IR 05000298/1999001

Insp Rept 50-298/99-01 on 990207-0320.Non-cited Violations Noted.Major Areas Inspected:Operations & Maint

ML20206H761
Person / Time
Site:	Cooper
Issue date:	05/05/1999
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20206H757	List: IR 05000298/1999001 ML20206H754
References
50-298-99-01, 50-298-99-1, NUDOCS 9905120009
Download: ML20206H761 (18)

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ENCLOSURE U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket No.:

50-298 License No.:

DPR 46

Report No.:

50-298/99-01 Licensee:

Nebraska Public Power District Facility:

Cooper Nuclear Station Location:

P.O. Box 98 Brownville, Nebraska Dates:

February 7 through March 20,1999 Inspectors:

M. Miller, Senior Resident inspector C. Skinner, Resident inspector Approved By:

C. Marschall, Chief, Project Branch C Division of Reactor Projects ATTACHMENT:

Supplementalinformation i

9905120009 990505

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PDR ADOCK 05000298 i

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EXECUTIVE SUMMARY l

Cooper Nuclear Station NRC Inspection Report 50-298/99-01 Operations

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. in general, control' room operators successfully. demanded support for and resolution of

problems encountered during daily activities as each occurred by interacting with staff members of the responsible departments. Support ranged from daily maintenance and engineering work to long-term reduction of control room distractions.' However, licensed operators continued to identify about five support problems per day, such as maintenance resulting in extending the unavailability of safety-related equipment and incomplete scope of engineering evaluations. Once inspectors identified the continuing nature of these :

problems,' shift managers and shift technical engineers focused on longer term issues and

escalated concerns in maintenance and engineering (Section 04.1).

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The management team and the safety review and audit board successfully demanded

effective evaluation of and corrective action for an identified high human performance error rate and related causes. Managers focused on improved performance indicators and evaluation techniques to clarify root causes and elicit correction of human performance problems (Section O7.1).

The licensee's project management of completion of corrective actions activities has

improved significantly over the past year. Management significantly reduced corrective action backlogs and overdue corrective actions. Four performance indicators tracked corrective action quantitative performance, such as corrective actions completed and overdue actions by department. On a weekly basis, the plant manager successfully emphasized department manager accountability for corrective action program completions

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Unlike the performance indicators for quantity of corrective actions, only two performance j

indicators track the quality of site-wide corrective actions. The inspectors found these indicators to be nonconservative and that managers do not use them to manage the Equality of corrective actions. Neither licensee management nor the safety review and

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audit board demanded more effective analysis of the quality performance indicators or Lpotential management tools to improve the quality of corrective actions (Section 07.3).

1 The review of significant conditions adverse to' quality after 1990 to date was a strong

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(quality effort. Review of nonconformance packages, a corrective action following 1997 escalated enforcement, proceeded with high standards; and resulted in reopening several old packages for correction and expansion of scope (Section 08.19).

Maintenance

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. Maintenance challenged the plant and the shift crews by inadequate planning of reactor

~ building ventilation system maintenance. Inadequate planning resulted in at

. least three avoidable challenges. These included an inadvertent entry into a 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />

shutdown action statement, an inadvertent entry into emergency operating procedures

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-- caused by high temperature in the reactor water cleanup room, and an inadvertent

- positive pressure above Technical Specification limits in the reactor building (Section M1.2).-

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Report Details Summary of Plant Status The plant was operated at 100 percent power, with two exceptions, during this inspection period.

Reactor power was reduced to 87 percent for planned turbine governor valve testing on February 19 and 68 percent on February 21 for routine turbine testing. On both occasions, the reactor was retumed to full power following the test evolutions.

I. Operations

Operator Knowledge and Performance 04.1 Observation of Control Room Evolutions a.

Inspection Scoce (71707)

Inspectors observed several control room evolutions. These included surveillance tests, coordination of routine and emergent maintenance tasks, and power manipulations.

