IR 05000295/1997013
| ML20217P970 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 08/15/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20217P964 | List: |
| References | |
| 50-295-97-13, 50-304-97-13, NUDOCS 9708290080 | |
| Download: ML20217P970 (18) | |
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U.S. NUCLEAR REGULATORY COMMISSION
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REGION lli-
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Docket Nos:
50 295, 50 304 License Nos:
50-295/97013(DRP): 50 304/97013(DRP)
Licensee:
Commonwealth Edison Company Facility:
Zion Nuclear Plant, Units 1 and 2 Location:
101 Shiloh Boulevard
Zion, IL 60099 Dates:
April 4 through May 29,1997 Inspectors:
A. Vogel, Senior Resident inspector D. Calhoun, Resident inspector E. Cobey, Resident inspector D. Chyu, Reactor Inspector J. Yesinowski, Illinois Department of Nuclear Safety inspec;or Approved by:
Melanie A. Galloway, Acting Chief Reactor Projects Branch 2
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9708290080 970815 PDR ADOCK 05000295 O
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EXECUTIVE SUMMARY.
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Zion Nuclear Plant, Units 1 and 2 NRC Inspection Report 50 295/97013(DRP): 50 304/97013(DRP)
' This inspection included aspects of licensee operations, maintenance, engineering, and plant support, The report covers an eight week period of inspection activities by the resident staff.
During this inspection period, the licensee focused a significant amount of effort in support of improving operator performance in the areas of procedural compliance and adherence to standards, as demonstrated in the Phoenix training program. However, as reflected in the occurrence of a fire in the Unit 1 containment, the delayed reporting of the fire to the control room, and the inspectors' identification of inadequate storage of equipment with respect to seismic concerns, inconsistent procedural compliance appears to be a problem that extends beyond the operations department. With respect to inadequate control of operator overtime, this issue has been a long term concem which the licensee has not yet adequately resolved.
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Doerations The inspectors concluded that the licensoo's decision to leave a fuel assembly
suspended for 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> and 23 minutes, whilo developing an action plan to retriove foreign material from the fuel assembly, was not conservative. (Section 01.1)
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The inspectors identified that poor control of a fuel oil transfer evolution, a deficient
procedure, and poor procedural compliance contributed to an auxiliary boiler fuel oil spill. (Soction 03.1)
The inspectors identified a violation involving licensed operators routinely exceeding
overtime limitations to accomplish operations department work activities.
(Section 08.1)
Maintenance The inspectors concluded that poor work practices contributed to the occurrence of
a hydraulic line rupture which resulted in a worker getting sprayed by hydraulic oil and the closure of the main steam line isolation valves. (Section M1.1)
The inspectors identified a violation involving the failure to ensure adequate
ventilation while using a flammable lubricant which resulted in a fire in the Unit 1 containment. (Section M1.2)
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The inspectors identified a violation involving the failure to ensure that equipment
stored in the vicinity of safety-related equipment was seismically restrained.
(Section M2.1)
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Ennt Sunnort
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- A Radiation Protection Technician failed to immediately notify the control room of
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the fire in the Unit 1 containment resulting in a violation. -(Section F3.1)
- The inspectors identified a violation involving the falsification of electrical-maintenance surveillance procedures by two ciectrical maintenance personnel (Section F8.1)
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Report Details Summarv of Plant Status During this inspection period, both units were maintained in a cold shutdown depressurized condition pending completion of restart actions delineated in the Zion Recovery Plan.
Unit 1 was defueled on April 27l 1997, and actions were initiated to place the unit in a lay-up condition.
1; Ooerations
Conduct of Operations
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01.1 Fuel Assembly issues identified Durino Unit 1 Defuelina a.
Insoection Scope (71707)
During the performance _of Unit 1 defueling activities, the licensee identified that the grid straps on fuel assernbly (FA) H04C were damaged. The inspectors interviewed
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the root cause investigator, nuclear engineering and fuel handling personnel. The inspectors reviewed applicable aspects of fuel handling procedures and Westinghouse Fuel Specifications, b.
