IR 05000298/1993025
| ML20058C557 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| Issue date: | 11/18/1993 |
| From: | Gagliardo J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20058C538 | List: |
| References | |
| 50-298-93-25, NUDOCS 9312020484 | |
| Download: ML20058C557 (20) | |
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APPENDIX B U.S. NUCLEAP, REGULATORY COMMISSION j
REGION IV
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Inspection Report:
50-298/93-25 Operating License: DPR-46
Licensee: Nebraska Public Power District P.O. Box 499 Columbus, Nebraska 68602-0499 j
Facility Name: Cooper Nuclear Station Inspection At:
Brownville, Nebraska Inspection Conducted: August 29 through October 9, 1993
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i Inspectors:
R. Kopriva, Senior Resident Inspector W. Walker, Resident Inspector
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W. Jones, Project Engineer
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G. Werner, Resident Inspectot-R. Mullikin, Senior Resident Inspector khb lt (3
Approved:
we J. E. Gagi Q 10, Chief, Project Section C Date Inspection Summary
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Areas Inspected: Routine, announced inspection of onsite response to events, operational safety verification, surveillance observation, maintenance observation, followup, and onsite review of licensee event reports (LERs).
Results:
The licensee's response to the emerging equipment operability issues e
resulting from the failure of a motor-operated valve to stroke during a surveillance test was mixed (Section 2).
e The licensee effectively utilized the shift supervisor's window to
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conduct operational activities and appreciably reduced the number of
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individuals entering the main control room.
It was noted that management's emphasis on personnel control room access had resulted in a decrease in potential operator distractions. However, the operator's response to an unexpected valid high pressure coolant injection (HPCI)
alarm was inadequate.
The operator actions were directed at disproving the alarm indication.
The associated alarm response procedure did not 9312O204B4 931123 PDR ADDCK 05000298 O
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l-2-provide sufficient guidance to the operators to ensure that the appropriate actions were taken with the HPCI system in operation (Sections 3.1 and 5.1).
Major flow path valves within the emergency core cooling system were
positioned in accordance with Mode 1 Technical Specification operating requirements. A core spray system walkdawn verified that the system was properly aligned, and there were no outstanding system deficiencies which would adversely affect system operability (Sections 3.2 and 6).
The effectiveness of present housekeeping activities was mixed. Some l
e areas of the plant, such as the area around the standby liquid centrol
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tank, were well maintained. Other areas, such as the HPCI room, had been identified as being in poor condition.
The licensee was not aggressive l
in correcting the poor housekeeping areas (Sections 2.2 and 3.2.1).
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The as-found conditions inside the safety-related starter racks and motor e
control centers indicate that plant personnel accepted substandard work practices during the outage and that management oversight and supervisory involvement was not adequate (Section 4.4).
Radiological hot spots in the plant were well controlled, and excellent
support was provided for an HPCI system surveillance.
The security program provided for the proper control of personnel, packages, and vehicles into the protected area. Security intrusion and detection equipment appeared to be well maintained (Sections 3.3 and 3.4).
e The licensee's conduct of maintenance and surveillance activities was mixed. Operations and maintenance personnel appeared cognizant of in-plant work activity requirements.
The impact maintenance activities would have on equipment operability was appropriately considered.
However, the scope of troubleshoating activities was not well defined, work package instructions were incomplete, and maintenance personnel did not consistently demonstrate good self-checking practices (Sections 4 and 5).
The licensee's response to the identified alarm procedure deficiency was e
inadequate and contributed to a subsequent event where the HPCI system was unnecessarily secured during a surveillance test (Section 5.2).
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Summary of Inspection Findings:
o Violation 298/93025-1 was opened (Section 5.1).
e Violation 298/93025-2 was opened (Section 5.2).
Inspection followup Item 298/9301-01 was closed (Section 7.1),
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e Inspection ollowup Item 298/9301-02 was closed (Section 7.2).
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LER 93-014 was closed (Section 8.1).
e LER 93-017 was closed (Section 8.2).
Attachment:
Persons Contacted and Exit Meeting
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l DETAILS
1 PLANT STATUS
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r At the beginning of this inspection period, the plant was operating at i
i 100 percent power. During the inspection period, the licensee noted an increase in conductivity of the water in the reactor vessel. At the end of this report period, the licensee had formulated plans to reduce power and
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inspect the condenser for tube leaks, which they believe to be the cause of the increased conductivity, j
i 2 ONSITE RESPONSE TO EVENTS (93702)
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t 2.1 Motor-0perated Valve (MOV) pinion Gear
On August 30, 1993, during the conduct of an HPCI surveillance test, M0V HPCI-MOV-MO-020 failed to stroke open after being closed.
The following day the
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licensee identified that the motor pinion gear was rotating freely around the motor shaft. The key which secured the pinion had moved axially along the shaft and fallen out. A discussion of the associated work activities is provided in Sections 4.2 and 4.3.
The licensee established a Problem Resolution Team (PRT) on September 1,1993, to determine the cause for the key falling out and the corrective actions
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necessary to address other potential valve operability concerns. The PRT consisted of a team leader, engineers, the MOV program-supervisor and manager,
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and an instrumentation and control supervisor. Their charter included an
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evaluation of the cause for the failure, an assessment of the generic implications, and the identification of the scope and time line for i
implementing corrective actions.