Inspectors also observed control room crew members' interactions with support staff members to resolve engineering and other support challenges. Inspectors reviewed logs, procedures, and lessons learned documents developed following a plant transient.

Additionally, the inspectors routinely observed and evaluated main control board indications.

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Observations and Findinas Oraanizational Sucoort for Daily Activities During coordination of activities, operators identified about five minor and short-term problems and schedule challenges on a daily basis. These challenges were the result of poor support for daily activities by personnel in the maintenance, engineering, and chemistry organizations. For example, on March 10, a shift technical engineer noticed that Problem Identification Report 4-01106, initiated by engineering approximately 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> earlier, had not been communicated to licensed operators. The shift technical engineer rocognized that electrical loading issues had not been promptly coordinated with the shift manager for immediate corrective action. In general, control room operators successfully demanded resolution of these problems as each occurred, by interacting with staff members of the responsible departments. In some cases, emergent problems became potential control room challenges, such as maintenance resulting in extending the unavailability of safety-related equipment.

Inspectors noted that the type and significance of these issues have been similar over the last several months, with little improvement by the support organizations. Inspectors noted that, although operators anticipated these issues, operators addressed the concerns individually and did not take actions to demand that these types of challenges be addressed on an overall basis and that the distractions be reduced by the departments

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causing the concerns.: After inspectors raised this issue, shift supervisors focused on

. broader problem resolution and demanded more accountability at a higher management level from the supporting departments.

Evaluatio'n of Lookeepina The inspectors identified approximately 20 errors over a two-week period in logkeeping and control of plant conditions.: All of these examples were minor and did not have a direct affect on safety. The three most significant examples involved notation that Reactor Protection System A was placed in the tripped condition when operators had placed the l

Reactor Protection System B in a tripped condition to satisfy a limiting condition for

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operations requirement. Also, an operator adjusted recirculation pump speed without.

i stating it he was raising or lowering the pump speed. Lastly, high winds on February 12-

'I caused an increase in reactor building pressure that exceeded the range of indication.

Licensed operators did not recognize the need to determine if the reactor building ventilation system components and indication had remained within the components'

design values. Subsequent engineering evaluation determined that pressures had remained within design values.

Lessons Learned followina a Feedwater Pumo Trio The inspectors reviewed a control room lessons learned document written following a feedwater pump trip on January 16. The document noted that the crew had performed well. However, the plant specific simulator had not modeled the expected plant response.

During interviews, the inspectors determined that licensed operators had anticipated a reactor scram consistent with the simulator response. The control room supervisor gave an order to manually scram the plant at an anticipatory level; however, that level was never reached.. The shift supervisor balanced several priorities well and properly-.

managed control room activities during the transient. The anticipation of a scram

' challenged the crew's teamwork, management, and decision-making, but did not result in

negative crew directions or actions. These lessons learned identified by the inspector were not recorded or shared with other crews. The lessons-learned document was issued on March 11,~ after inspector involvement, and did not include these observations.

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Conclusions In general, control room operators successfully demanded support for and resolution of problems encountered during daily activities as each occurred by interacting with staff members of the responsible departments.. Support ranged from daily maintenance and engineering work to long-term reduction of control room distractions. However, licensed operators continued to identify about five support problems per day, such as maintenance resulting in extending the unavailability of safety-related equipment and incomplete scope

of engineering evaluations. Once inspectors identified the continuing nature of these problems, shift managers and shift technical engineers focused on longer term issues and

- escalated concerns in maintenance and engineerin e-3-07-Quality Assurance in Operations

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07.1 Manaaement Evaluation of Human Performance Error Rate a,

insoection Scooe (71707')

Inspectors observed several management team daily meetings and a safety review and audit board meeting and held discussions with several managers.

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Observations and Findinaq :

During several routine daily management team meetings, the inspectors observed management focus on reduction of an identified high human performance error rate.

Plant managers demonstrated high standards and successfully demanded that managers

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and supervisors evaluate past human performance error rates and causes. In these and other meetings, managers focused on analytical tools for human performance indicators to

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further clarify root causes of these errors.. During observation of a safety review and audit board meeting, inspectors observed additional focus on and demands for improved evaluation techniques to clarify root causes and corrections for human performance

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problems, c.-

- Conclusions.

