IR 05000315/1990026
| ML17328A832 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 12/17/1990 |
| From: | Ring M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17328A831 | List: |
| References | |
| 50-315-90-26-EC, 50-316-90-26, NUDOCS 9012270256 | |
| Download: ML17328A832 (74) | |
Text
U.S.
NUCLEAR REGULATORY COMMISSION
REGION III
Reports No. 50-315/90026(DRS);
50-316/90026(DRS)
Docket Nos: 50-315; 50-316 Licensee:
Indiana Michigan Power Company 1 Riverside Plaza Columbus, OH 43216 Licenses No:
.DPR-58; DPR-74 Facility Name:
D. C. Cook Nuclear Power Station, Units 1 and
tleeting At:
Region III Office, Glen Ellyn, IL 60137 Meeting Conducted:
November 20, 1990 Type of Meeting:
Enforcement Conference Approved By:
Meetin Summar ar
.
>ng,
>re Engineering Branch
/2 /7/<e ate Meetin on November
1990 (Re orts No. 50-315/90026(DRS);
50-316/90026(DRS)
Matters Discusse
T e o
owing examp es o
apparent vso ations were sscusse
an inadequate emergency lighting evaluation of two Emergency Remote. Shutdown (ERS) procedure revisions; (2) inadequate corrective actions regarding emergency lighting system unit components; (3)
a postulated Appendix R fire in any of five fire zones could have resulted in a loss of HVAC for both units control rooms potentially affecting the ability to maintain the plant in a safe shutdown condition; (4) design translation deficiencies that could have resulted in the loss of control power to all four essential service water pumps or all four component cooling water pumps; (5) local shutdown instrumentation (LSI) panel cable routing errors; (6) lack of a completed high impedance fault analysis; (7) an inadequate shift staffing procedure; (8)
examples of mislabeling and/or difficult to accomplish steps in the ERS procedures; and (9)
a failure to design for a loss of control room ventilation due to postulated fires outside of the control room.
9012270256 901217 PDR ADQCK 05000315
DETAILS l.
Enforcement Conference Attendees American Electric Power Service Cor oration (AEP)
In sana sc s
an Power Com an I
- H. Alexich, Vice President, Nuclear Operations
- G. P. Arent, Acting Procedure Supervisor (Operations)
- T. G. Argenta, Assistant Vice President, Nuclear Engineering
- P. A. Barrett, Director, guality Assurance
- A. A. Blind, Plant t1anager
- S. Brewer, tlanager, Nuclear Safety and Licensing
- J. C. Jeffrey, hlanager, Power Systems and Human Factors
- R. A. Kraszewski", Nuclear Safety and Licensing Engineer'J.
Sampson, Operations Superintendent
- R. L. Shoberg, Manager, Technical Support
- B. Signet, Senior Attorney
- J. B.. Trad, Senior Engineer
- D. H. Williams, Jr., Senior Executive Vice President, Engineering and Construction U. S. Nuclear Re viator Commission (NRC)
- B. Berson, Regional Counsel, RIII
- B. L. Burgess, Chief, Projects Section 1B, Division of Reactor Projects (DRP)
- S. D. Burgess, Chief Maintenance and Dutages Section, Division of Reactor Safety (DRS
- R. L. Bywater, Reactor Engineer, DRP
- H. B. Clayton, Chief, Branch 2, DRP
- T. G. Colburn, Senior Project Hanager, Nuclear Reactor Regulation
- A. B. Davis, Regional Administrator, RIII
- R. N. Gardner, Chief, Plant Systems Section, DRS
- J. A. Hammer, Reactor Engineer, DRS
- B. L. Jorgensen, Chief, Projects Section 2A, DRP
- J. A. Lennartz, Acting Chief, Operator Licensing Section 2, DRS
- J. Lieberman, Director, Office of Enforcement, Headquarters
- T. 0. h1artin, Director, DRS
- C. J. Paperiello, Deputy Regional Administrator, RIII
- D. G. Passehl, Resident Inspector, D. C.
