IR 05000315/1990021

Forwards Insp Repts 50-315/90-21 & 50-316/90-21 Containing Results of Review of 900713 Electrocution Event

ML20059N754
Person / Time
Site:	Cook
Issue date:	10/05/1990
From:	Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Kosick P KOSIK, L. S.
References
NUDOCS 9010170245
Download: ML20059N754 (2)

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. OCT 0 51990: ,. ,

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Mr. Peter H. Kosick'

Kosick & Rochau .

' 818 Ship Street

- P.0_. Box P5 St. Joseph, MI . 49085

Dear Mr.:

Kosick,.

As we indicated :in our . letter tu you dated August- 25,!1990, a copy-of the results of the~ NRC's. review ofcthe' July 13. 1990, electrocution' event at the D..C. Cook l plant would be provided.:when the investigation.was>

. completed. ,The attached inspection report contains:the' fina1Lresults of:

.our investigation into.this-event.-

1 Although no specific root cause' for the event was identified by;the utility.

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. or by our investigation, several program weaknesses regarding lack of- clear

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guidance and definition of responsibilities for preparing;and: reviewing:

. clearance permit requests and jobt orders were identified'. The cover letter.-

to our; report requests'the utility to outline _ the: corrective actions taken in response to these.weaknesst.2. '

Should you _have any questions regarding the content of the report or our-

, review, please contact Mr. Edward G. GreenmanL of myl staff at 708/790-5518.

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Sincerely,

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-A. Ber Davis, ..

Regional l Administrator- '

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Attachment:

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l Inspection Report.. i J

Nos. 50-315/90-21; 50-316/90-21

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REGION til'

D' f' 799 ROOSEVELT RO AD ,

oLen 1:LLYN ILLINOIS = 60137 - .

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OCT 0 31990 j i

Docket No. 50-315 Docket No. 50-316 '

Indiana Michigan Power Company - ,

ATTN:- Mr. Milton P. Alexich Vice President .

Nuclear Operations Division. 'l

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1 Riverside Plaza '1'

' Columbus, OH -43216

' Gentlemen': . l

' . 9 This ref rs to the routine s'afety inspection: conducted by' J'.[A.; Isom, '

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- E . . Jorgensen, D. G. Passehl and R. :L. Bywater of this office on July 18 1 through August 28, 1990, ofc activities ;at the'DonaldiC. Cook Nucle'ar' Plant,  ;

Units 1 and 2, authorized by NRC 0perating Licenses Nok DPR-58-and DPR-74 andL

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to the discussion of our. findings with A. A. Blind,Jand;others of your. staff  ;

at the conclusion of'the inspection. .

The enclosed copy of our inspection-report identifies; areas: examined during i the inspection. Within these areas, the inspection consisted'of;Lai se'lective -

examination of procedures and. representative records,: observations, and- i interviews with personnel.

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No-violations of NRC requirements were. identified duringithe~ course of:thet-ins pec tion.- Weaknesses _in your program were identified, however, by the'

portion of this inspection conducted by the NRC's Human: Factors As'sessmentj s Branch on July 26 and 27,1990, regarding ~ the July.13,'x1990, electrocution .4 event which merit your _ consideration. The weaknesses: pertained toLlackcofi

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clear gui

_ clearance. dance permit and definition

' requests and jobof- responsibilities'

orders. for preparing

~ Based on'the aboveL youandshoulds reviewing- -

, review the event to determine any need for additional; controls-(validations,- '

L sign-off, w'alkdowns, and' verifications) to the clearance-request and work ,

review process. .This review should consider the need-to incorporateSdrawings- U

.to accurately identify the-location of plant equipment and the need for a.

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plant ~ standard regarding signs communicating. personnel:hazardstthroughout p the plant. = Af ter completing your review, please: submit: the results to the L  ;

NRC Region III office.~ 'l l .

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, in accordance with .10 CFR 2.790 of the Commission's regulations, a copy of .

l: this letter, and the enclosed inspe'ction report will be placed;in -the NRC

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Public Document Room, l q

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Indiana Michigan Power. Company- 2! i l

We will gladly discuss-any question $ 'you have concerning this . inspection. '

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S i ncerely,. g fQf.fi =-A Edward G."Greenman,iDirectori-l Division of. Reactor? Projects Enclosure- ' Inspection-Reports j-No.L50-315/90021 DRP);c NoE 50 316/90021 DRP) ,

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A. A. Blind,'Pla'nt Manager.

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DCD/DCB-(RIDS)' -.T. <

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0C/LFDCB-Resid.ent Inspector, RIII ,

James R. Padgett, Michigan Public-

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Service = Commission EIS Coordinator, USEPA d Region 5 Office Michigan-Department of Public' Health'

O. C. Cook, LPM,'NRR .

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U. S.-NUCLEAR REGULATORY < COMMISSION-I REGION III-Reports No., 50-315/90021(DRP);50-316/90021(DRP) ,

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l l- Docket Nos.'50-315; 50-316 . Licenses No. OPR-58;-DPR-74. !

' Licensee: American Electric Power Service Corporation ,

Indiana Michiga'n Power Company. '

'1' Riverside Plaza.

Columbus,- OH 43216- t

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Facility- Name: 'DonaldC.CookNuclear, Power.'. Plant,_ Units 1;andI2

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Inspection At: Donald C. Cook- Site,- Bridgman, Michigan _

f Inspection Conducted: _ July.k8lthroughAugust 28,'1990 q Inspectors: J. A.lIsom ,

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'B. L. Jorgensen

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D. G.'Passchl:

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R._L. Bywater Approved By: urgess, e .2/hd '

Projects Section 2A Date- .

InspectionSummarp

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' ' Inspection' on July 18 through- August 128,1990 (Reports No.350-315/.90021(DR'P);

No. 50-316/90021(DRP))- .

- <t Areas Inspected: Rouline unannounced inspectionLby the; resident inspectors

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of: actions on previously identified. items;(plant operations: including the electrocution event; radiologica1 controls; maintenance;' surveillance;. fire

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protection!and. cleanliness;.engi.neering;and< technical support;; emergency o

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"' preparedness;. security;; outages;! safety assessment quality verification; . . -

ireportable events; Bulletins,'Noticesiand' Generic Letters; Allegations; and, NRC Region. III requests'. No Safety ~ Issues Management: System;(SIMS)~ items were_

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closed.