Obsetyations and Findinas On April 23,1997, while performing Unh I defueling activities, fuel handling
personnelidentified foreign material on the grid straps of FA H60C The licensee stopped fuel handling activities and initiated an investigation. While the licensee inspected the affected FA and adjacent areas with a video camera, FA H60C was left suspended for 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> and 23 minutes. Subsequently, the licensee returned
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FA-H60C to the reactor vessel.
During the video inspection, the fuel handlers identified the foreign material as a loose, torn section of zircalloy grid strapping. However, the licensee found FA-H60C undamaged. During inspection of previousiv moved FA H04C, the licensee identified that the corner section of two Grid straps was torn away. The licensee inspected other previously moved FAs and did not note any damage. The licensee
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1-retrieved the Orid strap piece along with a second piece found on the reactor core plate, Based on licensee preliminary investigation results, the damage to the FA-H04C grid
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straps was caused during movement of the FA earlier in the day. Specifically, during the transfer of FA H04C from the reactor, the FA impacted the reactor core
- batfle which resulted in the grid straps being torn. At the end of the inspection period, licensee investigation of the circumstances which resulted in damage to FA H04C was in progress.
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Conclusion The insp0ctors determined that the licensee took appropriate action to stop fuel movement and promptly investigate the foreign materialidentified on FA H60C, However, the inspectors were concerned that the licent e's decision tr, maintain the FA suspended for 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> and 23 minutes was not conservative. With the FA suspended for an extended time over the reactor vessel, the potential for the assembly being dropped or damaged was increased. This issue is considered an
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unresolved itcm (50-295/97013-01) oending further NRC iwview for possible procedural deficiencies and/or deficient fuel handler actions that may have contributed to the damage of the FA.
Operations Procedures and Documentation
03.1 Diesel Fuel Oil Soill
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a.
Insoection Scoca f 71707)
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Approximately S_ gallons of diesel fuel oil were spilled on the ground while filling the auxiliary boiler fuel oil storage tank. The inspectors interviewed operations department personnel, inspected the applicable plant equipment, and reviewed the appropriate plant procedures, b.
_ Observations and Findinos On May 27,1997, the licensoo spilled approximately 5 gallons of diesel fuel oil on the ground while filling the auxiliary boiler fuel oil storage tank in accordance with System Operating Instruction (SOI) 11K, " Transfer of Fuel Oil from Tanker Truck to Fuel Oil Storage Tanks," Revision 4, Section 5.4. In response to the event, the licensee secured the evolution, cleaned up the spill, and initiated a problem identification form (PlF) 97 2577.
The equipment attendant (EA) performed a pre-evolution review of sol 11K in accordance with the Zion Operations Department Standards, Section Ill.A.
However, the EA failed to identify that the procedure did not address the operation of the fuel oil system while the truck operator transferred the fuel oil hose from an empty truck compartment to a full one.
In addition, the inspectors determined that the EA had not correctly adhered to the procedure. Zion Administrative Procedure (ZAP) 100-07, "Use of Procedures,"
specified that mandatory in har.d procedures be in the possession of the user such that each step is read prior to performance, performed in the sequence specified, and signed off when completed prior to proceeding to the next step. The licensee had designated SOI-11K as a " mandatory in hand procedure." Section 5.4, Step 7 of GOl-11K specified that when the fuel oil storage tank levelis greater than 22 feet or the tanker contents are empty, that the EA perform the following steps expeditiously to minimize backflow: (a) throttle ODOO203, fuel oil unload pump discharge valve, to ona turn open; (b) stop 0D0017, fuel oit unload pump; and
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(c) close ODOO203, fuel oil unload pump discharge valve. However, on two occasions during the fuel oil transfer, the EA secured the fuel oil unload pump when
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the hose began to collapse without closing the fuel oil unload pump discharge valve. This allowed backflow from the fuel oil storage tank to pressurize the hose and resulted in the diesel fuel oil spill when the truck operator disconnected the
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hose from the first empty compartment.