Cook Plant
- C. D. Pederson, Director, Enforcement and Investigation Coordination Staff, RIII
~H. Peterson, Reactor Engineer, DRS
- E. R. Schweibinz, Senior Project Engineer, DRP
- W. Troskoski, Senior Enforcement Specialist, Headquarters
- J. H. Ulie, Reactor Inspector (Team Leader),
- C.. H. Weil, Enforcement Specialist, RIII
- G. C. Wright, Acting Deputy Director, DRS Brookhaven National Laborator (NRC Contractor)
- A. N. Fresco, Research Engineer
- K. Sullivan, Research Engineer
- Denotes those persons in attendance at the enforcement conference on November 20, 1990.
Enforcement Conference As a result of the apparent violations of NRC requirements, an Enforcement Conference was held at the Region III Office in Glen Ellyn, Illinois, on November 20, 1990.
The preliminary findings which were the bases for these apparent violations of NRC requirements were documented in NRC Inspection Reports No. 50-315/90018(DRS);
and No. 50-316/90018(DRS)
and were transmitted to the licensee by letter dated November 9, 1990.
The attendees of this enforcement conference are denoted in Paragraph 1 of this report.
The purposes of the conference were:
(1) to discuss the apparent violations, the significance, cause, and the licensee's corrective actions; (2) to determine whether there were any mitigating circumstances; and (3) to obtain other information which would help determine the appropriate enforcement action.
The NRC representatives described the apparent violations and those deficiencies contributing to the apparent violations.
The licensee presented information which is included as Enclosure 1 to this report.
The licensee provided clarifying information for the following issues:
At the Eni'orcement Conference, the licensee position regarding the inadequate shift staffing procedure (315/90018-05(DRS);
316/90018-05(DRS))
was that the procedure in place was adequate to ensure that the required number of operators would, be available to implement the ERS procedure and still maintain a Senior Reactor Operator and a Reactor Operator in the unaffected unit.
The licensee stated that five licensed operators and one non-licensed operator would be utilized for implementation of the ERS procedure, whereas during the inspection, the licensee indicated that six licensed operators would be utilized to implement the ERS procedure.
Regarding the loss of HVAC to both control rooms, and subsequent inability to maintain the plant in a safe shutdown condition (315/90018-06(DRS);
316/90018-06(DRS)),
the licensee stated the control rooms would not have to be evacuated during this event.
The licensee stated that cold shutdown conditions could be achieved and maintained with reasonable operator actions such as opening control room doors and the use of portable fans to provide circulation.
The licensee stated that by taking the above actions, the control rooms'aximum temperature would be 132 degrees F at 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> into the event and normal shutdown would be accomplished within 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.
In addition, the licensee stated that 132 degrees F in the control room could be equated to 02 degrees F to a human due to the low humidity factor.
Therefore, minimal human discomfort would result from this event in that the control rooms would not be evacuated resulting in the ability to maintain the plant in a safe shutdown conditio llith regard to the 1990 identified human factor deficiencies of mislabeling and difficult to follow steps in the ERS procedure, the, licensee stated these 'deficiencies do not relate to the human factor deficiencies identified in previous NRC inspections.
For example, the 1982 ERS procedure deficiencies were categorized as technical in nature having major safety significance; whereas the recently identified human'actor deficiencies were not considered to be of major safety significance nor would those deficiencies have precluded successful completion of the ERS procedure.
Additionally, the licensee stated that a walkdown would be performed on the ERS procedures for both units as part of a manual action study which is scheduled for February 15, 1991.
Also, during the enforcement conference, questions were raised regarding the date that the emergency lighting Appendix R modifications were to have been completed.
According to the NRC letter dated December 11, 1985, the Appendix R modifications were to be made during the Unit 2 refueling outage with the lighting modifications completed within two months following restart.
It was determined that the plant first reached startup (Mode 2)
on July 7, 1986, following the Unit 2 refueling outage.
Therefore, the date for completing the emergency lighting modifications was determined to be September 7, 1986.
3.
Conclusion The evaluation and disposition of the apparent violations will be presented in subsequent communication NOVEMBER 20, 1990 APPENDIX R ENFORCEMENT CONFERENCE AGENDA Introduction Milton P. Alexich V. P. Nuclear Operations Div.