The licensee's supplier (Limitorque) had identified that valve motors provided
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by them should have had:
(1) the key way staked to prevent axial movement of the key, (2) the pinion gear set screw locked wired in place, and (3) the I
shaft dimpled to accept the set screw.
In 1989 the Limitorque Corporation had
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issued Limitorque Maintenance Update 89-1, which provided specific
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instructions to users on replacing motor pinion gears when installing new motors.
These instructions included drilling the motor shaft, lockwiring the set screw, and staking the key way, it was determined that the applicable maintenance procedures had not been revised to incorporate the vender recommendations until October 1991. A review of work activities performed prior to October 1991, involving the replacement of valve motors, was then performed to assess the need for rcwork.
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The PRT determined that the motor for Valve HPCI-MOV-M020 had been replaced in i
l 1990 (prior to the October 1991 procedure revision) and that the work i
l instructions used at that time did not require the shaft to be drilled or the
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key way to be staked.
Based on the cause for the failure having been
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l identified and knowing that the affected valves were those for which the motor
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l had been replaced, the licensee reviewed the work history for each Limitorque l
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valve.
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A total of 260 MOVs were identified as having been installed.in' the plant, j
Seventy-four of these valves had been refurbished using the revised.
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maintenance procedure.
Based on discussions with the vendor, it was.
l determined that valves with actuators sized smaller than SMB-0 were not
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susceptible to this problem because of internal clearance limitations. The licensee then established four groups of valves to be inspected based on their significance and priority. These groups were:
(1) safety related with an active safety function, (2) safety related with no active safety function, (3)
balance of plant and important to availability and, (4) remaining balance of.
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plant valves.
The licensee identified 6 valves which fell into Group 1.
These valves were
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in the HPCI and residual heat removal systems. Maintenance work requests were initiated to inspect the six valves.
In addition, a concurrent path was
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initiated to verify the assumptions made in determining the valves which may
not have been-affected. This included inspection of abandoned-in-place valves
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and valves received from the vendor which were stored in the warehouse.
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l The licensee found that the six Group 1 valve pinion gears had not been staked j
or the shaft drilled, but that they were secure and the set screws had been
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locked wired in place.
It was noted that the work activities to verify the l
l assumptions made was not well coordinated.
One instance was identified, as l
l noted in Section 4.3 of this report, where the key way was not staked as l
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previously assumed.
The licensee has established an aggressive schedule to inspect the Group 2 and 3 valves when operational' conditions permit. The licensee's overall response-to the concern was found to be appropriate and properly considered the potential safety impact on the plant. The licensee has documented their findings in Nonconformance Report 93-196.
I 2.2 Starter Racks J
During the conduct of postmaintenance testing for HPCI Valve HPCI-MOV-M020 on September 1,1993, the valve failed to close from the main control room. The licensee determined that a contact in the HPCI ' alve starter rack was not v
operating correctly. The subsequent troubleshooting activity identified that a foreign material (paint chip or metal shaving) had lodged in the closed contact, preventing the valve motor from energizing. A discussion of the work activity is provided in Section 4.4.
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The licensee initiated maintenance work requests to assess the condition of other HPCI motor starter racks. Similar conditions were identified in seven of the HPCI starter racks that were inspected, and the starters were cleaned to remove the foreign material. Based on this finding, the PRT was also tasked with investigating the failure and recommending corrective actions.
On September 3,1993, the inspector inquired into the cause for the valve failing to close, the conditions which had resulted in its failure and the corrective actions which had been initiated. The inspector found that PRT activities were focused on the MOV pinion gear problem and that
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responsibilities within the licensee's organization had not been clearly established to assess the starter rack concerns. An engineer had been tasked with providing an overall assessment of the event to management; however, the inspectors determined that he had not been provided with managements'
expectations and that he was not fully cognizant of the types of problems and l
l concerns that had been identified.
These concerns were promptly discussed with licensee senior management. The licensee's subsequent response was appropriate and included a comprehensive inspection of safety-related motor control centers. The licensee found that
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the extremely poor housekeeping conditions which had existed in the safety-related starter racks also existed in the motor control centers.
Each of the
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affected areas was subsequently cleaned.
The results of the licensee's investigation are documented in Nonconformance Report 93-199.
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2.3 Conclusions The implementation of a PRT to coordinate the licensee's response to the MOV and starter rack operability concerns was appropriate. The team provided an effective means of addressing the technical issues utilizing the cognizant personnel. However, the licensee was not completely effective in coordinating work activities to verify assumptions made in assessing the scope of the MOV concern.
In addition, the licensee's initial response to the starter rack operability concerns was not well coordinated. Management had not established clear responsibilities to address the operability concern, and managements'
expectations were not effectively iterated to the engineering personnel performing the review 3 OPERATIONAL SAFETY VERIFICATION (71707)
3.1 Control Room Observations The inspectors observed operational activities throughout this inspection period to verify that proper control room staffing and control room professionalism were maintained.