The inspectors also identified that the EA performing the evolution did not communicate his expectations to the truck operator for accomplishing the fuel oil transfer. As a result, during the evolution there was confusion over whether the truck operator was going to " Walk" the hose to ensure that the hose was empty prior to stopping the fuel oil unload pump. In addition, the EA was unaware of the truck operator's intent to disconnect the fuel oil hose when the pump was stopped.
The lack of communication betwoon the EA and the truck operator directly contributed to the occurrence of the diesel fuel oil spill.
c.
. Conclusions The inspectors concluded that this occurrence was indicative of a deficient procedure, poor procedure compliance, and poor control of the work activity.
Specifically, several performance defi:iencies resulted in the diesel fuel oil spill inclading: (1) the EA's pre-evolution review of SOI 11K did not identify the procedural weakness; (2) the EA did not close the fuel oil pump discharge valve once the pump was stopped, contrary to requirements of SOI 11K: and (3) the communications between the truck operator and the EA prior to and during the fuel oil transfer was insufficient to ensure that the evolution was conducted in a controlled manner. These deficiencies were not violations of NRC require nents because safety-related activities were not involved.
Operator Training and Qualification 05.1 Observation of Ooerator Phoenix Trainino Proaram a.
lnsoection Scone (71707)
The inspectors observed a conservativo decision making seminar and a simulator exercise which were part of the three-week Phoenix licensed operator remediation training program, b.
Observations and Findinas On May 13,1997, the inspectors observed Crew 1 in the simulator performing emergency procedures E 0, " Reactor Trip or Safety injection," and E-1, " Loss of Reactor or Secondary Coolant " A designated group, which included the assigned simulator training instructor, operations training supervisor, and peer mentors from off-site, monitored and assessed the emw's performance in the simulator. Also,
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the shif t manager independently monitored the crew's performance with respect to plant transients.
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On May 14,1997, the inspectors observed the conservativo decision making seminar for Crew 5. Tho seminar consisted of: (1) viewing a video tape bbout the Exxon Valdez oil spill accident, (2) a presentation on conservativo decision making principles and concepts, and (3) breakout sessions which allowed the students to apply the concepts presented during the seminar.
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Conclusion The inspectors concluded that the observed training incorporated elements to address the command and control and communications deficiencies identified in Augmented Inspection Team inspection Report No. 50-295/97-06.
Miscellaneous Operational Issues 08.1 (Closed) Unresolved item 5Q-295/96017-05. 50-304/96017-05: Review licensee actions implemented in response to NRC concerns with the control of overtime.
On November 14,1996, Site Quality Verification personnelinitiated a Level ll corrective action record (CAR) for overtime control, CAR 22-96-053. In response to the CAR, the licensee initiated immediate corrective actions which included the completion of individual departmental self-assessments and the communication of overtime expectations from senior management to all site personnel. The licensee completed long term corrective actions including revision of ZAP-200-04, " Overtime Guidelines," and training of station personnel on the revised procedure and management expectations.
The inspectors subsequently reviewed gatehouse access records for four Shif t Managers, three Unit Supervisors, and three Nuclear Station Operators from March 10 through May 18,1997, and identified 83 examples of unapproved overtime in excess of the guidelines specified in ZAP-200-04, Section F.4.b, including: one example of an individual working greater than 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> in a 24-hour period; three examples of individuals working greater than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> in a 7-day period; and 79 examples of individuals working greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> period, all excluding shif t turnover time. The failure to control the use of overtime in excess of the overtime guidelines by Shift Managers, Unit Supervisors, and Nuclear Station Operators is considered a violation of Technical Specification 6.2.1.i (50-295/97013-02, 50-304/97013-02), as described in the attached Notice of Violation.