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Results: Of:the,12areasLinspected,noviolationsJordeviations.werei

. identified.in;any areas.

Weaknesses were' identified-in yourl program regarding/ train.ingLof. con' tractors: ' I and placarding of felectrical. cabinets.L Additionally, there were a number of

[' ' Appendix R' issues identified by the -licensee-which affected both Units ;Some.

of these Appendix tR. issues required immediate short iterm corrective 1 actions byf the licensee in! order.to. ensure compliance with Appendix R requirements.

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Plant Operations:

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On August 23, 1990 at approximately 8:45 PM,; Unit 2 operators energized valves:

which provided the suction path from'the refueling water. storage-tank (RWST)

to the charging pumps, as a part of.the restoration from a half-loop. Because. ,

of the existing low level in the volume control' tank, when these suction : . ,

valves were . opened,. flow path' from the RWST to the; primary. system through. the' ~

charging pump suction cross-tie to the residual; heat' removal system was. 1 established.;; Additionally, because the charging: pump discharge cross-connget ,

t valves between the two units and the-cross tie drain valve were openia Lflow-path from the RWST to the Unit licharging pump room was' established. About! '

40 000 gallons of water was lost out of the RWST with most of the water'

fillingtheRCS,RHR,andthelowerreactor. cavity (anareanormally-flooded- h during' refueling operations). Some water. drained into the Auxiliary Building?

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sump and the lower containment area. Inspection of: the charging pump room and the: lower containment area by'the residents found minor or no equipment 1 damage. 4 Followup.of the July 13,1990, electrocution event by the Human, Factors ,1 Assessment inspectors determined-that the licensee did not fully: consider?the; g information provided by the industry?(Wolf Creek and San Onofre) and NRC! ,'

i Information Notice (IN)' 88-96) regarding information learned from'similar , ,

previous events. Secondly, though there were inconsistent views on where the.

current transformers were located, the drawings that would have shown .the '

location of the current transformers were not used.. Finally, the-licensee should' review the event to determine the need for additional controls' y (validations, sign-of f, walkdowns','and' verifications) to the clearance R request and work review process.. This review should consider the'need to incorporate drawings.to place the location of plant equipmentiand:the need ,q for a >1 ant standard regarding signs' communicating ~ personnel ~ hazards througiout the plant.  !

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Engineering.and Technical Support- ,

j 1. On July 29, 1990, based on three separate walkdowns performed' in.the -

auxiliary building, licensee determined that: inadequate emergency: lighting: ;j existed as required by Appendix R. The walkdown. conducted by the'licenseeL

identified 61 Appendix R components and routes as'being inadequately' lit.. j" Additional Appendix-R lighting'is expected to be installed by? August 31'; <

1990 under a expedited plant modification. During~thel interim-period, j

~ licensee has ordered miner's hard hats with battery powered lamps.- d 2. On August 2, 1990, licensee-determined;that a potbntial loss of auto-start' l features for either all four ESW or all= four CCW pumps:could be caused by 1 an electrical short due to a f. ire which'could destroy the cables for the ESW and CCW low header pressure switches. Because these: instrument cables 1 for all four ESW or CCW pumps:were located within-one fire zone; it would J be.potentially possible for a fire to affect the auto-start feature for' i either the CCW or ESW pumps. . Additionally. becauseLof a;designi &

implementation error, this postulated fire-induced electrical: fault could not be isolated from the auto-start portion of the circuit withian: i installed fu::e. When the fuse coordination problem was identified,Lthe H licensee corrected the problem by' replacing the existing 10-amp withia. '

5-amp fuse for the pressure switch' circuits. The electrical circuits 'p will be modified to provide a permanent correction.

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3. On August 2, 1990, licensee retermined that exposed structural steel members of walls which were located within five:1ube oil: storage rooms did not have fireproofing material. This condition was determined to_be outside the design basis of the plant and is not covered by c>er. ting or ,

emergency procedures.

4. On August 24, 1990 licensee discovered that a-postulated fire in any one of three Unit I fire. areas affecting .the cable between panels LSI-6 and LSI-6X could have resulted in an inability to maintain power to the LSI panels from Unit 1 or to repower these panels from Unit 2. ,This scenario would have resulted.in.the loss of all process' instrumentation used in Appendix R safe shutdown scenarios. Licensee initiated a temporary modification to install a 1.25 amp fuse between panels LSI-6 and LSI-6X.

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DETAILS

'1.- Persons Contacted a. Inspection - July 18 through August 28, 1990

• A. Blind, Plant Manager

• J. Rutkowski, Assistant Plant Manager - Technical Support -

• L. Gibson, Assistant Plant Manager - Projects

.K. Baker, Assistant Plant Manager - Production

• B. Svensson, Executive Staff Assistant

• J; Sampson, Operations Superintendent

• P. Carteaux, Safety and Assessment Superintendent Maintenance Superintendent T. Beilman, Technical Superintendent - Engineering J. Droste,-

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• T. Postlewait, Design Changes Superintendent

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• L. Matthias, Administrative Superintendent J.- Wojcik, Technical Superintendent - Physical Sciences

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M. Horvath Quality Assurance Supervisor D. Loope, Radiation Protection Supervisor

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l The inspector also contacted a number of other licensee and contract employees and informally interviewed operations, maintenance, and technical personnel.

• Denotes some of the personnel attending the Management Interview on August 31, 1990.

b. Management Meeting - July 31. 1990

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Licensee Personnel M.Alexich,/icePresident-Nuclear (AEP)

A. Blind, Plant Manager-J. Rutkowski, Assistant Plant Manager - Technical Support L. Gibson, Assistant Plant Manager - Projects-B. Svensson, Executive Staff Assistant P. Mangan, Quality Assurance Engineer-J. Kingseed, Senior Engineer, Nuclear Safety and Licensing-B. Hennen System Engineering Supervisor B. Wonn, Administrative Compliance Coordinator A number of other licensee personnel were also invol'ved in discussing selected topics.