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The manageme_nt team and the safety review and audit board successfully demanded effective evaluation of and corrective action for an identified high human performance

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error rate and related causes. Managers focused on improved performance indicators

- and evaluation techniques to clarify root causes and elicit correction of human performance problems.

07.2.Proiect Manaaement of the Corrective Action Proaram

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insoection Scope (71707)

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The inspectors observed the plant manager's weekly discussions with department heads regarding completion of corrective actions. The inspectors reviewed the performance

- indicators used to track departmental completion of corrective actions and problem report closures.

- bi JObservations and Findinas

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~ During weekly meetings to evaluate site-wide departmental performance in the area of

. corrective action, the' plant manager tracked performance indicators on each department's completion of corrective' actions and evaluation and closure of problem reports.: Four independent' performance indicators tracked quantitative aspects of corrective actions indicating effectiveness of corrective action management. The plant manager successfully

emphasized department managers' accountability for the quantity of corrective action

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completions. This resulted in significant reductions in overdue carrective actions. All departments on site also significantly reduced outstanding evchotions and overdue

problem reports.

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Conclusions The licensee's project management of completion of corrective actions activities has

improved significantly over the past year. Management significantly reduced corrective action backlogs and overdue corrective actions. Four performance indicators tracked

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corrective action quantitative performance, such as corrective actions completed and overdue actions by department. On a weekly basis, the plant manager successfully emphasized department manager accountability for corrective action program completions.

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073 Review of Performance indicators on Quality of Corrective Actions a.

inspection Scope (71707)

. The inspectors reviewed processes used to manage the quality of corrective actions. The inspectors reviewed completed corrective actions, as well as corrective action review board evaluations of completed problem evaluations. Additionaliy, the inspectors held discussions with performance analysis staff and managers, the plant manager, and se nior site managers, b.

Observations and Findinas The inspectors found that the performance analysis group tracked two performance indicators on the quality of corrective actions. These two performance indicators, corrective action review board rejection rate and quality of corrective actions, listed site performance without departmental breakdowns. Unlike the performance indicators -

documented in Section 07.2 of this inspection report, on the quantity of corrective actions, the plant manager did not hold department managers accountable for the quality of corrective actions in the weekly meetings.

The inspectors noted that the corrective action review board rejection rate was about 53 percent. The records of board comments on significant problem report evaluations included several evaluations that corrective actions did not address the root cause.

Several more indicated no root cause had been documented. However, these reports

. were not rejected, but were considered to " pass with comment." The inspector found that performance evaluation staff later assisted the line organization with resoMng these issues. However, the rejection rate performance indicator was nonconscivatively low.

- After the inspectors discussed this concern with the plant manager, he immediately addressed the concern by adding a category of " rejection with no re-board" for problem reports. This addressed the tendency of the board to pass an inadequate evaluatic n based on the knowledge that the performance evaluation group would assist the line organization in correcting the inadequacies.

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The inspectors also reviewed the performance indicator for effective corrective actions.

'This indicator consisted of corrective actions identified as inadequate by the quality assurance organization, the NHC, or as documented in additional problem reports.

> However, this indicator was based on the assumption that all other corrective actions on site were effective. This indicated that all unreviewed corrective actions were adequate.

Therefore, the number of inadequate reports identified were compared to the total number of problem reports issued as opposed to the limited number reviewed by the ove~rsight organizations. Additionally, no analysis tools such as type of failures or sources of errors a

were in place to evaluate the poor quality of corrective actions.

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During a safety review and audit board meeting, the plant presented corrective action performance indicators and discussed site wide corrective action performance. Board members acknowledged the continuing concern with adequacy of corrective actions, but

' did not discuss methods to better measure and manage the quality of corrective actions.

However, the'y had raised several well focused questions on methods and tools to further i

evaluate data and performance indicators during the earlier presentations of the human

performance errors.