The inspectors identified programmatic concerns with the operator overtime process which may be contributing factors to the above violation. The licensee was not able to quantify which part of an operator's work hours constituted turnover time, and hence could not accurately determine the work hours applicable to overtime limitations. (During their review, the inspectors allocated one hour for shif t tumover for each day worked in accordance with ZAP 200-04, Section D.3.)
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In addition, the licensee had not been thorough in the completion of overtime variation authorization forms. The inspectors identified that 22 of the 76 forms reviewed were incomplete; specifically, the justification for concluding that significant reductions in personnel etfectiveness will not occur was blank. Also, the level of detail of the information provided in the majority of the forms was not sufficient to clearly understand the need for the overtime variation approval.
This unresolved item is closed.
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11. Maintenance M1 Conduct of Maintenance '
M1.1 Maintenance Mechanic Soraved with Hydraulic Fluid a.
Insoection Scone (62707)
A pressurized electro-hydraulic control (EHC) line separated while maintenance personnel were performing work. The inspectors interviewed maintenance, operations, and work planning personnel. The inspectors also reviewed the associated work request and walkdown verification forms.
b.
Observations and Findinas On April 23,1997, a team of engineering and maintenance personnel conducted a
" alkdown and performed work on the Unit 2 main steam system to address
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material condition deficiencies. The team performed work under Work Request No. 970035895-01 which allowed the perfocmance of minor repairs. During the walkdown, the team determined that they could remove an abandoned EHC line under the work request. To gain access to the abandoned line, a mechanic used a wrench to move an adjacent EHC line out of the way. The adjacent EHC line was pressurized to 1700 psig and served a main steam isolation valve (MSIV). While attempting to move the adjacent line, a compression fitting separated and sprayed EHC fluid on the mechanic. Due to the EHC leak, the " Loop A and C MSIV trouble" annunciators were received in the control room, and the MSIV hydraulic pumps started. The control room operators closed the MSIVs and stopped the leak. The local hospital subsequently released the mechanic after determining that he had no injuries.
The inspectors determined that the control room operators had not been aware that the walkdown was being conducted or that maintenance was being performed.
. Prior to conducting the walkdown, the team completed a pre-job briefing; however, operatio.1s department personnel were not in attendance. The control room operators became cognizant of the work after the system engineer notified them of the EHC line separating.
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_ As a result of the event, the licensee initiated immediate corrective actions which included quarantining the area and initiating a root cause investigation. The licensee subsequently inspected the EHC line and determined that it had been improperly constructed during original installation. The licensee also inspected eight other compression fittings on the same line snd deterrnined that the fittings had been properly assembled.
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Conclusion The inspectors concluded that a maintenance mochanic demonstrated poor work practicos when he utilized a wrench to move a pressurized EHC line out of the way in order to remove an abandoned EHC line. In addition, the inspectors concluded that the failure of the walkdown team to obtain approval from the control room to perform minor mainteriance during the walkdown reflected deficiencies in the implementation of the site work control program.
M1.2 Poor Work Control Resulted in Flash Fire in the Unit 1 Reactor Vessel Stud _tigigs a.
Insnection_ Scone (62707)
On May 24,1997, a flash fire occurred while maintenance personnel were cleaning and lubricating the Unit 1 reactor vessel stud holes. The inspectors interviewed maintenance, fire protection, and radiation protection personnel and reviewed applicable documentation.
b.
Observations and Findinos in preparation for placing the Unit 1 reactor in wet layup, mechanical maintenance (MM) personriel were performing a routine refueling activity using procedure RC001 1, " Reactor Vessel - Closure Head installation," Revision 4, to clean and lubricate the Unit 1 reactor vessel stud holes. With the reactor defueled and the station's plans to not reinstall the studs, the licensee had changed the plant configuration that existed when procedure RC001-1 had been previously performed.
Specifically, maintenance supervision failed to assess the impact of the change which inadvertently altered the ventilation to the work area when herculite sheeting was moved to support the installation of metal plates in the stud holes.