NRC Personnel

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J. ProjectsIII,IV,andV.

Zwolinski Assistant Director NRR Division of Reactor l

J. Isom, Senior Resident Inspector.

D. Passehl, Resident Inspector

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Management Visit August 28, 1990 i i

Licensee Personnel l i

A. Blind, Plant Manager i J. Rutkowski, Assistant Plant Manager - Technical Support  ;

B. Svensson Executive Staff Assistant 2 S. Faalow, Issistant Section Manager, I&C Section  ;

.: . C.-Savitscus, Instrument.and Controls Engineer '

i T. Langlois, Senior Project Engineer (

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NRC Personnel l

.B. Clayton, Branch Chief, Reactor Projects Branch 2, R-III  ;

B. Burgess, Section Chief, Projects Section 2A, R-III  ;

J. Isom, Senior Resident Inspector-  ;

3 D. Passehl, Resident Inspector 2. ActionsonPreviouslyIdentifiedItems(92701,92702) 'f a. (Closed)UnresolvedItem(316/88023-01): The hydrogen skimmer test'

procedure contained acceptance criteria for compartment flows which ~

was less conservative than the.FSAR limits. Licensee performed new -

analysis to show that even with the as-found lower compartment 4 i flows, post-accident hydrogen concentration woult' be less than that -  :

required by Regulatory Guide 1.7.. Additionally, the FSAR (Section 't 14.3.6) was revised to reflect the revised lower compartment flows requirements,

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b. (Closed)UnresolvedItem(315/88012-01;.316/88014-01):- On March 30, 1988, the licensee learned from Limitorque Corporation that a torque .

switch design in some safety related Model SMB-00 motor operators had not been tested to verify their qualification. The licensee has- 1 since replaced all unqualified torque switches;in the affected l Limitorque operators. 1

No violations,' deviations, unresolved or open items were identified.

. j 3. Operational Safety Verification (71707. 71710. 42700) i Routine facility operating activities were observed as~ conducted in the plant and from the main control rooms. Plant startup, steady power

o)eration, plant shutdown, and system (s)_ lineup and operation were )

oaserved as applicable.

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The performance of licensed Reactor Operators and Senior Reactor Operators, of Shift Technical Advisors, and of auxiliary equipment  ;

operators:was observed and evaluated including procedure use and  !

adherence, records and logs, communications, shift / duty turnover, and the degree of arofessionalism of control room activities.- The Plant Manager,.

Assistant ?lant Manager-Production, and the Operations Superintendent were well-informed on the overall status of the plant, made frequent ; -

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visits to the control rooms, and regularly toured the plant.  :

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Eva10ation, corrective action, and response to off-norma). conditions or

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I events, if ariy, were examined. This included compliance with any reporting requirements. ,

Observations of the control room monitors,-indicators, and recorders were- !

made to verify the operability of emergency systems, radiation monitoring a systems.and nuclear reactor protection systems, as applicable. Reviews- 1

- of surveillance, equipment condition, and tegout logs were conducted. 1 proper return to service of selected components was verified. .

a. Unit 1 operated continuously at 100-percent power during this_

inspection period with no significant operational problems, t

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-At the beginning of the inspection period, Unit 2 was in MODE S for 'l a refueling outage. ,On uly 18,.1990,, Unit 2 was placed in MODE 6 - 3 and unloading of the reactor core began July 26, 1990. At the end 1 of the inspection period, Unit 2 remained in MODE 6 and core reload i

, is expected to begin on August 31.= Licensee entered 6 planned 1 Unusual Event as defined in the Cook Nuclear Plant Emergency  :

Classification procedure PHP 2080 EPP.101 "Emer Category", ECC-10 which states " Loss of all on-skency Condition.

te AC power-capability (both diesel generators for one Unit are unavailable or j inoperable due to mechanical, electrical, or error effects)." . Both

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Unit 2 emergency diesel generators were made inoperable for outage j related work. -

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b. On August 23, 1990 at approximately 8:45 PM, unit 2 operators l energized valves 2-IMO-910 and 2-IMO-911, which provided the suction

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l path from the refueling water storage tank (RWST) to.the charging- -

pumps, as a part of the restoration from a half-loop. The t restoration included removal of approximately 400 tags and- 1 restoration of numerous valvos and breakers.1 Because of the existing low level in the volume control: tank, when valves 2-IM0-910

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t and 2-IMO-911 were o)ened, flow path from.the RWST to the primary 1 system through the.c1arging pump suction cross-tie to the residual l heat removal system was established. Additionally, because charging. ;

pump discharge cross-connect valves between the two unit's were'open ,

andbecausethecrosstiedrainvalve(1-CSL548)wasopen,-flowpath' s from the RWST to the Unit-1 charging pump room was established.

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This event lasted approximately one hour and cbout!40 000' ga-11ons of l water was lost out of the RWST. MostofthewaterfilledtheRCS, RHR, and the lower reactor cavity (an area nonna11y flooded during !

refuelingoperations). Some water drained into the Auxiliary  ;

Building sump and the lower containment area. The problem was  !

discovered during a tour of the Unit 1 auxiliary building by the auxiliary equipment operator who noticed ~that the'1eak containment ,

device for 1-05-548 was over-flowing. The resident inspector made )

a tour of the Unit I charging pump room and areas of containment to determine the extent of damage to equipment and-found through direct

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observations and interviews with plant individuals involved in the.

cleanup effort, thatLlittle or no equipment damage occurred.

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At the end of the inspection period, licensee was still conducting their investigation into the August 23 event. ,

' l c. Inspectors' limited walkdown of the Unit.1 safety injection (SI) 1 system found that valves were properly identified and none were

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mispositioned. Inspectors used a valve lineup list from Procedure 1-OHP 4021.008.002, " Placing Emergency Core Cooling Systen '$

Standby Readiness." Approximately 100 components were ch o .J to j verify their proper identification and position. Although there-  :

were no major )roblems identified during the walkdown, inspectors ,

and some material j did identifywhich conditions tie following drawingtodiscrepancies,for were identified the licensee corrective l action:

l (1) Vaive 1-SI-146N and valve'1kSI-1465, discharge drain valves for  !

the North and South SI pumps, respectively, are listed on the j valve lineup sheet but are not indicatea on drawing No. l

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OP-1-5142-12.  !