On September 16, 1993, the licensee issued a letter to all managers and supervisors emphasizing the expectations for control room access and conduct.
Conduct of Operations Procedure 2.0.3, " Control Room Access, Conduct, and Staffing Requirement," contains specific requirements for control room
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-7-activities. The inspectors discussed the conduct of operations and management expectations for control room personnel with the operations manager. The licensee had emphasized the necessity for the shift supervisor to maintain control of all activities concerning plant operations. During recent tours of the control room the inspectors noted fewer individuals inside the control room and more operations business being conducted at the shift supervisors window. The inspectors observed that Technical Specification limiting conditions for operation were properly documented and tracked.
Plant management was observed in the control room on a daily basis.
3.2 Plant Tours 3.2.1 HPCI Room On September 21, 1993, the inspectors toured the HPCI room to assess the overall condition of equipment within the room.
It was noted that grease had accumulated beneath the HPCI pump and turbine coupling, and a bolt approximately 4 inches long by 1 inch in diameter was located under the HPCI booster pump. Also, during the tour of the room, the inspectors noted a white crystalline substance on one of the green indicator lights for the 125 VDC electrical feeder box from the 125 VDC switchgear.
Each of these observations was promptly reviewed with licensee management.
The licensee indicated that the grease had come from the HPCI pump and turbine coupling and that it was not detrimental to the coupling.
The license reviewed the area around where the bolt was observed and did not identify any missing bolts.
The HPCI 125 VDC electrical feeder box was opened and found to be relatively clean of any internal water contamination.
This electrical box had been identified during the July 1993 building water inleakage as a box where water intrusion had occurred. The inspector reviewed with the licensee what actions had been taken, such as drying the electrical components to assure they could perform their intended safety function.
The licensee's actions, which consisted of drying and inspecting the electrical box, were found to be appropriate.
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Several additional housekeeping items were noted by the inspectors.
Paper and plastic debris was found under the suction pipe which enters the HPCI room.
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The inspectors noted that poor housekeeping conditions in the HPCI area were allowed to continue until the end of the inspection period.
3.2.2 Torus Area On September 21, 1993, the inspectors toured the area underneath the torus.
The overall housekeeping within this area was good. The inspectors noted that temporary lighting cables in the area were in poor condition and some light sockets had missing protective shields or light bulbs. These conditions were subsequently identified to licensee management and corrected.
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3.2.3 Emergency Core Coolino System Lineups l
The inspectors verified that valves within the accessible emergency core cooling system major flow paths were properly aligned. The inspectors walked down portions of these systems and verified that the valve lineups were in accordance with the operating procedures.
Required auxiliary systems were
found to be operable. The main control board indications were found to be consistent with the field conditions.
3.2.4 Standby Liouid Control System The inspectors conducted a walkdown of the accessible portions of the standby liquid control system located in the reactor building. The valve positions
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were verified to be aligned in accordance with the valve position checklist provided in System Operating Procedure 2.2.74A, Revision 0, " Standby Liquid i
Control System." Valves designated as locked open or locked closed were found to be appropriately secured.
A review of the area found the housekeeping activities to be good, and no discernable system leakage was noted.
The hoses and equipment required to establish the alternate reactor core isolation cooling baron injection flow path was properly staged.
3.3 Radiological Protection Observation The inspectors reviewed the activities associated with the implementation of the radiological protection program. The review consisted of observing activities requiring radiation work permits, tours of the radiologically controlled area, and accompanying radiological protection personnel.
The inspectors noted that the radiological protection personnel provided excellent support for the HPCI surveillance test on September 1,1993. The area was appropriately identified as a high radiation area and continuous radiation protection personnel coverage was provided while the HPCI pump was running. The operations, engineering, and maintenance personnel were aware of the radiation work permit requirements and obtained the appropriate dosimetry prior to entering the room.
The inspectors accompanied several radiation protection personnel during their survey of selected emergency core cooling system areas.
Each individual was very thorough and demonstrated good radiological work practices. The radiological postings in each of the areas rarveyed was found to be appropriate.
3.4 Security Program Implementation The inspectors observed security access controls at the primary access point.
Personnel and packages entering into the protected area were properly surveyed. An early morning observation of security access controls was
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performed. The interior of the protected area fences was walked down by the i
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Appropriate compensatory posts
were established for areas along the fence line which were breached by the i
high Missouri River level.
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3.5 Conclusions The licensee effectively utilized the shift supervisor's window to conduct
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operational activities and appreciably reduced the number of individuals
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entering the main control room.
It was noted that management's emphasis on
personnel control room access had resulted in a decrease in potential operator
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distractions.
t The effectiveness of housekeeping activities was mixed. Some areas of the
plant, such as the area around the standby liquid control tank, were well
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maintained. Other areas, such as the HPCI room, had been identified as being i
in poor condition. The licensee was not aggressive in correcting identified
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poor housekeeping areas.
The emergency core cooling systems were found to be properly aligned. The control room operators demonstrated that they were cognizant of each safety-related system's status.