In this altered configuration, as mechanics began to siraultaneously perform cleaning and lubricating activities as allowed by the procedure, vapors from the lubricant accumulated and eventually migrated into the motor housing of the cleaning machine, Sparks from the motor ignited the vapors which caused a flash fire that lasted approximately 90 seconds.
Af ter hearing a loud sound and observing the fire, a Radiation Protection (RP)
Technician who was providing RP coverage for the job directed all the workers to
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evacuate the containment. After being notified, the fire brigade responded to the scene; however, the fire had already extinguished itself by the brigade's arrival.
The licensee's response to the fire is further discussed in Section F3.1 of this report.
The licensee's immediate corrective actions included establishing a quarantine of the affected area and initiating a root cause investigation. In eldition, station personnel assessed potential damage to the reactor vessel and determined that no damage had occurred cs a result of the fire except for some melted herculite.
The licensee subsequently determined that the approved lubricant was used; however, the work procedure failed to state that the lubricant was flammable, in
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addition, during the pre job briefing, the licensee staff did not discuss the flammability of the lubricant, and the MM personnel failed to read the warning label of the lubricant prior to performing work, c.
Conclusions The inspectors concluded that poor work control and inattention to detail contributed to the occurrence of this event. Specifically, maintenance supervision failed to assess the impact that the altered plant configuration had on the ventilation of the work area, and MM personnel failed to take necessary precautions while working with a flammable lubricant.
Section F.7 of ZAP-900 05 " Control, Use, and Storage of Flammable and Combustible Liquids and Aerosols" required that adequate natural or mechanical ventilation is ensured in areas where flammable liquids or aerosols are to be used.
The failure of the licensee to ensure that adequate ventilation was being provided to the work area on the Unit 1 reactor vessel head prior to the use of a flammable lubricant as required by ZAP 900-05 was considered a violation of 10 CFR 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings,"
(50 295/97013-03a), as described in the attached Notice of Violation.
M2 Maintenance and Material Condition of Facilities and Equipment M2.1 Inadeauate Storane of Plant Eouip_ ment a.
Insoection Scone (62707)
On May 19,1997, while touring the auxiliary building (AB) and the fuel handling building (FHB), the inspectors identified several examples where the improper storage of equipment created seismic concerns. The inspectors interviewed an MM staff support supervisor and a Seismic maintenance engineer. Also, the inspectors reviewed the applicable equipment storage procedure and other documentation associated with the implementation of the equipment storage procedure.
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Observations and Findinas
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While touring the AB and the FHB, the inspectors identified several examples involving the improper storage of plant equipment. The inspectors were concerned that if the plant equipment was not properly stored, the equipment could potentially impact safety-related plant components during a seismic event. The inspectors identified the following concerns:
(1)
A cylinder bottle, used for a whole body counter, had been secured to a flanged section of a heating, ventilation, and air conditioning (HVAC) duct riser by a metal clamp which was chained to the cylinder bottle. This configuration had not been seismically analyzed.
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(2)
A storage cabinet utilized by operations personnel was moved from its seismically approved location in the AB at the 617 foot elevation to an unanalyzed location on the same elevation.
(3)
A deconning machine, located on the 617 foot elevation of the AB was near the electrical penetration system which was not a seismically-approved storage area, The seismic maintenance engineer informed the inspectors that station personnel had attempted to control storage of equipment in safety-related areas by issuing ZAP-400-14 " Equipment and Tool Storage in Safety Related Areas," Revision 0, on March 29,1994. The procedure specified that items which did not meet a prescribed height-to-width ratio and were not stored in an approved location must be seismically restrained. When station personnelimplemented the program in 1994, the maintenance engineer performed several walkdowns to assist the station in achieving compliance with the procedure. For items which did not meet the requirements of ZAP-400-14, the maintenance engineer performed calculations which concluded that it was acceptable to leave items in unapproved areas because if the items were to tip over during a seismic event, there would be no adverse impact to safety-related equipment.