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(2) Valve 1-SI 147N and valve 1-51-1475, suction drain valves for :f the North and South SI pumps, respectively, are listed on the-valve lineup sheet but are not indicated;on drawing No. i OP-1-5-5142-12.  !

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(3) Valve 1-SI-109N.and valve 1-51-109S,' discharge valves for the i North and South SI pumps, respectively, have pressure.teet  ;

gauges where the valve lineup sheet and drawings No.  !

OP-1-5142-12 indicates the valves are capped.. '  :

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(4) Dim lightine. conditions in the South SI pump room required that' l flashlights be used-during the inspection. '

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(S) The junction box cover for the. North SI pump inboard and.

outboard seal housing high. temperature' alarms ~(ITA-251 and j

ITA-252)wasloose.lAlthoughthethermalsensors!are 7 i

non-safety related, procured commercial grade and the failure j of the alarm to annunciate in:the control room woul'd not affect i pump operability, the-loose junction box cover was: identified t to the licensee because the alarms-provide control. room i indication of

to the seals. possible low component cooling water (CCW) flow- l

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d. Inspectors' tours >in the auxiliary building to determine the '

adequacy of housekeeping,, contamination control,' and control, and.

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coordination of activities found that,~in general, conditions were "

acceptable considering Unit 2 was in.an outage.: However, inspectors

.noted the following which were' relayed to cognizant licensee-personnel for appropriate action:;

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(i) the work area atop;the' ice ~ machine was messy with hoses,. '

, drop cords = and- tools ( and' no work was ongoing; .  :

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(ii) a. radiation control boundary rope for a temporary work ]

area between the Unit 2 CCW heat exchangers was found j lying on the floor; and, j

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(iii) a tag for Job Order (J0) B018816 was'found on the floor .

behind a breaker panel on the 633-foot level, far from the ll r component (2-HV-CIR-3) originally tagged on June 11, 1990.  !

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Additionally, during the weekly tour with.the Assistant plant Manager 3  ;

(APM) to the Unit 2.4KY room and various, areas of the auxiliary builcing, i inspectors noted that the entrence to the auxiliary building from.the.  :

turbine building needed some cleanup.

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On July 13, feed cable in breaker cubicle T2101.1990 . The;a-contractor flash which electrician resulted contacted an

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electrical. .

from the contact resulted in one. fatality and seriously. injured three  !

personnel. The licensee formed an' accident investigation team which1 J visited the accident scene, reviewed documentation associated with,the  !

work activity. and , interviewed numerous licensee personnel to determine . j the cause _of the accident and what actions, if any, were necessary at the i site to prevent'a similar occurrence. Because'the accident team was not  ;

able to interview-the three survivors of the accident,>the licensee has  !

not yet closed the' investigation. .

l The licensee's accident investigation team was not able to positively .  ;

determine why the deceased contract electrician' approached close enough to-  :

the energized conductors to initiate a fault. The licensee team determined '

that although none of the individuals involved in the accident: knew the exact physical location of the_ current transformers, they had received'  !

training on plant safety policy which stressed that potentially energized 'i equipment should be considered energized until positively proven de-energized. Training on this, electrical' safety policy was performed  !

during the Nuclear General Employee Training provided before the granting '

of unescorted access to protected areas. 1 The licensee's preliminary assessment of'the' electrical accident and  !

determined that the licensee had several program processes in' place that- l could have prevented the accident. First, the licensee found that ,

although the design change and job order packages associated with the. 1 accident did not contain information on the location of the current transformers there were drawings onsite which contained sinformation on-  ;

the general location of the transformers. The knowledge of the location i of the current transformers by the technicians might have prevented the '

opening of the rear door of cabinet T2101, exposing the technicians.to the energized 4KV cable terminals. Secondly, the licensee's. clearance L .i process, if properly performed,' could have prevented the accident by l ensuring that all power sources were secured:to.the T21CITcabinet. The' ^

licensee found that although the clearance was performed as requested by ,

the 18C technician involved in the: accident, the clearance request was- *

deficient.' Finally, the licensee required that' supervisors responsible i for an activity ensure that an appropriate ~ job briefing be conducted. The J inspectors were informed that the-job briefing was conducted by the-

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instrument maintenance supervisor who was responsible for the instal 14 tion- l of the' design change.

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Af ter review of work control and training processes that were used, the ,

licensee concluded that there was nothing wrong with the processes nor any- '

violations that significantly contributed to the event other than a failure to check that the equipment was de-energized. Additionally, the inspectors noted that immediately after the accident, a stop work order ,

was. issued until the cause of the accident could be determined and  ?

training'on configuration of electrical cabinets similar to T21C1 was )

given to the maintenance department. Also, the importance of electrical i safety was reiterated by the plant manager to all personnel through a.

mandatory lecture.

The Human' Factors Assessment Branch /NRR investigation cond' ucted on_ July 26 !

and 27, 1990, indicated that improvements could be made to the licensee's  !

clearance request process. Theseimprovementsconcerned(1): clearly.- '

defining who is responsible for assessing the adequacy of the clearance boundary, (2) . training for workers emphasizing'the need for face-to-face  !

comunications when establishing clearances to minimize misunderstandings -j among workers, and (3) . definition of. the scope and' extent of the clearance .

boundaries. The : inspectors:also observed that the licensee could make  !