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Radiological protection personnel provided excellent support for the HPCI
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system surveillance test. The security program was properly implemented for personnel and package entry into the primary access point. Compensatory security posts were established as required.
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r 4 MAINTENANCE OBSERVATIONS (62703)
i 4.1 Reactor Core Isolation Cooling (RCIC) System Valve Packing Adjustment On August 8,1993, the inspectors observed mechanical maintenance personnel
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adjusting the RCIC system Valve RCIC-MOV-0132 packing. This valve is required
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to open on an RCIC initiation signal to provide cooling water to the reactor
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vessel and closes on a high reactor vessel level. The inspector reviewed
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Maintenance Work Request 93-3216 and questioned the mechanics about the proper
torquing of the packing nuts. The work activity was performed in accordance
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with the maintenance work request. The inspector then reviewed the
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postmaintenance test requirements with the control room operators. This valve
was required to be stroked per the licensee's inservice testing (IST) plan, Procedure 3.9, "ASME Code Testing of Pumps and Valves." ASME Section XI
requires testing after packing adjustments to demonstrate that the performance
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parameters were within acceptable limits.
It was noted that the valve stroked
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within the time requirements established in the IST plan.
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During the discussions with the control room operators and a review of the control room log, it was noted that the licensee had not declared the valve and RCIC system inoperable from the time the packing was adjusted until' the j
postmaintenance test was successfully completed. The inspector reviewed the c
conditions that would have required the valve to be declared inoperable.
Both
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r the on-duty shift supervisor and operations manager indicated that it had been
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normal practice to enter into action statements on safety-related equipment removed from service for maintenance, however, neither person felt that the
valve was inoperable. This was based on the valve not being removed from i
service and the short period between the packing adjustment and the I
performance of the stroke time test. The licensee did specify that, if the j
valve failed the IST or an extended period occurred between the time the valve i
packing was adjusted and the time the IST was performed, it would be declared t
inoperable and Technical Specification Action Statement 3/4.5, " Core and
Containment Cooling Systems" entered.
The inspector reviewed the licensee's administrative requirements identified l
in Procedure 2.0.2, Revision 21, " Conduct of Operators."
It was found that
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operator's performance was consistent with the established administrative requirements.
The inspector concluded that the licensee had adequately considered the valve operability concern and was cognizant of the Technical Specification action
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requirement time limitations to ensure they would be met if the valve had not been promptly tested in accordance with the IST requirement.
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4.2 HPCI MOV M0-20 Troubleshooting On August 31, 1993, mechanical and electrical maintenance technicians were i'
observed removing the motor on Valve HPCI-M0V-MO-20. The valve had failed to stroke open the previous day during the valve IST. The licensee's initial investigation found that the motor would operate without-any corresponding valve movement.
It was also determined that the valve could be manually stroked. Efforts were focused on motor removal since the apparent failure indicated a possible problem with the motor pinion gear key.
l Maintenance Work Request 93-3323 was initiated to authorize work activities for Valve HPCI-M0V-M0-20. The inspectors noted that the work package i
contained a rigging evaluation to use permanently installed pipe supports as the anchor points to attach a chain fall to remove the valve motor. The inspectors observed that the initial rigging configuration allowed a lifting sling to contact a snubber extension. The lifting sling was configured such that it applied a lateral load to the snubber when tensioned..The engineering rigging evaluation did not account for the interference with the snubber.
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i This observation was brought to the attention of the HPCI system engineer, who then stopped the work activity. The technicians repositioned the slings.
Approximately 6 licensee personnel, including supervisory personnel, were present during this time and did not identify the sling arrangement that could have resulted in damage to the snubber.
The inspector reviewed the rigging evaluation provided in the work package.
It was noted that specific pipe supports were to be used; however, no pipe support numbers were stenciled on the supports and no isometric drawings were included in the work package to enable the technicians to self-verify that the supports used were in fact those specified in the evaluation. A mechanical
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conducted by the supervisor to ensure that the supports he was requested to use were actually included in the rigging evaluation. The inspectors
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discussed the above poor safety-and self-verification p.'actices with licensee
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management.
The motor was removed in accordance with Maintenance Procedure 7.2.50.16,
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Revision 0, "Limitorque SB-3 Valve Operator Maintenance." During the
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inspection of the motor, the technicians found that the motor pinion key had
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fallen out of the motor shaft and gear. The key way shaft had not been staked
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nor had the shaft been counterbored to increase the holding power of the
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pinion gear set screw as recommended by Limitorque Vendor Letter 89-01.
The motor components were inspected for damage and none was identified.
Technicians then installed a new key, counterbored the shaft, and staked the
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key way shaft. The motor was reinstalled and successfully stroked open and closed several times. The electricians verified that initial open and close i
currents and running currents were normal.
4.3 Various MOV Motor Removal and Inspection
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The licensee conducted inspections of various installed, abandoned-in-place,
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and warehouse stored Limitorque MOVs in order to bound the scope of the j
problem concerning valves without the motor keyway staked and counterbored for l
i the pinion gear setscrew. The inspectors observed the following valves being disassembled and inspected:
Valve RHR-MOV-M0-39B (a Limitorque SMB-1) was inspected under MWR 93-3384
using Procedure 7.2.50.9, Revision 0, "Limitorque SMB-1 Valve Operator l
Maintenance." The inspection determined that the keyway was not staked and the motor shaft was not counterbored. The key was tight within the motor pinion gear and the gear's setscrew was lockwired. This valve had been replaced prior to the licensee incorporating the maintenance bulletin recommendations in October 1991.