The maintenance engineer informed the inspectors that he had not been contacted to assist in seismically securing the cylinder to the HVAC duct riser. He also agreed with the inspectors that the storage cabinet and the deconning machine did not meet the height to-width ratio requirement nor were they stored in a seismically-approved area. As a result, the items wors required to be seismically restrained as specified by the procedure.
The maintenance engineer generated a PlF for each seismic concern. Other immediate corrective actions taken by the maintenance engineer included writing action requests to relocate the deconning machine and the storage cabinet to approved areas and preparing engineering request No. 9703284 to evaluate the acceptability of securing the gas cylinder to the HVAC duct riser.
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Conclusions
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The inspectors concluded that the maintenanco engineer understood the importance and need to properly store equipment and had taken extensive efforts to assure the station had boon in compliance with the procedure. However, the inspectors werd concerned that although there was specific guidance available to station personnel regarding proper storage of items, not all plant personnel were cognizant of the requirements. The inspectors determined that the failure of the licensee to seismically restrain the deconning machine and the operations storage cabinet in accordance with ZAP-40014 is considered a violation of 10 CFR 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," (50-295/97013-03b; 50 304/97013 03b), as described in the attached Notice of Violation.
11 1n910201i02 E2 Engineering Support of Facilities and Equipment E 2.1 Overloadina of a Safetv Related 120 Volt Transformer a.
Insnoction Scone (62707)
Tho licensee identified that one phase of a safety-related transformer had boon ovorloaded. The inspectors interviewed maintenance and design engineering personnel and reviewed applicable documentation for this issue which included a contingency plan for what actions to take while the transformer was overloaded or if the transformer were to fail and the exempt change modification to redistribute the loads, b.
Qbservations and Findinas On May 13,1997, a non licensed operator noted a burnirg smell while performing his rounds in the Bus 248 essential switchgear room. The licenseo determined the smell to be emanating from a burnt lighting ballast. However, while investigating the problem, the licensee discovered that phase "B" of the 480- 208/120 V power transformer was hotter than the other two phases; the "B" phase was determined to be 302 degrees F which was approximately 100 degrees F above the other two phases. The power transformer was located in the 480V motor control conter (MCC) 23818, cubicle F3.
The licensee identiiiod the following loads on phases "A" (5.6A), "B" (32.8A), and
"C" (7.5A); each phaso was rated for a load of 25A. The licensee implemented immediato corrective :: cions to reduce the load on the "B" phase to 18.8A which lowered its temperature to 186 degrees F. The licensee determined that the transformer should be replaced.
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The licensee performed thermography checks on all other safety related MCCs. The thermography did not reveal any other overheating conditions which may have been
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condition of the transformers. Therefore, the licensee initiated a review of all
safety-related MCCs to determine the loading status of each transformer. As a _
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result, the licensee identified five additional MCCs that contained a transformer
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with unbalanced loading conditions. Following the identification of each unbalanced
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loading condition, the licensee conducted an evaluation for disposition of each condition.
The licensea determined that the overload condition in MCC 23818 occurred as a result of a temporary blower for the Unit 2 auxiliary building vent stack radiation monitor being added to the "B" phase of the transformer. Zion Radiation Procedure (ZRP) EMO 10, " Temporary Pump / Blower installation and Removal Instructions for inoperable Radiation Monitors," Revision 4, was used to add the temporary load.
The inspectors requested a copy of the 10 CFR 50.59 safety evaluation for this procedure which approved the use of adding the temporary blower as an additional load to the transformer; however, the licensee was unable to locate the safety evalua' tion by the end of the inspection period.
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Conclusions
Pending further NRC review to determine the cause of improper loading of transformers, this issue is considered an unresolved item (50 295/97013 04;
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50 304/97013-04). Specifically, the inspectors planned to review: (1) the adequacy of the licensee's program for tracking and evaluating the eddition of loads to the safety-related transformers, (2) the safety evaluation for ZRP-580010 which allowed the temporary blower to be added as a load to the transformer, and (3) the licensee's evaluation of the loading status of the other 480 - 208/120V safety-related power transformers.