1mprovements to the worL process in the following areas: planning ~and. ,

executing work and providing location drawings to workers.. Root cause i assessment by the Human Factors Assessment Branch /NRR--inspectors  !

determined that the licensee did not fully. consider the information  !

provided by the NRC-(IN 88-96) and industry regarding similar previous  !

events (i.e., Wolf Creek and San Onofre). Secondly, though there were i inconsistent views on where.the current transformers were beated. the  ;

drawings that would have shown the location of the current transformers ,

were not'used. Finally, a review of the event.to determine (1) the.need J for additional controls.(validations, signoffs, walkdowns, and verifications) #

totheclearancerequestandworkreviewprocess;'(2)theneedto-  !

incorporate drawings to show the location of plant equipment; and-(3).the-  !

need for a plant standard regarding signs communicating personnel hazards

'

throughout the plant was considered warranted.- The licensee's review of 1 these three: items is an open issue. J No violations or deviations were identified. The NRC staff's' request for' -

an additional review by the licensee, discussed above, is considered an I

"Open Item" to be closed by the NRC resident inspector (315/90021-01;' A 316/90021-01), i RadiologicalControls(71707)

'

4..

f During routine tours of radiologically controlled plant facilities or areas, the inspector observed occupational radiation safety practices by  !

the radiation' protection staff and other workers.. 1

Routine tours of the' auxiliary building and containment indicated that, in general, workers were adhering to personnel radiation practices:to~

minimize contamination and dose received. ' Inspectors 1did find that because the exit pathway from the. lower containment area was confined,

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potential.for cross contamination existed between those workers coming  ;

out of containment. Additionally, the congestion in this area was  ;

'

increased because this exit path was also used by the workers to enter the lower containment area. ,

.

No violations, deviations, unresolved or'open items were identified. . l t

" 5. Maintenance (62703,42700)  !

= i Maintenance activities in the plant were routinely inspected, including i both corrective maintenance (repairs) and preventive maintenance.  ;

Mechanical,- electrical,,and instrument and control group maintenance- i activities were included.as av6ilable.

'

The focus of the inspection was.to assure the maintenance activities reviewed were conducted in accordance with approved procedures, ,

regulatory guides and industry codes or. standards and in conformance with -

Technical Specifications. The following items were considered during. '!'

this review:-the Limiting Conditions for Operation were met while L.

components or systems were removed from service; approvals were obtained  ;

prior to initiating the work; activities were accomplished using approved procedures; and post maintenance testing.was~ performed:as applicable. -

The following activities were inspected:  !

a. Job Order JO B003754: " Remove all intercell connectors on 2CD-Battery. Clean connectors and terminal posts. Coat with NO-0X-ID- ,

grease and reinstall."' l l

Although there was no procedure used forLthe job, activities- i performed appeared to the inspector to be within the skill of . l the. craft. Additionally, the job order contained specific job- l attributes such as required torque values for the intercell  ;

connectors and the requirement to verify the' presence of NO-0X-ID grease on the terminal posts.. Inspector did note that the handle.

of the torque wrench was not insulated to prevent accidental arcing. 1 The licensee. responded that they would prepare-a " guideline" which J would address this concern.

b. **12 MHP 5021.082.017 Rev. 6: " Preventive Maintenance of Installed i Motor and Valve Control Centers,-and Overcurrent Testing of Molded 3

-

Case Circuit Breakers." Overcurrent testing of various breakers in-600 Volt Motor Control Center EZC-A, located in the Unit.2 4KV a switchgear. room was observed. The in-progress work was checked for  !

pro)er documentation and that the. procedure was being'followed. No I pro)1 ems were noted. i c. **12MHP4030.STP.046 Rev. 2: " Emergency Diesel Generator System 18 Month: Inspection" Inspector observed corrective maintenance: , a performed on leaking Unit 2 CD diesel generator lube oil strainers and found no discrepancies. Licensee was in the process of filling ,

the lube oil' system for the 18 month inspection of the diesel generator when they discovered that the lube oil strainers leaked  ;

excessively at the lube oi1 ~ strainer top cover area. The leak was  ;

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believed to be caused by a bad 0-ring and the 0-ring was replaced. i Although the craft did not have a detailed procedure to replace l the 0-ring, it appeared that the nature of the work was within the 3

. skill of the craf t and the craft displayed good maintenance .

practices.  !

,

No. violations, deviations, unresolved or open items were identified.  !

i 6. Surveillance (61726,42700)- .

The inspector reviewed Technical Specifications required surveillance  !

testing as described below and verified that testing was performed in i accordance with adequate procedures, that. test instrumentation was calibrated, that Limiting Conditions for. Operation were met, that removal  :

and restoration of the affected components were properly _ accomplished,- i that test results conformed with Technical Specificath ns.and procedure  ;

requirements and were reviewed by personnel other than the individual  ;

di.r,ecting the test, and that deficiencies identified during the testing  ;

were properly reviewed'and resolved by. appropriate management personnel. l

The following_ activities were inspected::  ;

,

'

a. **12 THP 6030 IMP.014. " Protective Relay Calibratio'n" for Unit 2 4KV .

'reaker protective relays.

!

b. **12 MHP 4030 STP.047, "18-Month.Surve111ance Test Procedure for AB, '}'

CD, and N-Train Batteries and Chargers Using-BCT-1000 Computerized; Test System." s

, This test was observed on the Unit 2 CD battery; it utilized a load l'

profile developed by the licensee's corporate office'in about 1984-85 as an 8-hour drawdown to. simulate. post-accident ^ conditions. l This profile was augmented by the test engineer onsite, to both increase current draw ard prolong it, through the' test.' '!

c. **12 OHP 4030 STP.046, "New and Spent Fuel Hoist Height Interlock j

- Operability Verification."t - This test was-being serformed for the j first time by the plant Operations Department (t11s was previously aMaintenanceDepartmenttest)incompanywiththefuelhandling..

contractor, Master-Lee.

_

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l d. **12 OHP 4030 STP.249, " Containment Divider Barrier Seal- _

o Inspection." The-licensee was performing a Technical; Specification required surveillance of the Unit 2 Divider Barrier Seal when it wast '

determined the seal-did not meet acceptance criteria. The-seal was- !

declared INOPERABLE on August 1, 1990.

.

'

It was subsequently determined that a11'the seal material (Uniroyal' -!