Warehouse spare valve Serial Number L433926, Type SMB-2 valve, received
from Limitorque on April 11, 1901 under Limitorque Purchase Order 326430 was inspected under Maintenance Work Request 93-3368 using Procedure
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7.2.50.10, Revision 0, "Limitorque SMB-2 Valve Operator Maintenance. The motor shaft key way was staked, the shaft was counterbored, and the setscrew was lock wired.
Additionally, Warehouse spare valve Serial Number 102329, Type SMB-2 valve, was also inspected. This valve was missing the setscrew lockwire and the key way was not staked; however, the shaft had been counterbored for the setscrew.
Spare valve Serial Number 102329 was worked in August 1992 under
Maintenance Work Request 92-1326 subsequent to the procedure revision of i
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i October 1991 which required the, key way to be staked and the shaft i
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counterbored. The licensee's assumption that all Limitorque MOV work
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done after the procedure change would incorporate the staking and
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counterboring of the motor pinion shaft was not valid-in this instance.
l The inspectors noted that, when the technicians removed the first motor from j
the valve in the warehouse, the technicians did not utilize Procedure 7.3.33,
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Revision 7, " Electrically Disconnecting and Connecting Limitorque Valve Operators." This procedure provided a record of termination of each
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electrical lead prior to the removal of the electrical leads, and this step is a quality control hold point. When questioned, the electrician indicated that
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he thought he did not need a termination sheet for work in the warehouse.
Procedure 7.2.50.10, which the technicians were using to remove the motor, did l
not contain Section 8.6, " Electrical Component Disassembly and Re' assembly,"
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which referenced Procedure 7.3.33 in order to identify wire terminal
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locations.
Procedure 7.2.50.10 had been marked to only require Sections 8.3, i
" Disassembly," and 8.5, " Reassembly," to be completed. The maintenance work.
i request was not adequate for the work in the warehouse and this contributed to
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the technicians not using the termination sheet. An electrical maintenance
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supervisor also felt that no terminal verification record ' sheet was necessary since the motor would be operationally checked prior to: placing it in service.
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The inspectors noted that a wiring. error could result in damage to the motor
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j or valve when it is initially installed and subjected to operability testing.
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4.4 HPCI MOV-020 Starter Box Relay Troubleshootina
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l On September 1,1993, the inspectors observed the troubleshooting activity associated with the failure of Valve HPCI-MOV-020 to stroke. The licensee was
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l in the process of performing the postmaintenance test to return Valve HPCI-MO-M020 and the HPCI system to service when the valve motor failed to energize on
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a close signal.
The licensee promptly initiated troubleshooting activities
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for the problem using Maintenance Work Request 93-3323. This. maintenance work
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request had been initiated to troubleshoot and repair the motor pinion work l
described in Section 4.2 of this report.
No additional work instructions were
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provided.
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The electrical maintenance personnel initiated the troubleshooting activity at i
the HPCI MOV-020 starter rack. The 72/c and 72/m contacts were observed to be pulled in, but the motor was not running.
Both the 125VDC control power and 250VDC power supplies were available. When the starter rack control power was deenergized, the contactors dropped out. The undervoltage relay was reset and the disconnect switch closed. The main control room was then. able to remotely -
open and close ~the valve.
A visual inspection of the starter components was'then performed. During the disassembly of the contacts, a small piece of material appeared to fall out.
A towel was then placed below the starter contacts. Additional debris was observed to fall onto the towel..The debris appeared to be both metal-shavings and fine pieces of paint.
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-13-The inspector noted that the starter box interior paint had began to peel and metal shavings were present on the bottom of the cabinet. The overall i
housekeeping conditions within the starter box were extremely paor. A nonconformance report was initiated to evaluate this condition. The
postmaintenance test was then performed successfully, and HPCI-M0V-M0-020 was returned to service.
On September 2, 1993, the inspectors observed the inspection of an additional seven HPCI starter rack.
These work activities were authorized by Maintenance Work Request 93-3366. Similar conditions (foreign material) were noted to exist in each of the starter racks. The foreign material included both small paint chips and metal filings. A small metal chip was found under the close contactor cover for Starter Rack HPCI-MOV-M0-058.
For each of the above starter racks the contactors were inspected and the starter rack cleaned.
Postmaintenance tests were performed for each of the starter racks which were deenergized. Deficiency reports were initiated for each of the identified concerns.