IV. Plant Suonort F3 Fire Protection Procedures and Documentation
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F3.1 Imorocer Notification of a Fire in the Unit 1 Refuelina Cavity a.
insoection Sec7e (71750)
- A flash fire occurred while maintenance personnel were cleaning and lubricating the
' Unit 1 reactor vessel stud holes. The inspectors assessed the licensee's response
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.to the fire including conducting a review of applicable procedures and interviewing operations, RP, and fire protection personnel.
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b, Observations and Findings On May 24,1997, a fire occurred whilo cleaning and lubri<: sting the Unit 1 reactor vessel stud holes (500 Section M1.2). The HP Technician, porforming tomoto doso monitoring of the maintenanco at:tivity, notified his supervisor of the fire instead of the control room. Af ter notifying his supervisor, the technician obtained a fire extinguishot. Once ho determined that tho extinguisher would not put out the firo, ho directed the mochanics to ovacuata the area.
The RP Supervisor subsequently notified the onshift control room personnel of the fire, who then sounded the fire alarm and dispatched the fire brigade. When the fire brigade responded, two fire brigade members entered the refueling cavity area af ter the RP Technician performed air samplos of th9 area and verified that the fire was extinguished, The licensco informed the inspectors that some actions taken in tosponse to the fire woro not consistont with ZAP 900 08, ' Station Fire Brigade," Rt vision 3. The proceduto specifies that any person discovering a fire shallimmb %toly report it to the control room by calling x2211; howevor, the RP Technician li ormed his
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supervisor of the fire instead of the control room. As part of the licenson's correctivo actions. the RP Supervisor counsellod the technician on the proper notification and responso to a fire. During tno Juno 11,1997, oxit mooting, sonior station personnelindicated that they woro not awaro that control room personnel had not boon proporly notified of the fire, c.
Conclusions The inspectors concluded that the fire brigade's response to
..to was adequato, though their initial responso was delayed due to the control wom not being promptly notified of the firo. The RP Technician's failure to report the firo in the Unit 1 reactor cavity to the control room as required by ZAP 900-08 is a violation of 10 CFR 50, Appendix B, Critorion V, " Instructions, Proceduras, and Drawings,"
(50 295/97013 03c), as described in the attached Notico of Violation Although this violation was identified by the licensoo, it is being cited because it is indicativo of continuing problems with plant personnel failing to f J10w proceduros.
F8 Miscellaneous Fire Protection issues
F8.1 Cinged) Unresolved item 50 295/95022-02, 50 304/95022-02; Review on omorgoncy lighting unit surveillances that contained questionablo data shoots.
in response to inspectors' concerns, the licensoo's investigation team dated March 13,1996, concluded in its report that two individuals knowingly recorded inaccurato data on the Attachment C data shoote of Electrical Maintenance Surveillanco Proceduto (EMSF) 03, " Emergency Ligi t Surveillance," Revision 1.
The licensee's investigation tea.n also concluded that de individuals' actions woro
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examples of indifference toward their responsibilities. The inspectors reviewed the licensee's investigation report and concluded that the same two individuals falsified
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these surveillance records.
During the investigation, the licensee identified that on May 24,1994, an individual recorded 12 volts for 19 six volt ernergency lighting unit batteries on the Attachment C data sheets. Both the licensee and the NRC concluded that the individual recorded voltage data on the Attachment C sheets with intent to falsify the documents. In addition, on September 12 and October 11,1995, the same mdividual recorded data for emergency lighting unit battery surveillances. However, the security cornputer access records showed that the individual had not entered the areas necessary to record the data. On August 27 and 28,1995, another individual recorded 20 readings in 19 minutes. Based upon a walkdown of the applicable emergency lights, the licensee concluded that recording each reading exactly o ie minute apart was extremely difficult to achieve.