3807) needed to be replaced due to cracks found under a backing  ;

plate that cannot be detected by visual inspection of the installed.

material..Thereplacementseal(Uniroyal41300)hassuperior

-

properties _(such as tensile strength, elongation, aging) and-is expected to be installed prior _to startup of the unit.  ;

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Concerns about the integrity of the Unit I seal'(Unit 1 is presently at power) were raised and addressed. The licensee currently is preparing a Justification for Continued 0)eration so the unit could continue operation for the remainder of tie current cycle, scheduled H to end mid-October,1990. At that time, replacement of the 3807 material in Unit I will be performed.

e. **1 IHP 4030 STP.003, " Reactor Coolant Flow Protection Set III SurveillanceTest(Monthly)." ,

This test described the procedure used by the.I&C techniciansLto i determine the operability of the reactor. coolant system flow j protection. set III b.t verifying the proper flow bistableitrip-

.

values. Additionallt,-loop low flow; indications in the control room 1 was verified. I

Inspector observed the 180 technician perform the. surveillance and- )

. reviewed the procedire and noted no discrepancies. The inspector .j found that the surveillance procedure was generally well-written, )

all voltages were tithin the' required tolerances, and all '

indications in.the control room functioned as required.

Additionally, the IAC technician displayed good working knowledge.

of the procedure and the anticipated system indications as a result 1 of-initiating various signals throughout the test. j I

No violations, deviations, unresolved.or:op w items were identified.

7. FireProtection(71707.64704)' -l

. J Fire protection program activities, including fire prevention and other ]

activities associated with maintaining capability for early detection and '

suppression of: postulated fires, were examined. Plant cleanliness, with a focus on control of combustibles and on maintaining continuous ready'

access to fire fighting equipment and materials,;was. included in the q items evaluated, j y

LicenseeidentifiedthefollowingAppendix'Rissuesjduring'this )

inspection period:

a. On July 29, 1990 the licensee' determined reportable'to NRC a  ;

situation where potentially inadequate lighting l existed in a'reas of: 1 the auxiliary building required for. emergencyf remote-shutdown of the l reactor per.10CFR50 Appendix R. ' The lighting conditions were evaluated during three separate walkdowns of the auxiliary buildingt 1 starting on April 19-1990 and ending on July 17.-1990c The licensee believed the safe shutdown could have been performed i since operators normally carry flashlights while executing theirc regular plant duties.. Short term corrective: actions were addressed with procurement of hardhats with lights mounted to the front and powered by battery packs attached at the waist. Long term corrective actions scheduled to be complete on August 31, 1990 ,

included upgrading the system with more lighting focused at:the 1 proper locations.

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b. -On August 2, 1990 a concern that cable routing for component cooling I water (CCW) and emergency service water (ESW) pump control circuitry J

,

did.not meet 10CFR50 Appendix R requirements was reported to NRC..  ;

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'

Specifically,.the cabling for the ESW and CCW-low header pressure.-  !

l switches were located in the same fire area and did not meet l

,

Appendix R separation criteria. Because of-a fuse coordination j problem between the automatic start switch and the rest of the circuitry, it was possible for a short circuit in the. pressure . 4  !

L switch wiring to disable the CCW and ESW pumps auto-start capability.

.

'i i

The problem was corrected when it was identified by replacing fuses 1 in the pressure switch circuitry.  ;

t c. On August 24,'1990 licensee discoveted during-s review of a licensee !

problem report that because of cable-routing for a cable associated I with the Unit 1. shutdown indication.(LSI) panels, a postulated fire- !

. in any one of three Unit 1 fire areas (Fire Zones!41, 55 or 56). l could have resulted in an inability to maintain power to the LSI ' i panels from Unit 1 or to repower the pinels from Unit 2. This J scenario would have resulted.in the pracess monitoring  !

instrumentation used in the Appendix R safe shutdown scenarios to become unavailable.

.

The cable is 1-2968G, which connects LSI panel 6 to panel 6X.' ,

The routing for the cable- 1-29685G includes Fire Zones 41,.55,.

and 56. A postulated fire in any of these zones could create a :l fault on cable 1-29685G and has also been found to fail'the~ELSC  !

bus on Unit 1. Since.the cable is not fused at the present time, *

a switchover to the Unit 2 ELSC bus for LSI panel 6.would-place-  ;

the fault on the Unit 2 bus and result in failure of.that bus.

Unless the leads to the shorted cable _at LSI panel'6'were lifted,  !

the result would be total loss of power-to all of.the Unit.1 LSI J panels. Additionally, credit for; control room process monitoring  !

instrumentation cannot be taken for this situation'because '

instrumentation is powered by'the CRIDS which are'also postulated a to fail in the event of a fire -in the affected areas. ,

Licensee. initiated a temporary modification to install a 1.25- amp. ;

fuse between panels LSI-6 and LSI-6X.

d. Additionally, licensee determined on August 2, 1990, that as a result of surveillance inspection and field walkdown performed ,

of existing fireproofing on June 15, 1990, that fireproofing 1 material was not installed on exposed structural steel members '

of. walls in the;following lube oil rooms-Unit 1 - Turbine lube oil nom  !

Unit'l - Turbine oil tank room -

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Unit 2 - Turbine lube oil rem i Unit 2'- Turbine oil' tank room Unit 2 - Misc. oil storage room ~-

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The fire detection system (s) are wired into the contro1xroom alarm system which'should alert and cause the dispatch of the fire brigade. In

,

addition,- the suppression syste;n(s) are detector actuated CO2 dispensing type and are present in all the subject rooms.

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The issues discussed in this section wil'1 be reviewed during an Appendix R inspection scheduled for September 10 through 14,~1990.

8. Engineering and Technical Support .

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.

