determination Manual (ZODM) for each PT-14 initiated.
Tailgated the event with all operating shifts.
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Management conducted station-wide departmental meetings to heighten the level -
of awareness of all personnel.
Procedure changes will be trained and simulated in the current training cycle and -
will be incorporated into Continuing Training in September.
Zion's Technical Specifications Improvement Program currently in progress will alleviate confusion in this specification.
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koo Tsoh Failure to take actions required by Technical Specifications for two inoperable trains of auxiliary feedwater (AFW) within the required time period.
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Attachment
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Issue 3: Emergency Core Cooling System (ECCS) valves found with lifled leads (1MOV- ,
VCll2D and VCll2E)
Event Causes: Management Deficiency
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Cumbersome paperwork and processes led to improper signoffs.
Human Performance Deficiency
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Individuals reviewing paperwork failed to identify missing signatures.
Safety Sigmficance: The leads that were lifled on IMOV-VCl12D & E disabled the automatic signal for the valves to open on either a low Volume Control Tank (VCT) level or a safeguards actuation.
Operation of these valves was always available to the operator from the main control board.
Nuclear Fuel Services performed an evaluation which demonstrated that the defeated interlocks represented minimal safety significance based on plant condi-tions (e.g. minimal decay heat, significant excess shutdown margin).
Corrective Actions: Physical verification performed of Motor Control Cubicle (MCC) wiring on IMOV-VCll2B, C,2MOV-VCll28, C, D and E to ensure that these MOV's did not have lified leads.
Zion Station Support Engineering developed a matrix for both units for all safety related MOV's that receive a safeguards actuation signal or perform an interlock function and experienced maintenance during the Dual Unit Outage. All of these MOV's were verified by testing or visual inspection.
Interim measures that were instituted to better control lifted leads include:
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increased management overview oflifted leads
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double verification oflifted leads
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Quality Control performing an independent verification oflifting and landing ofleads l
The Electrical Maintenance (EM) Supervisor and the Quality Control (QC) ,
Inspector were counseled on the importance of attention to detail. I Event promptly reviewed during EM Department weekly meeting.
An investigation is being performed by an MOV Improvement Task Force based on testing, documentation and process problems identified during the Dual Unit Outage.
Standards for EM Department package documentation are being developed and .
communicated to EM personnel.
A review will be performed for other shops to determine F ' nilar. standard upgrades are necessary.
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Page 10 of 19 Issue 4: Inadvertent capping of containment pressure sensing lines ,
Event Causes: Management Deficiencies
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Containment penetrations inside containment were not labeled.
Lack of supervisory follow-up.
Human Performance Deficiencies
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Inadequate communications between the work crew and supervisor regarding the extra lines being capped.
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The grid map identifying the penetrations was incorrectly read.
Safety Sigmficance: Due to inoperable transmitters, the engineered safeguard features (ESF) auto-matic actuation functions based on the containment pressure signal were also inoperable. The affected ESF functions were:
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Safety Injection (SI) on a containment high pressure signal '
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Containment Spray (CS) actuation, Phase B containment isolation and MSIV isolation on a containment high - high pressure signal ~
An evaluation was performed which demonstrated that the inoperable contain-mert pressure transmitters had minimal safety significance based on the less limiting actual plant conditions (e.g. minimal core' decay heat, lower containment temperature and significant excess shutdown margin) existing during the event.
CorrectiveActions: Removed pipe caps from the Unit 1 containment pressure sensing lines. :
Inspected Unit 2 containment pressure sensing lines.
Inspected both units and verified that appropriate lines were open.
Conducted interviews to determine the number and locations of the caps installed.
Walkdowns were performed and no additional caps found incorrectly installed."
i As an interim measure, restricted maintenance work activities in the Auxiliary
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Building and both containments to a formal work control process.
Discussed expectations with individuals involved in inadequate follow-up. l l
Management conducted station-wide departmental meetings to heighten the level 'i of awareness of all personnel. q
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L CorreetireActions: Tailgating event and Appendix A ofZion Administrative Procedure (ZAP) 400-
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(Continued) 01, " Station Material Condition Program " in the maintenance departments. . .
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Reviewing options for labeling ofpenetrations inside Unit I and 2 containments.
Reviewing minor maintenance activities performed since the inception of the Minor Maintenance Crew to identify other activities which'could potentially warrant .
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the use of a Nuclear Work Request (NWR); no discrepancies identified to date.