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- The inspectors questioned the lack of qualitative performance indicators to manage departmental corrective actions performance. The inspector noted that analytical tools and departmental breakdowns illuminated the human performance area problems and

' assisted in the understanding of human performance errors. Strong expectations and accountability by management had been at least partially successful in addressing human performance errors.' Licensee managers agreed to evaluate additional approaches and analytical tools to manage and improve the quality of corrective actions.

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Conclusions

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Unlike the performance indicators for quantity of corrective actions, only two performance L indicators track the quality of site-wide corrective actions. The inspectors found these indicators to be nonconservative and that managers did not use them to manage the

. quality of corrective actions. Neither licensee management nor the safety review and audit board demanded more effective analysis of the quality performance indicators or c potential management tools to improve the quality of corrective actions. After the inspector raised this concern, the senior managers planned to more effectively use quality performance indicators.

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Miscellaneous Operations issues (92901, 92902, 92903, 92904, and 92700)

3dministrative Closure of Violations l

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The Severity Level IV violations listed below were issued in Notices of Violation prior to the j

i March 11,1999, implementation of the NRC's new policy for treatment of Severity Level IV l

violations (Appendix C of the Enforcemenf Policy). Because these violations would have been treated as noncited violations in accordance with Appendix C, they are being closed

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.6-08.1 (Closed) Violation 97010-01: A procedure used an inappropriate methodology. This violation is in the licensee's corrective action program as Condition Adverse to Quality 98-0051, Problem Identification Reports 2-19606 and 2-23370.

08.2 ; (Closed) Violation 97011-06: Failure to correct Technical Specifications surveillance

- requirements. This violation is in the licensee's corrective action program as Significant Condition Adverse to Quality 97-1541and Problem identification Report 2 25915.

j 08.3 (Closed) Violation 98022-01: Inadequate corrective action regarding the implementation i

' of the unauthorized modification review program. This violation is in the licensee's corrective action program as Significant Condition Report 98-11164 and Problem identification Report 3-53094.

08.4 (Closed) Violation 98015-03: Failure to perform an adequate test after relief valve

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' adjustment as required by 10 CFR Part 50, Criterion XI. This violation is in the licensee's corrective action program as Problem identification Report 2 28063.

08.5 - (Closed) Violation 298/97011-03: Procedure allowed installation of nonessential fuses.

This violation is in the licensee's corrective action program as Significant Condition Adverse to Quality 98-0038.

08.6 (Closed) Violation 298/98002-02: Three examples of inadequate procedures / instructions.

This violation is in the licensee's corrective action program as Significant Condition Adverse to Quality 98-359.

' 08.7c (Closed) Violation 298/98002-03: Two examples of inadequate corrective actions. This violation is in the licensee's corrective action program as Significant Condition Adverse to Quality 98-0358.

- 08.8.(Closed) Violation 98003-03: Failure to report inoperable radiation monitor. This violation

'is in the licensee's corrective action program as Condition Adverse to Quality 98-0431 and Problem identification Report 2-21526.

Administrative Closure of Licensee Event Reports The following licensee event reports were reviewed in accordance with inspection Manual

. Chapter 92700. Each report documented a violation of NRC requiremonts.- Each was entered in the licensee's corrective action program. These Severity Level IV violations are ~

.being treated as a noncited violation, consistent with Appendix C of the NRC Enforcement Policy,

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08.9. ; (Closed) Licensee Event Reoort 98013-00: Missed surveillance of a secondary

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containment isolation valve. This missed surveillance test was in violation of Technical Specification Surveillance Requirement 3.6.4.2.1. This Severity Level IV violation is being treated as a noncited violation, consistent with Appendix C of the NRC Enforcement Policy.' This report is in the licensee's corrective action program as Significant Condition Report 98-1235 and Problem Identification Report 4-00177 (50-298/9901-01).