The inspector monitored engineering and technical support activities at the site ~and, on occasion,-as provided to the site from the corporate office. The purpose of this-monitoring was to assess the adequacy of these functions in contributing properly to other functions such as >

operations, maintenance, testing, training, fire protection:and : .]

configuration management, j 1  !

a. , On-July 26, 1990, the resident inspector-office was-informed by site j

- management of a potential weld' deviation existing for.certain model  :

Centrifugal Charging and Safety Injection. Pumps manufactured by j Dresser Pump Division (previously, Pacific Pump ~ Division). The 'J information was transmitted to the licensee in a. July 2, 1990- '

Westinghouse letter which stated a concern that welds associated with the inboard locating lugs and outboard centering fins may not meet the manufacturer's minimum acceptance criteria. D. C. Cook was not listed as having the Safety Injection Pumps in question. . They -;

were, however, referenced as having been supplied the Charging -

-l Pumps. 1  :

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The letter recommended, and the licensee performed, inspection of the welds to ensure adequate deposit of weld _ material. The  ;

!

inspection identified weld deposit ranging from about 14-percent to l 60-percent of that necessary under the generic loading' assumptions-provided-by Westinghouse. The licensee pursu'ed plant specific '

loading assumptions along with possible weld enhancements;and began-the process for an NRC Waiver of Compliance request.

- .

A few days later, the results'.of the plant- specific analysis. done by  !

'

Dresser and the licensee's corporate office found that minimum weld requirements based on service nozzle loading and seismic forces.

(supported by values contained-in the Final Safety halysis Report)

were met with'the as-found condition. . The " worst" Charging Pump met ,

the minimum weld area by about 17-percent.

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The licensee is deciding whether to pursue plans for laying additional weld material during the next set of refueling outages,

'

a possible design fix which would eliminate the need for-the welds. 1 completely, or leaving the welds "as is" based on' engineering. '

review. J b. On July 23, 1990, the resident inspector office was informed that i'

eddy current testing of the Unit 2 incore flux monitoring thimble -

tubes-showed the tubes to be substantially degraded. Of the 58 total tubes:

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degradation.

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-1 had indication of approximately 50-percent through-wall degradation. .

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-6 had indications of approximately 60-percent- hrough-wa11 i degradation 1-2 had indications of approximately 90-percent through-wall 5

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degradation-1hadindication'of100-percentthrough-walldegradation(was ,

leaking)

All of-these thimble tub'es were previously replaced during the last? I refueling' outage in 1988.' A few weeks prior to-the outage, a tube _;

which had 100-percent through-wall was isolated after it was  ;

identified'as leaking (Ref. NRC Inspection Report 50-315/90013(DRP);  :

4 ,

.50-316/90013(LRP) Paragraph 2.b).

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1

. The. thimble tubes, manufactured by Westinghouse were installed at-other U.S. utilities where this~ degree of wall: loss has not been: ')

experienced. In an attempt to identify.the cause of the aggressive: l wall. loss,. Westinghouse-and the licensee reviewed plant operating  :

conditions _during previous-fuel. cycles as well as fuel assembly geometry, i A concern was expressed with Unit 1 thimble tubes as they- are also j of the same material and dimensions as the Unit 2' tubes; however, i no_ problem has yet been identified at Unit 2. The licensee has l replaced all 10 tubes which were determined to have greater than- .

50-percent _through-wall reduction. The investigation to~ determine  !'

the root cause'of the thimble tube thinning'was still in-progress as this inspection period came to a close '

'No violations, deviations, unresolved or open items were identified.

i 9. EmergencyPreparedness(82201,82203)

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,

I On -July 29, 1990, the licensee carried forth-a planned evolution -

regarding a dual emergency diesel generator outage which place (the-unit in an Emergency Plan." Unusual Event" condition. Unit 2 Train A

,

Diesel Generator was made inoperable to allow work on its 4160 Volt l Emergency Bus-(Paragraph 3.a.) and Train B Diesel Generator was *

L removed from service as  :

TechnicalSpecificatIonr. equired planned,-anddeclaredINOPERABLEtoperform inspections. The unit remained in' .

an Unusual Event condition at.the close of the inspection period.

Train A diesel generator is expected to.be declared operable around 1 August 31, 1990.

L

No violations, deviations,' unresolved or open items were identified. .

10. Security-(71707)'  !

Routine facility security measures, including control of access for  !

vehicles. packages and personnel, were observed. Performance of-dedicated physical. security; equipment was- verified during_ inspections in

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various plant areas. The activities of the professional security: force- l in maintaining facility security protection were occasionally. examined or  :

reviewed, and interviews were occasionally conducted with security force j members. i l

On August 3, 1990, and again on August 18, 1990, the licensee reported to j NRC that a contractor supervisor tested positive..for alcohol. The  ;

earlier event resulted from a random Fitness For Duty (FFD) test; the 1 latter from an attempt to enter the protected area while under the influence.. In both cases, site access was' suspended, among other things, i in accordance with'the licensee's FFD policy.

.No violations, deviations, unresolved or:open items were identified.. ,

',

11. Outages (37700,42700,60705,60710,61701,61715,86700)1 In response to Generic Letter 88-17. " Loss ~ of Decay. Heat Removal," the licensee committed to install two independent electronic monitoring systems which would monitor the. reactor coolant, system (RCS) level-during i reduced inventory operation. The inspector observed installation and- i performed a walkdown of accessible portion of the system.

The RCS mid-loop system consists of-two electrically independent level )

indication system and a sight glass. One level indication system is a standard differential pressure transmitter type and a second-indication ,

system is a capacitance probe type. Additionally, there is a local sight j glass with can be viewed with a video camera in the control room. Both '

electrical level detectors also have remote indications in the control room.

The narrow range level detector (ca)acitance probe type) is' connected to .

the number two hot leg piping and t1e loop's byaass temperature manifold. 1 This instrument readout is from just below the 1alf loop to the top of the hot leg.  ;

i The wide range leve1' detector (differential pressure type) is' connected  ;

to the the piping from the number four steam generator to.the reactor coolant pump (intermediate leg) and to the vent piping from he pressurizer. This instrument readout is from approximately reactor  ;

vessel flange level to the bottom of the: hot ~1eg. i No violations, deviations, unresolved or open' items were identified. ] i 12. Safety Assessment /0uality Verification' (35502, 37701, 38702, 40704, 92720) ')

Ins ector performed Inspection Procedure 35502 " Evaluation of Licensee

- Qua ity Assurance Program Implementation" and found that the licensee l 1s generally showing improvements or has improved in 3 of the 7 SALP 1 function areas since the SALP 7 cycle. These three areas where improvements have been evident were plant operations, einergency preparedness, and security. In the other 4 SALP functional areas,  :

radiological controls, maintenance / surveillance, engineering / technical- i support'and safety assessment / quality verification it was difficult to '

determine whether improvements made by the licensee, have contributed :j

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towards major improvements in these areas. Examination of the numerical ratings in the SALP categories for these 4 SALP functional areas appeared !

to indicate that there were no negative trends developing and that the i licensee has maintained a steady performance in these areas. -

- The purpose of the inspection procedure was to evaluate'the effectiveness of the licensee's implementation of its quality assurance program by -

,

reviewing inspection reports for the past 12 months, SALP reports for the !