Revising General Operating Procedure GOP-0, checklist E, '" Containment Close Out", to verify penetrations or associated lines are open/ uncapped before plant heatup. This procedure is performed by a Licensed Shift Supervisor.
Revising ZAP 400-01, "Statio Material Condition Program" and 400-02,
" Initiating and Processing a Work Request", to clarify and strengthen minor maintenance restrictions en plant changes.
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Attachment Page 12 of 19 Inadvertent Caoolna of All Four Containment Pressure Sensina Lines
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INSIDE OUTSIDE CONTAINMENT CONTAINMENT 1PT CS19
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F41 1CS0052 1CS0053 -
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/ W W 7 78 1CS0054 1CS0055 1PT CS21 7 N M P-02 1CS0056 1CS0057 1PT 1PDT CS22 RV85
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P-54 1CS0058 1CS0059 1PP0609 t-8A-I
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Page 13 of 19 !
Aggregate Assessment of the Four Events -
Broad Based Corrective Actions Pmeram Deficiencies Improvements in the Work Control Procesc ,
b Work Control Center ,
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single point of contact for work authorization
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all disciplines in one general area
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smoother flow of work to the field
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improved communication of work to the field
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standardized work packages b Electronic Work Control System
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action requests utilized to ensure screening review by system engineer owning system -
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only work control center can generate a work request b Operating Period Planning
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look at required work activities for future quarters
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allow better planning and resource utilization
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Page 14 of 19_ *
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Human Performance Deficiencies
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Three basic elements to Human Performance:
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procedures
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supervision ,
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Corrective Actions to Human Performance problems typically focus on ,
corrections to procedures or trauung !
Improvements to Supervisory Processes include:
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increased focus on accountability
+ follow-up
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+ commitment
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increase use and understanding of self assessment
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+ integrated reporting ,
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+ monthly Integrated Quality Efrorts (IQE) process ,
+ trending ;
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Summary -
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b From a broad perspective ma~ nagement is focusing on:
O ensuring effective communications
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O simplifying overly complicated / burdensome processes .
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O addressing this common thread of critical path activity execution O emphasizing accountability
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O ensuring / encouraging panicipation by all levels in assessing the need for and identifying appropriate corrective actions
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k Need to maintain a self-critical perspective to ensure that performance, culture, and processes continue to improve.
b Periodically reassess corrective actions to ensure they continue to be effective and make changes - 1 when appropriate. 1
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Page.16 of 19
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Attschment: Chronologies for Individual Events .
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ISSUE 1: HIGII HEAD SAFETY INJECTION LOW FLOW 6/21/92 ' Following Technical. Staff Special Procedure (TSSP) 139.92, " Charging and Safety :
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Injection Check Valw Venfication Test " successful completion, valve restraints are welded _,
in place. -
/d21 2/19/94 1630 - TSS/ 4-3992 was started.
1710 - The 1 A charging pump was started per section 8.1 of the. test.
- 1716 - Testing-was suspended due to flow abnormalities. Valve. positions F were reviewed and found to be in accordance with the valve lineup.
2100 - The IB charging pump was started per section 8.2 of the test.
2300 - Section 8.1 was restarted. Total injection flow measured at IFI -
934 was 360 gpm.
2/19/94 Troubleshooting efforts were undertaken. Four theories were investigated
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including flow blockage, pump degradation, leakage, and throttle valve position.
2/20/94 (
Radiography results received.
1510 - Section 8.2 was initiated to collect pressure data.
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1611 - The IB charging pump was' started and run for approximately 30 minutes. The pressure data was reviewed. Preparations were made to rebal--
ance flow through the injection. lines.
2/21/94 1735 - Repositioning of the HHSI branch line throttle valves began. !
2/22/94 0700 - Test. completed successfully. Injection flow was measured at 435 and 440 gpm for the IB and 1 A' pumps respectively.
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ISSUE 2: FAILURE TO TAKE - ACTIONS REOUIRED BY ~ TECHNICAL- .
SPECIFICATIONS WITHIN THE REOUIRED TIME PERIOD -
J 3/7/94 During Technical Staff Surveillance (TSS) 15.6.43, " Endurance Testing of Diesel Generators During Refueling", the 2A Auxiliary. Feedwater (AFW) Pump tripped on overspeed.
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0533 - The 2A AFW pump was declared inoperable and,a'. periodic ~ test (PT)
14 was initiated.
0618 - The'2B diesel generator began experiencing frequency. swings and!
was manually tripped. The 2B DG was also declared inoperable and PT 14, " Inoperable Equipment Surveillance Tests" was initiated.