High-Impedance Fault Study Brian McLean Engineer Power Systems
'& Human Factors Operator Staffing John Sampson Operations Superintendent Cook Nuclear Plant Human Factors Gordon Arent Procedure/Training Administrator Cook Nuclear Plant Control Room HVAC Roger Shoberg Section Manager Technical Support ESV & CCW Isolation Relay Circuitry Roger Shoberg Section Manager Technical Support LSI - Cable Routing Brian McLean Engineer Power Systems
& Human Factors Emergency Lighting Steve Brewer Manager Nuclear Safety & Licensing Summary Steve Brewer Manager Nuclear Safety 6 Licensing
ars en on
$r4
$i2
$io
$8 illiono 1X
$12.436
""
$6:rr52-01 ca ronsard
$3.965
~
~
~
~
~
$0.i3
$0.245 i982 i983 1984 1985 i986 Year elncludes AEPSC Engineer ing Expenditures
$0.548
$2.i64 t98V
>988
$0m5
$
""'989 i990
AEPSC Engineering Manhours Spent on Appendix R
Thousands of Engineertng Manhours 36.75
31.031
19.997
13.192 11.802 6.258 3+458
1982 1983 1984 1985 1986 1987 1988 1989 Year
MULTIPLE HIGH IMPEDANCE FAULTS
4/24/86 GENERIC LETTER 86-10 GUESTXON 5.3.8-SHORT CIRCUIT COORDINATION STUDIES SIMULTANEOUS HIGH IMPEDANCE FAULTS (BELOW THE'TRIP POINT FOR THE BREAKER ON EACH INDIVIDUALCIRCUIT) SHOULD BE CONSIDERED FOR ALL ASSOCIATED CIRCUITS LOCATED IN THE FIRE AREA OF CONCERN TO MEET THE SEPARATION CRITERIA OF APPENDIX R SECTION III.G.2 AND CLEARING SUCH FAULTS HAY BE ACCOMPLISHED BY MANUAL BREAKER TRIPS GOVERNED BY PROCEDURES
6/17/88 AEPSC PREPARES POSITION PAPER ON MULTIPLE HIGH IMPEDANCE FAULTS ISSUE.
THE PAPER CONCLUDES THAT FIRE-INDUCED HIGH IMPEDANCE FAULTS OF A STABLE, SUSTAINED NATURE ON MULTIPLE CABLES ARE NOT CREDIBLE.
11/1-2/89 MEETING. AT COOK NUCLEAR PLANT WITH NRR AND REGION III STAFF TO DISCUSS FIRE PROTECTION ISSUES.
DURING THE MEETING WE ARE REQUESTED TO SUBMIT, OUR. POSITION ON MULTIPLE HIGH IMPEDANCE FAULTS.
2/21/90 WE SUBMIT AEP:NRC:0692BT,
"NRC REQUEST FOR ADDITIONAL INFORMATION, POST-FIRE SAFE SHUTDOWN METHODOLOGY."
PAGE 13 OF ATTACHMENT 1 DISCUSSES OUR POSITION THAT THE OCCURRENCE OF MULTIPLE HIGH IMPEDANCE FAULTS IS NOT A CREDIBLE EVENT.
OUR POSITION PAPER IS INCLUDED AS ATTACHMENT /26/90 NRC FORWARDS THEIR SAFETY EVALUATION OF OUR FEBRUARY 21, 1990, RESPONSE TO UNRESOLVED ISSUES RELATED TO POST-FIRE SAFE SHUTDOMN METHODOLOGY.
ISSUE 2.23.1 CONCERNS MULTIPLE HIGH IMPEDANCE FAULTS.
THE SAFETY EVALUATION ACKNOMLEDGES THAT ME PRESENTED OUR JUSTIFICATION FOR THE POSITION THAT MULTIPLE HIGH IMPEDANCE FAULTS ARE NOT CONSIDERED CREDIBLE.
THE SAFETY EVALUATION STATES THAT THE STAFF MILL SCRUTINIZE OUR POSITION DURING THE UPCOMING FIRE PROTECTION AUDIT AND THE ISSUE IS lEFT
"OPEN."
l l
II
AFTER RECEIPT OF THE APRIL 26, 1990, SAFETY EVALUATION, THE STATUS OF THE MULTIPLE HIGH IMPEDANCE FAULTS ISSUE WAS RESEARCHED.