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-7-08.10' (Closed) Licensee Event Report 98013-01: Missed surveillance of a secondary containment isolation valve. This revision documented the same violation as discussed in

Section 08.9 of this inspection report. This issue is in the licensee's corrective action

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program as Significant Condition Report 981235 and Problem Identification Repcrt 4-00177.

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08.11 (Closed) Licensee Event Report 97006-01: Failure to perform emergency core cooling system surveillances within required interval. This report documented the failure to -

perform surveillance testing of 23 instruments in accordance with Technical Specifications.

Upon testing, allinstrumentation met the acceptance criteria. The failure to test instrumentation in accordance with Technical Specification requirements is a Severity Level IV violation and is being treated as a noncited violation, consistent with Appendix C of the NRC Enforcement Policy. This violation is in the licensee's corrective action program as Significant Condition Adverse to Quality 97-0954 (50-298/9901-02).

08.12 (Closed) Licsnsee Event Report 97004-00: Reactor trip signal engineered safety features actuation, loss of shutdown cooling. This event resulted from an instrumentation and controls technician that inadvertently returned a level instrument to service while the reactor was shut down. The failure of technicians to perform testing in accordance with adequate, approved procedures is in violation of 10 CFR Part 50, Appendix B. This Severity Level IV violation is being treated as a noncited violation, consistent with Appendix C of the NRC Enforcement Policy. This violation is in the licensee's corrective action program as Problem identification Report 2-14334 and Significant Condition Adverse to Quality 97 0914 (50-298/9901-03).

08.13 (Closed) Licensee Event Reoort 97004-01: Reactor trip signal engineered safety features actuation, loss of shutdown cooling. This revision documented the same violation as -

discussed in Section 08.12 of this inspection report. This issue is in the licensee's corrective action program as Problem identification Report 2-14334 and Significant

. Condition Adverse to Quality 97-0914.

08.14 (Closed) Licensee Event Reoort 96015-00: Reactor water sample valves inoperable.

This report documented that a single. active failure could cause both reactor coolant

system containment isolation valves to be inoperable. However, review of past operability indicated that nonsafety-related components had been reliable and provided the appropriate pressure protection of the containment isolation valves. The failure to provide fully qualified pressure protection of safety-related equipment was in violation of 10 CFR Part 50,' Appendix B. This Severity Level IV violation is being treated as a noncited

. violation, consistent with Appendix C of the NRC Enforcement Policy. This violation is in the licensee's corrective action program as Condition Adverse to Quality 96-0950 (50 298/9901-04)l Administrative Closure of Ooen items The following open items were reviewed in accordance with NRC inspection procedures.

The safety significance of each item was evaluated. Based on the low safety significance,

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the item is being closed administratively. Although no further NRC action is warranted,

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' each item has been entered into the licensee'r., corrective action program for evaluation s and appropriate action.'

08.15 (Closed) Unresolved Item 97007-07: Reviewed revised operability assessment on reactor vessel water.' This issue is in the licensee's corrective action program as Problem

' identification Report 2-23448.

- 08.16 (Closed) Insoection Followuo item 97009-01: Failure to implement actions stated in licensee submittals.. This inspection followup item is in the licensee's corrective action

program as Problem identification Reports 2-25007 and 2-18953 and Condition Adverse to Ouslity 97-1456.

08.17 (Closed) inspection Followuo items 97003-04: Procedure use and adequacy. This

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. inspection fol:owup item is in the licensee's corrective action program as Condition Adverse to Quality 97-1035 and Problem identification Report 2-21320.

Ooen items Reviewed The inspectors evaluated the following open items in accordance with the NRC inspection

- procedures. Each item was dispositioned as documented.

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'0818 (Closed) Inspection Followuo item 96007 01: Emergency core cooling system rolief valve

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setpoints. ' The inspector reviewed the basis and coordination for assumptions regarding relief valve setpoints on the emergency core cooling systems and found them to be reasonable. The engineering organization intends to address the more general concerns

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regarding the engineering basis fot design values in a separate program.

08.19 (Ocen) Violation 50-298/97012-03: Multiple examples of failures to correct conditions adverse to quality. Inspectors evaluated the licensee's corrective action to improve overall

. corrective actions.