,

past 2 years,- outstanding Regional open item list. . licensee corrective ;

actions for NRC Inspection findings, and LERs for the past 12 months. .'

The inspector, b0 sed on review of these documents, determined whether j negative trends c'>uld be~ determined which could indicate problems with

'

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the licensee's QA program implementation.

{

No violations, deviations, unresolved or open items were identified. j

'12. A11egations(92705)

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A11'egation Follow-up (AMS No.:RIII-90-A-0059)

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Discussed below is an allegation received by the NRC Region III Office relating to surveillance tests at D. C. Cook, which was evaluated during t-this inspection. The evaluation consisted of record and procedure review

'

and interviews with licensee personnel.  ;

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Allegation: A surveillance test.on an Engineered Safety Features ViniU TaE 5n Unit (AES Fan) was not redone during August 1982 to cover 1

'

steps missed in part of the procedure. Additionally, it was common ,

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practice for technicians not to obtain required signatures indicating .

control room notification until after-the test.was completed.; 3 Discussion: Surveillance test records for the AES fans associated'with -[

both units were reviewed. A historical record for surveillances .. l performed since the early 1980's was retrieved,'with' review emphasized.

on several tests completed since 1985. 'No.significant problems were l noted during the review, and no violation of Technical Specification surveillance requirements were noted.

'

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Several procedures were sampled and individuals interviewed to see'if

, control room notification requirements were being fulfilled. All. .

L documents reviewed showed control room concurrence, verbal or written L* (some procedures allow for verbal notification), prior to start of .

l surveillance tests. All. individuals interviewed' indicated: understanding '

'

of the notification requirements.

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Finding: The allegation was not substantiated. '

No violations, deviations, unresolved or open items were identified. l

l; 13. R g on III Requests (92701, 92705)

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a. In response to a May 25, 1990 memorandum from~the Director, Division' ,

n .of Reactor Projects, Region III, this-inspection included an investigation into'the licensee's methods for monitoring 'and-  ;

l controlling Zebra mussels, i

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• On July 18, 1990, divers discovered two adult Zebra mussels in the !

screenhouse intake forebay. Problem Report (PR) 90-0945 was .

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generated to document the finding'and provide a mechanism to track !

action on the discovery. ,

j The licensee already had.a program in place to monitor biological ;

fouling as a result of commitments made-in response to NRC Generic :'

Letter 89-13 (Service Water, System Problems Affecting Safety-Related Equipment). ' This included collection / analysis of sediment and ,

.l substrate samples as well as water samples. A beach walk program: l was also instituted for Zebra mussel colonization. t

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To aid in formulation of;the plant's Zebra mussel control strategy, !

meetings were held with three vendors which were familiar with Zebra :

mussel control on July 25, 1990.- The next day, an informational i meeting.with the Michigan Department'of Natural Resources (MDNR).- l among.others, concluded with a presentation of the plant's suggested ;

, control strategy. The MDNR indicated that the use of a molluscicide could be approved in a relatively short time frame, provided the -

product had been previously: approved for use elsewhere in Michigan, Theplantrequested,inaletter,useiofsuchaproduct(Clam-Trol j .

" CT-1) along with.an easing _of-chlorination limits.  !

,

The licensee's sampling and analysis program for Zebra mussels is ,

contained in Procedure No. 12 THP 6020 ENV.101 'At'this writing, l

. the procedure is-in draft form and out for comments. No major-changes _are expected to be added. Areas of the plant to be sampled ;

at various locations . include the Circulating Water,. Service, Water, i and - Fire Protection Systems. The results of the sampling and '

analysis program are. expected to be included in the' licensee's-Annual Environmental Operating Report.  ;

b. In response to a July 10, 1990 memorandum from t'he Director,  !

Division of Reactor Projects,_ RIII to Senior Resident-Inspectors,;

several examples regarding Technical Specification Limiting  ;

ConditionofOperation(LCO)ActionStatement'entrieswereprovided-. :

to the Region III Technical Su) port staff. The specific examples ;

were restricted to those for w11ch preventive maintenance was i performed. The examples included the affected equipment, the LC0 i entered,.and the actual time required to perform the maintenance. !

>

- No violations, deviations, unresolved or open items were_ identified.

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14. ManagementMeeting(30702)

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a. On July 31, 1990, the licensee hosted an NRC management visit by. i Mr. John Zwolinski, Assistant Director, NRR Division of. Reactor '

Projects III, IV,.and V. The purpose of the meeting was to discuss i various licensee initiatives and to tour the plant. t

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Among the topics discussed were: l

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- Unit Two outage. status ~

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- Modification in progress l

- Design Change process  :

- Maintenance v evam update l

- Human Peri m r, Enhancement System (HPES) 1

- System Engi..w r concept and experience to date j b. On August 27,.1990, the' licensee was visited by Messrs. Brent Clayton - l Chief, Reactor Projects Branch 2 and Bruce Burgess, Chief' Projects

,

a section.2A. The purpose of the visit was-to review the licensee's '!'

installation of the half loop instrumentation, to tour Unit 2 '

containment, and various areas of the Auxiliary and Turbine buildings.

15. ManagementInterview(30703) i-i The. inspector met with the-licensee representatives (denoted in .

.

i Paragraph 1.a)onAugust 31, 1990,.to discuss the scope and findings of

~

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the inspection as described in these details. In addition,.the inspector  ;

also discussed the likely informational content of the inspection report *

with regard to documents or processes reviewed by the inspector during '

s the inspection. The licensee did not identify any such -i document / processes as proprietary. i l

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