The actions by the two individuals to falsify the data sheets for EMSP 03 on May 24,1994, August 27 and 28,1995, September 12,1995, and October 11, 1995,is considorod a violation of 10 CFR 50.5 (tiO 295/97013 051 50 304/97013-05), as described in the attached Notico of Violation. The NRC dotormined that no action against the individuals was appropriato following the consideration of the factors listed in Section Vill of NRC Enforcement Policy, NUREG 1600. The individuals are no longer employed at the Zion facility.
Thoroforo, the inspectors concluded that the correctivo actions described in the licensoo's April 3,1996, responso to the Soverity L.ovel ill Notice of Violation and Civil Penalty dated March 22,1996, were adequato and addressed the root causes of the violation.
No separato responso is required for this violation. Th;s untosolved item is closed.
V. Management Meetinati X1 Exit Meeting Summary The inspectors presented the inspection results to membois of licenseo management at the conclusion of the inspection on June 11,1997. The licenseo acknowledged tho findings presented.
The inspectors asked the licensoo whether any materials examined during the-inspection should be considered propriotary No proprietary information war identified.
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Management Meeting Summary The NRC's Executivo Director for Operations and the Deputy Director for the Office of Nuclear Reactor Regulation toured the Zion facility and met with licensoo management on May 5.1997.
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i fartN ust of Persons Contasted
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LICRaita J. Mueller, Sl:e Vice President R. Godley, Regulatory Assurance Manager J. Lewis, Radiation Protection Manager
T. Luke, Engineering Manager
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M. Wels, Support Services Director
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R. Zyduck, Site Ouality Verification Director
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T. Cromeans, Materials Management Supervisor E. Falb, Maintenance Support Supervisor D. Glornoth, Shift Manager
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C. Allen, Regulatory Assurance D. Beutel, Regulatory Assurance HilG
- A. Ve001, Senior Resident inspector D. Calhoun, Resident inspector E. Cobey, Resident inspector i
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i List of.inanection Procedures used
iP62707 Melntenance Observation
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IP 71707 Plant Operations
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IP 71750 '
Llat of items Onened, Closed, amu}lacuaned l
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Onen t
t 50 295/97013 01 URI Damaged grid straps on fuel assembly (FA) H04C while t
transporting the FA to the Spent Fuel Pool.
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- 50 295/304 97013 02 VIO The failure to control the use of overtime in excess of I
the overtime guidelines by Shift Managers, Unit
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Supervisors, and Nuclear Station Operators, j
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50 295/97013 03a VIO The failure of the licensee to ensure that adequate
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ventilation was being provided to the work area on the Unit I reactor vessel head prior to the use of a flammablo lubricant.
50 295/304 97013-03b VIO The failure of the licensee to soismically restrain the
deconning machine and the operations storago cabinet in areas not seismically qualified as storage areas.
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50 295/97013 03c VIO The RP Technician's failure to report the fire in the Unit
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1 reactor cavity to the control room.
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50 295/304 97013-04 URI Overloading of a safety related 120 volt transfortner.
50 295/304 97013-05 VIO Roview of emergency lighting unit surveillances that contained questionable data shoots.
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- 50 295/304 95022 02-URI Review of emergency lighting unit surveillances that contained questionable data sheets.
50 295/304 96017 05 URI Review licensee actions implemented in response to
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NRC concerns with the control of overtime, i
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o LJst of Acrortynn e
AB Auxiliary Building CAR Corrective Action Record EHC Electro Hydraulic Control
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EMSP Electlical Maintenanco Surveillanco Proceduro EA Equipment Attendant FA Fuol Assembly FHB Fuel Handling Building HVAC Heating, Ventilation, and Air Conditioning MCC Motor Control Contor MM Mechanical Maintenance MSIV Main Steam isolation Valve
NRC Nuclear Regulatory Commission PlF Problem identification Form PDR Public Document Room RP fiadiation Protection SFP Spent Fuel Pool sol Systern Operating Instruction
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TS Technical Spocification URI Unrosolved item VIO Violation ZAP Zion Administrative Proceduro ZRP Zion Radiation Procedure
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