To prevent recurrence of this violation, the licensee took actions to improve the overall

. staff performance in the area of corrective actions. The corrective action program implementation will be reviewed during the NPC pilot baseline inspection program.

Therefore, this portion of the violation response was administratively closed.

The resident inspectors evaluated the licensee's review process to identify past inadequate corrective actions. The program was designed to evaluate past corrective

f actions (to 1990) for significant conditions adverse to quality. This review has progressed slowly over the last 2 years. Only about 5 percent of the review scope has been

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completed. However, plant management recently provided additional resources to the

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revied group and the rate of completion was expected to increa >e. The inspectors

~ re' iewed the products of the effort and found that several problem identification reports v

' had been reopened by the initiative because they were inadequate. The review group

. assigned these reports to line organization owners to adequately correct the concerns..

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The reasons for reopening the packages included inadequate evaluation of extent of the i

condition and corrective actions that did not address the root cause. This was a credible effort to identify past ir' adequate corrective act!ons. Additionally, this item will remain open to determine if the effort is continuing in an effective manner.

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2 Conclusions

The review of significant conditions adverse to quality after 1990 to date has proceeded slowly,.but was a strong quality effort. : Review of nonconformance packages, a corrective f

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action following 1997 escalated enforcement, proceeded with high standards, and resulted in reopening several old packages for correction and expansic.1 of scope.

11. Maintenance

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Conduct of Maintecance M1.1 General Comments

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Insoection Scooe (62707 and 61726)

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Tho inspectors reviewed work packages and held discussions with maintenance craft, J

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operations, and management.

in addition, the inspectors observed all or portions of the following activities:

Maintenance Work Order 98-4331 Replacement of Reactor Water Cleanup Pump B Mini Purge Flow Regulator y

i Maintenance Work Order 98-1044 Heating and Ventilation Air-Operated Vortex

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Dampers Pf95A and 1005B Surveillance Procedure 6.2RPS.710 South Scram Discharge Volume High Water

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i.evel Switches and Transmitter Channel '

Functional Test (Division 2)

' Surveillance Procedure 6.2RBM.302 Rod Block Monitor Channel Calibration (Division 2)

Surveillance Procedure 6.HPCI.705 High Pressure Coolant Injection Turbine High Exhaust Pressure Channel Functional Test b.-

Observations and Findinas

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Th'e inspector noted that maintenance craft controlled activities and performed work instructions as written. Good radiation protection work practices were exhibited by all personnel in the activity, and support was timely, All replacement parts were properly f

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-10-labeled consistent with the work document requirements. The work supervisor, engineering personnel, and the work week director were observed in the field during portions of the maintenance. Measuring and test equipment.was within calibration and properly logged on the work document. Housekeeping and plant material conditions were good.

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Conclusions.

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With one exception, as documented in Section M1.2 of this inspection report, the maintenance observed was well-controlled and performed in a step-by step manner.

Maintenance supervision and engineering personnel were observed to be in the field actively overseeing activities. Housekeeping and plant material condition were good.

M1.2 Reactor Buildina Ventilation System Maintenance a.

Inspection Scooe (93702 and 62707)

The inspectors observed portions of maintenance on the reactor building ventilation system and the control room operator's response to consequences of the maintenance on March 1,1999. The inspectors reviewed maintenance packages, clearance orders, and control room logs. Addit!onally, the inspectors interviewed personnel from the work control, engineering, and operations organizations.

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Observations and Findinas

On March 1,1999, the following problems developed during preparation for maintenance on components of the reactor building ventilation system:

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Upon removing the ventilation system from service, the control room received an -

alarm for high temperature (140sF) in the reactor equipment cleanup pump room.

i Licensed operators entered Emergency Operating Procedure 5A, " Secondary Containment Control," because of the high temperature alarm, opened doors to provide a heat removal path, and exited the emergency procedure; (2)

Operators discovered that, because the clearance orders had resulted in the isolation of radiation detector process flow, operators had needed to enter a

' 12-hour shutdown adan statement; and

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. Upon returning the systen, to normal operation, reactor building pressure briefly exceeded emargency operating procedure entry conditions.