3/8/94 It was determined ~ that technical specification limiting condition for opera-tion 3.7.2. action E should have been entered at 0618 on March 7,1994 due to Technical Specification 3.0.5 applicability for the redundant motor driven AFW pump inoperability.
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ISSUE J: ECCS VALVES FOUND WITH LIFTED LEADS (MOV-VC112D AND . l MOV-VC112E 3/26/04 1245 - During Technical Staff Surveillance (TSS) 15.6.35, " Manual Actuation of the
~ Safety Injection and Safe Shutdown Systems and Diesel Generator Loading Test ", on train A, IMOV-VCll2D (RWST to charging pump suction isolation valve) failed to open. This placed unit 1 on a 7 day LCO.
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I820 - Surveillance PT 10-4, " Safeguards Actuation Miscellanco's",u section 5.9 was performed to support troubleshooting of failures from TSS 15.6.35. No problems were identified.
2100 - TSS 15.6.35 was restarted for troubleshooting.
2200 - One of the engineers performing TSS 15.6.35 and an electrician found two wires that were lified and taped in the MCC breaker cubicle for IMOV-VCl12D.
2330 - The MCC breaker cubicle for IMOV-VCll2E was inspected. The same two wires were found to be lifted and taped in this cubicle also.
Because both IMOV-VCll2D and IMOV-VC112E were both found to have their SI signal inoperable, this placed Unit I on a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> clock to cold shutdown. Both of these valves were still able to be manually stroked from the control board switch.
3/27/94 0130 - The electricians relanded the two leads on IMOV-VCl12D under work request
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237327. Surveillance PT 10-F, " Safeguards Actuation ofSVA G lalves -MOV-SI8808A, B, C & D-MOV-SI8812A & B -MOV-RH8703 -MOV-S18802 -MOV-SI8806 ", section 5.1 was performed again and IMOV-VCll2D was opened and IMOV-VCll2C was closed as designed. IMOV-VCl12D was then declared operable. Because only VCll2D had been declared operable, the Unit I clock was changed to a 7 day clock starting at 1245 on 3/6/94. The electricians then relanded the two leads on IMOV-VCl12E under
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work request Z377331.
s 0200 - The electricians and the system engineers verified that there were no lifled leads in the MCC breaker cubicles for 2MOV-VCl12B,2MOV-VCl12C,2MOV-VCl12D,-
or 2MOV-VCl12E.
3/27/94 0215 - A four hour red phone call was made for an inoperable high head injection path for Unit 1.
1330 - A level 2 .avestigation was requested.
3/28/94 Level 2 investigation' team formed.
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Page 19 of 19
- ISSUE 4: INADVERTENT CA PPING OF CONTAINM ENT PRESSURE SENSING LINES .
- 3/19/94 Pipe caps were installed at penetraticas P-41, P-54, P-78 and P-82. The unit was in cold shutdown, Mode 5 but transitioned into Mode 3 prior to discovery.
3/23/94 0022 - 0512 The Operating department attempted to vent containment several times to reduce pressure due to heatup of the reactor coolant system. But the indicated pressure - ,
on IPI-RV85 did not decrease as expected. The valve lineups were verified and the vent lines were drained in efforts to lower containment pressure. On the following shift, the venting problem persisted so operators expanded the troubleshooting efforts.
1445 - The containment pressure and vacuum reliefs were verified to be open.
1630 - The IPI-CS19 was reading approximately 1.5 psig with the redundant pressure channels showing no elevation in pressure. With IPI-RV85 and IPI-CS19 both indicat-ing a high pressure, Operations dispatched a Shia Foreman to containment to investigate further.
The Shift Foreman found a newly installed pipe cap on the sensing line for IPI-CSl9 at containment penetration P-41 and reported this finding to the Control Room.
The shift determined that this installation was improper and the cap was removed. Pres-sure indication on IPI-CS19 dropped in response to the now open penetration.
The Shift Foreman then inspected the other penetrations which support containment pressure indications. He found newly installed pipe caps on the other three sensing lines for Unit I containment pressure. These were also determined to be improper and were
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removed. Upon removing the cap from the line that supplied IPI-RV85, indicated pres-sure dropped.
1754 - A total of four caps were removed from instrument sensing lines (penetration numbers P-41, P-54, P-78 and P-82). These caps had rendered inoperable 8 containment pressure instruments.
1806 - An ENS red phone call was made to the NRC to report the inoperability of the containment pressure transmitters.
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