4.5 Thermal Examination of Diesel Generator 2 Electrical Components On September 14, 1993, the inspector observed electrical maintenance technicians performing thermal examination of Diesel Generator 2 electrical components under Maintenance Procedure 7.3.14, " Thermal Examination of Plant Components.".The thermography was performed as part of the licensee's preventive maintenance program at 6-month intervals on the diesel generator electrical components. During performance of the test, the inspector discussed the use of the equipment and the acceptance criteria being used by the electrical technicians. The electrical boxes examined were clean and no abnormalities were noted by the technicians. The data collected by the electrical technicians was to be further analyzed by a maintenance engineer who would perform an assessment of the data to assure there are no problems reouiring immediate action. The thermal examinations were performed with the emergency diesel generators fully loaded so that any thermal inconsistencies indicating degraded components could be detected.
During discussions with the inspector, electrical technicians conducting the testing appeared knowledgeable of the benefits of thermography and its j
usefulness in early detection of degraded electrical components in the plant.
4.6 Conclusions The licensee's conduct of maintenance activities was mixed. Operations and maintenance personnel appeared cognizant of in plant work activity requirements and the impact that maintenance activities would have on equipment operability. However, the scope of troubleshooting activities was not well defined, work package instructions were incomplete, and maintenance personnel did not consistently demonstrate good self-checking practices.
The as-found conditions inside the safety-related starter racks and motor control centers indicate that plant personnel accepted substandard work
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-14-practices during maintenance and modification activities and that management and supervisory involvement was not adequate to prevent these poor work practices.
5 SURVEILLANCE OBSERVATIONS (61726)
l 5.1 HPCI Inservice Test
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On September 1, 1993, the inspectors observed the HPCI IST
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Procedure 6.3.3.1.1, Revision 2, "HPCI IST and Quarterly Test Mode Surveillance Operation." The balance-of-plant operator was observed following the procedure and using good communications with the station operator. The
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surveillance was completed and initial results were satisfactory.
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Approximately 7 minutes after the HPCI pump was started, the Annunciator 9-3-2/C-2, "HPCI Turbine Inlet Drain Pot Hi Level," alarm actuated. The BOP operator promptly silenced the alarm, however, he did not review the alarm
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response procedure or take any additional actions. The inspectors questioned i
the reactor operator (RO) about the alarm and he stated that the alarm did not normally actuate during the test, and he did not indicate that he was aware of
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the cause of actuation.
The RO subsequently reviewed Alarm Procedure 2.3.2.22, Revision 16, "HPCI Turbine Inlet Drain Pot HI Level," for Panel / Window Location 9-3-2/C-2, Section 2.0, Operator Observation and Action. This procedure specif4d the
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(1) verify open Valve HPCI-AO-53, COND DRAIN P0T TRAP
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BYP VLV; (2) check proper operation of steam trap HPCI-TP-57; and (3) if alarm fails to clear, manually drain condensate from line or remove HPCI system from service. The inspector observed that the R0 initially completed only the first step of Section 2.0 until the inspector questioned the R0 about the remaining two steps, and the R0 appeared to be unsure how to check the steam trap operation as identified in Section 2.0.
The inspector noted that no additional actions were taken.
The inspector reviewed the alarm with the control room supervisor (CRS).
It also appeared that he was not cognizant of the cause of the alarm.
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Additionally, the CRS was not aware of the actions necessary to complete the l
final two steps of the alarm procedure. When questioned as to how long the
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and held discussions with the shift supervisor concerning the required I
actions. The shift supervisor and tr.e CRS determined that the step referred to isolating the steam trap line and not securing the HPCI system.
The R0 and balance-of-plant operator subsequently reviewed the annunciator and based upon their discussions, they decided not to rely on their indications of high water level in the drain pot. The station operator who was in the HPCI room was contacted to mechanically agitate the level switch (HPCI-LS-90) in an attempt to clear the alarm. During the process of discussing the alarm and attempting to clear the annunciator, both licensed operators and CRS were heavily distracted in an attempt to clear the alarm.
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l After the performance of the surveillance test, the shift supervisor had I
instrumentation and control maintenance personnel check the operation of Level
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Switch HPCI-LS-90. No operational problems with the level switch were identified. A maintenance work request was then written to inspect Steam Trap S-57.
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The inspectors were unable to determine from discussion with the licensed operators the function of the trap and whether the trap was operating
properly. A review of the system operating procedures and drawings and an f
interview with an electrical engineer identified that the trap was isolated and would not operate when the inlet steam supply valve (HPCI-M0V-M0-14) was
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open. The steam trap prevents water buildup in the steam line when the HPCI i
turbine is secured, therefore, preventing turbine damage /overspeeding on a
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HPCI start. Valve HPCI-MOV-MO-14 is interlocked with two air-operated valves
(HPCI-AO-42 and -A0-43) which are downstream of Steam Trap S-57.
When HPCI-i MOV-MO-14 is open, -AO-42 and -A0-43 automatically close, thereby isolating
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tne steam trap.
l Based upon the control room staff's actions,'their response to inspectors'
questions, and their internal discussions, the inspector determined that the i
operators were not fully cognizant of the steam trap configuration with the
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HPCI system in operation. The inspectors reviewed alarm Procedure 2.3.2.22,
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Revision 14, "HPCI Turbine Inlet Drain Pot HI Level," and identified that the l
alarm response procedure failed to specify the HPCI system operational i
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l conditions when the alarm response procedure was not applicable. The failure j
l to provide specific operational guidance contributed to the cperators
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I assessing an unexpected valid main control board alarm that required no l
immediate actions. The failure to implement an adequate alarm response procedure is a violation (298/93025-1) of Technical Specification 6.3.2.