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Plant managers raised concerns that planning and work control had not poperly anticipated consequences of the clearances for the work.

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. Conclusions b

Maintenance challenged the plant and the shift crews by inadequate planning of reactor building ventilation system maintenance. ' Inadequate planning resulted in at j

J least three avuidable challenges. These included an inadvertent entry into a 12-hour

shutdown action statement, an inadvertent entry into emergency operating procedares L

. caused by high temperature in the reactor water cleanup room, and an inadvertent positive pressure above Technical Specification limits in the reactor building.

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- Quality Assurance in Maintenance -

L M7.1. Critiaces of Maintenance Performance

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a-Insoection Scooe (71707)

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. Inspectors reviewed the critique of a feedwater pump speed controller replacement and

.' other critiques by work control work week supervisors. Inspectors interviewed the plant manager, management of the work control, maintenance, and operations organizations

. and work week supervisors.

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After a feedwater pump speed controller failure on ' January 16, maintenance and work I

control personnel coordinated the replacement of a speed controller. The work week-

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coordinator documented several delays and challenges in the critique. The critique was comprehensive and self-critical. It addressed specific examples of weakness in work (

coordination and maintenance.1 During the presentation of the critique findings, the work -

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week supervisor discussed his conclusions with various managers and indicated that they

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h had not corrected the continued challenges to the conduct of maintenance over the past

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several months. In response, the maintenance management addressed each item -

separately and did not address overall continued challenges to maintenance.

The inspector found the other work week critiques to be well focused and self-critical. The L

. work week supervisors had previously documented similar challene's to effective'and l

efficient maintenance. The plant manager stated that these critiques would be included

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and evaluated in the maintenance self-assessment scheduled within the month.

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. Conclusions '

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' The' responsible work week supervisor identified several indications of inaiequate

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maintenance standards as documented in the work control lessons learned critique for the replacement of the feedwater pump speed controller after the January 16 fecdwater pump trip. The critique was well focused, timely, comprehensive and self-critical. However, the

maintenance management response did not comprehensively address the continued challenges to effective and efficient maintenance. The plant manager stated that these critiques would be included in the maintenance self-assessment.

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IV. Plant Support

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- S1 Conduct c' Security and Safeguards Activities i

iSI.1 Evaluation of a Tamoerina Event a;

Insoection Scope (71707L The inspectors reviewed the resolution of a M,uary 1999 tampering event. The

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inspectors interviewed the individuals involvs:::, including an operations shift supervisor,

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security shift supervisors, and the security manager, b. -

Observations and Findinas

. On March 1,1999, operators and security personnel responded to a tampering event. A technician found a gaitronics phone disabled by tampering. Operators and security l personnel concluded that the phone had been altered during the recent outage.

Operators and security officers immediately responded by inspecting other gaitronics -

phones. 'The inspector determined that several nearby items such as feedwater pumps, circuitry in panels,'and controllers could have been altered by tampering without revealing degraded performance until challenged.. Operations shift supervisors and security managers stated that no searches had been performed to identify if additional tampering had occurred. Operators had concluded that equipment in the area of the tampering had not been. harmed. They based their conclusion on the successful transition of the

_ equipment from shutdown to power operations. Security had not documented why the search for tampering was limited to phones, the basis for why no other equipment was degraded, or the potential extent of the tampering.

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Conclusions Security reviewers did not perform a systematic evaluation of the extent of condition of a

- tampering event. Tampering of a gaitronics phone had been identified. Security officers j

checked all gaitronics phones in the plant, and operators observed that balance-of-plant l

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equipment was running without problems. However, this did not systematically rule out

. the potential that tampering with other plant equipment had occurred. Although these actions provided a rapid first assessment, neither group systematically bounded the tampering. event.