THIS EFFORT INCLUDED CONTACTING COGNIZANT INDIVIDUALSAT SEVERAL POWER PLANTS AND ATTENDING NRC EXIT MEETINGS AT THE DAVIS-BESSE APPENDIX R AUDIT.
DESPITE OUR CONTINUED BELIEF.THAT MULTIPLE,.
SUSTAINED FAULTS ARE NOT A CREDIBLE EVENT, IT WAS CONCLUDED THAT SUCH A POSITION WOULD NOT BE ACCEPTED BY THE NRC.
BASED ON THE ABOVE, A MULTIPLE HIGH IMPEDANCE FAULTS STUDY WAS INITIATED IN, MAY 1990 AND RECENTLY COMPLETED.
THE STUDY DEMONSTRATES THAT FIRE-INDUCED MULTIPLE HIGH IMPEDANCE FAULTS WOULD NOT ADVERSELY IMPACT POST-FIRE SAFE SHUTDOWN CAPABILIT INSPECTION REPORT NO. 90018 ITEM 8.A.(l)
o THE LICENSEE WAS TO HAVE COMPLETED THE APPENDIX R REVIEW INCLUDING THE HIGH IMPEDANCE FAULT ANALYSIS BY JULY 11, 1986.
(NOTE:
GL 86-10 WASN'T ISSUED UNTIL 4/24/86)
WE BELIEVE THAT THIS ISSUE HAS BEEN CLOSED BY OUR SUCCESSFUL COMPLETION OF THE HIGH IMPEDANCE FAULT STUDY AND THAT THE ACTIONS TAKEN IN RESPONSE TO THIS ISSUE WERE TIMEL SHIPZ MANNING REQUIREMENTS JOHN R.
SANPSON D.
C COOK NUCLEAR PLANT OPERATIONS SUPERI'.'ENDENT NOVEMBER 20, 1990
SHIFT MANNING R GMR MENTS 1.
BACKGROUND 2.
MANNING BASIS 4.
SHIFT STAFFING ROOT CAUSE SAFETY SIGNIFICANCE CORRECTIVE ACTION
EMERGENCY REMOTE SNUTDOMN PROCEDURE BASIS REVISION 6-8:
SHIFT SUPERVISOR (SRO)
UNIT SUPERVISOR
<RO)
2 OPERATORS, TASK QUALIFIED REVISION 9:
2 ADDITIONAL OPERATORS, TASK QUALIFIED
SHIFT MANNING REQUIREMENTS TECHNICAL. SPECIFICATION PARAGRAPH 6.2.2 PLANT CONDITION:
ONE UNIT OPERATING (MODES 1-4)
ONE UNIT SHUT DOWN (MODES 5o6)
TECHNICAL SPECIFICATIONS IMPLEMENTATION LICENSE CATEGORY SENIOR OPERATING LICENSE -
(SHARED)
OPERATING LICENSE - OPERATING UNIT (2)
SHUTDOWN UNIT (1)
NON-LICENSED - OPERATING UNIT (2)
SHUTDOWN UNIT (1)
FIRE BRIGADE -
5 MEMBERS (NOT DESIGNATED FOR SAFE SHUTDOWN)
SHIFT SUPERVISOR (SRO)
REACTOR OPERATOR (RO)
REACTOR OPERATOR (RO)
REACTOR OPERATOR (RO)
AUXILIARYEQUIPMENT OPERATOR+
AUXILIARYEQUIPMENT OPERATOR AUXILIARYEQUIPMENT OPERATOR ASSISTANT SHIFT SUPERVISOR 3 AUXILIARYEQUIPMENT OPERATORS TOTAL COMPLEMENT:
11:
- SHIFT MEMBERS UTILIZED FOR FIRE BRIGADE
SHIFT MINIMUMMANNING OHI-4011 PLANT CONDITION:
ONE UNIT OPERATING (MODES 1-4)
ONE UNIT SHUT DOWN (MODES 5,6)
OHI - 4011 SHARED, BOTH UNITS OPERATING UNIT SHIFT SUPERVISOR UNIT SUPERVISOR REACTOR OPERATORS REACTOR OPERATORS SHUTDOWN UNIT AUXILIARYEQUIPMENT OPERATORS AUXILIARYEQUIPMENT OPERATORS REACTOR OPERATOR AUXILIARYEQUIPMENT OPERATOR FIRE BRIGADE -
5 MEMBERS ASSZSTANT SHIFT SUPERVISOR
+3 hUXILZARY EQUIPMENT OPERATORS TOTAL COMPLEMENT:
12 SS, ASST SS, UNIT SUPERVISOR, 3 RO'S, 6 AEO'S
+ SHIFT MEMBERS UTILIZED FOR FIRE BRIGADE
hDDITIONAL'HI-4011 MANNING REQUIREMENTS 1,
MINIMUMTOTAL SHIFT MANNING - 14 2,
SUPERVISORY COMPLEMENT:
o SHIFT SUPERVISOR (SRO)
o ASSISTANT SHIFT SUPERVISOR (SRO)
o 2 UNIT SUPERVISORS (SROs)
3.