5.2 HPCI Surveillance Testing On September 29, 1993, the inspectors again observed the performance of Surveillance Procedure 6.3.3.1, Revision 41, "HPCI Monthly Test Mode i
Surveillance Operation."
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l The inspector initially observed the-HPCI turbine start locally and then went to the control room.
Upon entering the control room, the inspector observed Annunciator 9-2-2/C-2, "HPCI Turbine Inlet Drain Pot Hi-Level," alarm activated. The inspector then observed a nearly identical repeat of the events described in Section 5.1 of this report, which occurred on September 1, 1993, during conduct of the same survelilance test. After approximately 20 minutes, the shift supervisor ordered the HPCI turbine shut down. During the inspector's observation, it was evident that the crew performing the HPCI surveillance test was not aware of the difficulties experienced during the previous surveillance test on September 1,1993.
The inspector promptly reviewed this observation with licensee management and the potential significance of not promptly assuring that the operators would
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appropriately respond to the alarm. After discussions with the inspector, the j
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licensee initiated a temporary procedure change to the annunciator procedure and reviewed the event with all the operating crews. The inspector identified the failure to initiate prompt corrective action to assure that the operators would properly respond to the alarm as a violation (298/93025-02) of Appendix B, 10 CFR 50, Criterion XVI.
5.3 Torus to Drywell Vacuum Breaker Operation The inspectors observed the R0 conducting Surveillance Test Number 0-0333F using Procedure 6.3.10.5, Revision 27, " Torus to Drywell Vacuum Breaker Operation." All required signatures to commence the procedure were signed and the prerequisites were completed.
The R0 consistently referenced the procedure and used excellent self-verification techniques. A review of the completed procedure indicated that all acceptance criteria were satisfied.
5.4 Conclusions The operators' response to the unexpected valid HPCI alarm was inadequate.
The operator actions were directed at disproving the alarm indication.
In addition, the cause for the alarm and its significance was not well understood. The associated alarm response procedure did not provide sufficient guidance to the operators to ensure that the appropriate actions were taken with the system in operation.
The licensee's response to the identified alarm procedure deficiency was inadequate and contributed to a subsequent event where the HPCI system was l
unnecessarily secured during a surveillance test.
l 6 ENGINEERED SAFETY FEATURE SYSTEM WALKDOWN (71710)
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6.1 Core Spray System The core spray system was selected for the engineered safety feature system wal kdown. An integrated inspection of the core spray system was conducted to I
include a system walkdown, comparison of the system piping and instrumentation diagram to the system lineup procedures, and a review of inservice testing data and all open industry / technical notices and bulletins.
All accessible portions of the core spray system were inspected during the walkdown, which was conducted with the assistance of the system engineer. All major flow path valves and control switches were verified to be in the correct position. Overall, the core spray system was in excellent condition, with only 1 minor discrepancy noted (loose handwheel on Valve CS-11.) Housekeeping was very good in all areas of the radiologically controlled areas which contained core spray system components.
The system engineer described the core spray system as having an excellent operating history. He identified that no repetitive wo.k items or historical equipment problems existed with the system.
However, the engineer did state that Core Spray Pump B had experienced vibration problems and was on an l
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increased inservice test schedule. The pump vibration concern appeared to be l
caused from piping vibration. The licensee had been conducting testing to
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determine the cause for the vibration differences between the two core spray trains. Currently, the licensee.had no active or open design modifications i
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being conducted or planned on the core spray system.
The inspectors reviewed Procedure 2.2.9A, Revision 3, " Core Spray System Valve
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Checklist," and compared the valve lineup procedure to the core spray flow diagram, Burns and Roe Drawing 2045.
Sheet 20 of Procedure 2.2.9A lists Valve
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CS-65 as the low side isolation for Instrument DPIS-45B and Valve CS-64 as the i
low side isolation for Instrument DPIS-43a; however, Core Spray System l
Drawing 2045 has the isolation valve numbers reversed. This discrepancy was
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identified to the control rcom supervisor and the lead mechanical engineer for resolution and identification as to the correct valve configuration. At the i
end of the inspection period, the inspectors reviewed the actions the license had initiated to resolve the drawing and procedure discrepancy.
It was i
determined that no corrective action had been initiated. The licensee
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l subsequently entered this discrepancy into the corrective action program.
The inspectors requested a list of any open regulatory guidance, industry information, and vendor notices pertaining to the core spray system. The licensee indicated that all published information on core spray system
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components had been reviewed.
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6.2 Conclusion
i The inspectors found no outstanding work items, industry concerns, or l
equipment conditions that may adversely effect the core spray system from performing its intended safety function. Overall, the system was in very good condition. The licensee needs to evaluate and correct the procedure / drawing discrepancy to prevent improper equipment isolation.
7 FOLLOWUP (92701)
The following items were reviewed to ascertain whether the licensee had taken sufficient action.