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. Exit Meeting Summary f

.:The inspectors presented the inspection results to members of licensee management at the exit

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= meeting on March 18,1999. Licensee managers present acknowledged the findings presented.

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' The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.

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- ATTACHMENT PARTIAL LIST OF PERSONS CONTACTED Licensee D. Buman, Acting Plant Engineering Department Manager J. Burton, Performance Analysis Department L.~ Dewhirst, Nuclear Licensing Specialist K. Fike, Chemistry C. 'Gaines, Maintenance Manager M. Kaul, Operations Support Group -

D. Kimball, Radiation Operations Supervisor J. McMahan, Work Control Supervisor L. Newman, Acting Licensing Manager J. Peters, Nuclear Licensing and Safety Secretary A. Shievier, Operations Manager J. - Swailes, Vice Presiaent, Nuclear Energy, NPPD R. Tanderrup, Shift Manager / Work Control R. Wachowiak, Engineering Safety Department INSPECTION PROCEDURES USED IP 61726: Surveillance Observation IP 62707: Maintenance Observation IP 71707: Plant Operations IP 71750: Plant Support Activities IP 92901: Followup - Plant Operations

IP 92902: Followup - Maintenance IP 92903: Followup - Engineering IP 92904: Followup - Plant Support IP 92700: LER - Onsite Review IP.93702: Onsite Response a

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ITEMS OPENED, CLOSED, AND DISCUSSED L

Open and Closed l-

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50-298/90001-01 NCV Missed surveillance of a secondary containment isolation valve j

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(Section 08.9)

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'50-298/99001-02_

NCV - Failure to perform surveillance testing of 23 instruments in accordance with Technical Spech.<:ation surveillance requirements

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(Section 08.11)

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50-298/99001-03 NCV Failure of technicians to perform emergency core cooling system a

instrumentation testing in accordance with adequate, approved l

procedures (Section 08.12)

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- 50-298/99001-04'

NCV Failure to have containment isolation safety functions performed by safety-related equipment (Section 08.14)

Closed 50-298/97010-01 VIO. A procedure used an inappropriate methodology (%ction 08.1)

L 50-298/97011-06-

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Failure to correct Technical Specifications surveillance requirements (Section 08.2)

'50-298/98022 01 VIO Inadequate corrective action regarding the implementation of the

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une.uthorized modification review program (Section 08.3)

50-298/98015-03 VIO Failure to perform an adequate testing after relief valve adjustment as required by 10 CFR Part 50, Criterion XI (Section 08.4)

50-298/97011-03-

'.VIO Procedure allowed installation of nonessential fuses (Section 08.5)

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50-298/98002-02 VIO Three examples of inadequate procedures / instructions

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'50-298/98002-03'

VIO Two examples of inadequate corrective actions (Section 08.7)

50-298/98003-03 VIO Failure to report inoperable radiation monitor (Section 08.8)

I 50 298/98013-00 LER-Missed surveillance of a secondary containment isolation valve

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(Section O8.9)

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50-298/98013-01 LER Missed surveillance of a secondary containment isolation valve (Section 08.10)

'50-298/97006-01 LER ' Failure to perform emergency core cooling system surveillances j

within required interval (Section 08.11)

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l 50-298/97004-00'

LER Reactor trip signal engineered safety features actuation, loss of shutdown cooling (Section 08.12)

50-298/97004-01 LER Reactor trip signal engineered safety features actuation, loss of

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. shutdown cooling (Section 08.13)

50-298/96015-00'

'LER Reactor water sample valves inoperable (Section 08.14)

-50-298/97007-07-URI-Reviewed revised operability assessment on reactor vessel water (Section 08.15)

50-298/97009-01-

. IFl Failure to implement actions stated in licensee submittats (Section 08.16)

L 50-298/97003-04 IFl Procedure use and adequacy (Section 08.17) '

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50-298/96007-01.

IFl Emergency core cooling system relief valve setpoints (Section 08.18)

Discussed 50 298/97012-03 VIO Multiple examples of failures to correct conditions adverse to quality (Section 08.19)

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