7.1 (Closed) Inspection Followup Item 298/9301-01:
Licensee Review of Temporary Design Changes This item concerned the licensee's use of temporary design changes which are plant temporary modifications installed for more than 6 months. The inspector had noted that some temporary design changes could possibly be removed or made into permanent plant modifications. The inspector had noted that all of the
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open temporary design changes had minor safety significance. The licensee committed to review the open temporary design changes to determine which ones could be removed or made permanent.
The inspector reviewed the results of the licensee's review of the 25 open temporary design changes. The licensee was able to remove eight and converted
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five temporary modifications into permanent plant modifications. This action i
satisfied the licensee's comitment to the NRC on this concern.
7.2 (Closed) Inspection Followup Item 298/9301-02:
Comitment to Annotate Control Room Orawings Affected by a Temporary Modification
This item concerned the lack of control room drawings and procedures to
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I indicate that a temporary modification affected it. The licensee comitted to enhance the temporary modification process to resolve this concern.
The inspector reviewed Conduct of Operations Procedure 2.0.7, Revision 17,
" Plant Temporary Modification Control." The inspector verified that the
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procedure was changed to require the shift supervisor to stamp affected control room drawings and procedures with the temporary modification number.
In addition, the inspector verified that a control room drawing and procedure affected by an open temporary modification were properly stamped with the
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modification number. This satisfied the licensee's comitment to the NRC on this concern.
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8 ONSITE REVIEW OF LERs (92700)
8.1 (Closed) Licensee Event Report 93-014:
Service Water Throttle Valv'e
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Erosion Due to inadeauate Valve Desian The licensee reported that, during plant shutdown for normal refueling, a l
small throughwall leak developed on the high pressure side of the Service i
Water Throttle Valve SW-MOV-M089A Residual Heat Removal Heat Exchanger A l
service water outlet. The service water system was'in operation at the time
of the leak in support of Loop A shutdown cooling during the defueling of the
reactor vessel.
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The licensee determined that the leak was caused by erosion due to the
internal design of the valve and the suspended solids in the process fluid.
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The licensee's corrective action was to weld repair the through-wall opening
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in the valve body in accordance with the applicable codes. Also, through-cage i
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support guides were modified to allow improved flow distribution while the valve is operated in a throttled condition.
Erosion control epoxy was applied to the interior of the valve body, a new trim was installed in the valve, and -
the system was returned to service after testing.
I The licensee had also decided to increase the frequency of visual inspection -
i of both service water outlet valve (SW-MOV-89A and SW-MOV-M089B) internals from once every three cycles to once per cycle.
In addition, ultrasonic i
testing of the valves would be performed on an increased frequency based'on accumulated in-service time for each of the valves. The inspector found these actions to be acceptable.
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8.2 (Closed) LER 93-017: Technical Specification Violation for Missed Fire j
Watch Patrols
.i The licensee reported that an hourly fire watch patrol was missed in violation
of Technical Specification 3.14.B.
The fire watch patrol was for the -
northwest and southwest quadrants of the reactor building. These areas
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contain the residual heat removal system pumps and fan coil units and the HPCI
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system pump.
The licensee determined this event was caused by two factors. - First, the
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person responsible for the missed fire watch patrol believed someone else was l
performing the patrol. A contributing factor was the lack of a schedule which delineated the individuals responsible to perform the fire watch patrol -for-each watch period.
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The second factor was an inadequate Fire Watch / Fire Watch Patrol Log, which f
lacked specific requirements associated with performing the fire watch patrol.
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To effectively implement the fire watch. patrol', the specific areas listed' in
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the design change documents as having inoperable detectors should have been
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noted on the Fire Watch / Fire Watch Patrol Log. The licensee's corrective.
l actions included counseling the individuals on the importance of performing
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required fire watch patrols and a review of the fire watch implementation i
process, including the controls: for assignment of fire watch patrol personnel.
i The inspector-reviewed the licensee's records and verified that the corrective l
actions had been completed. The inspector found the licensee's actions to be j
acceptable.
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l ATTACHMENT j
1 PERSONS CONTACTED i
L. E. Bray, Regulatory Compliance Specialist i
M. A. Dean, Nuclear Licensing and Safety Supervisor l
C. M. Estes, Senior Manager of Operations
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J. R. Flaherty, Engineering Manager
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R. L. Gardner, Plant Manager E. M. Mace, Senior Manager Site Support l
D. L. Reeves, Senior Staff Engineer J. V. Sayer, Radiological Manager G. E. Smith, Quality Assurance Manager
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V. W. Stairs, Assistant Operations Manager
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M. E. Unruh, Maintenance Manager j
l The licensee personnel listed above attended the exit meeting.
In addition to i
the personnel listed above, the inspectors contacted other personnel during
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this inspection period.
2 EXIT MEETING An exit meeting was conducted on October 14 and supplemented on November 10, 1993. During the first meeting, the inspectors reviewed the scope and
findings of this report. During the second meeting the inspectors reviewed
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I Violation 298/93025-2. The licensee acknowledged the inspection findings and
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did not identify as proprietary any information provided to, or reviewed by, i
the inspectors.
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