NORMAL CONTROL ROOM MANNING o
UNIT SUPERVISOR o
2 REACTOR OPERATORS 4;
NORMAL AEO MANNING -
DETERMINED BY:
o MINIMUM TOTAL COMPLEMENT (14)
o TECHNICAL SPECIFICATION MINIMUMMANNING o
FIRE BRIGADE REQUIREMENTS
SIIIFT SUPERVISOR ASST SHIFT SUPV UNIT SUPERVISOR REACIQR OPERA%8 AUXILIARY EQUIPHEHT OPERAIOR UTILITY OPERAS TRAIHIHG R. A. Blyth R. 0. Freehling~~5 C. R. Smith H. A. Gember5P H. h. Russell D. A. Head (SRO)
F. L. Baker C. H. Hnanlcek B. M. Kalfacre D. K. Dolby (SRO H. S. Fish L. M. Baun S. D. Behrens R. P.
Rose 0. M. Meddle T. E. Sulhart J. 0. Pobuda R. T. Branch H. D. Cross G. A. Tollas I. D. Burrls M. D. Etherldge~e S. R. Xosharp K. B.
H. T.
H. A.
K. R.
D. A.
M. J.
Hyers (SRO)
Harrington Rlegle (SRO)
Kendal 1 Hason Snyder J. K. VanGemeren 0. A. Stelnbrook S. R. Vanatta J. A. Groat N. GlldeLamadrld
'.
T. Glenn 5 R. L. Hoschlonl S. R. Schuettpels J. L. Marrens D. L. Badgero D. P. Light t.. 0. Boone B. K. Huts~~p C. J. Archey J. H. Tllly D. A. Rumpf59 D. R.
R. M.
0. P.
L, O.
0. K.
H. P.
S. K.
J. S.
Johns Petro (SRO)
Hennlng (SRO)
Koch Hiller Desmet Gressley Berry 0. A. Dotson G.
Bruirbe I snab I.. D. Baker J.
D. Lord S.
Humes R. L. Moodhouse D. R. Scott H. M. Tallman I. G. Reed H. D. Palen H. A. Mollenslegel R. J. SleberiiB R. L. Strasser R. Piller 8 ~ E. Caperton J.
E. Hlmtx J. A. Harrington (SRO)
R. M. Foster S. H. Partfn (SRO)
L. M. Nordell H. J. Schoonhelm
$
H. A. Seldler B. M. Gurno C. T. Gorton J.
E. Brooks J.
D. Blerl H. R. HcGath T. G.
Br'.
M. Bennett 0. Spauldlng L. K. Smith R. J. Perrlne J. K. Buursma8 V. Moods J; P. O'Mell*e G. R.
Kuhn T. M. Melch (SRO)
D. h. Cobb F. A. Helmblgner T
HCHutuaty B. E. Evans T. B. Lain J. A. Dlpert T. P.
Appelman R. G. Cessna D. D. Horrls D. R. Malter J. S. Honroe R. E. Harrah J. H. Meaver SPECIAL 5MSQNQK R. O. Heathcote G. A. Zlsmerwan M. J. Lents J.
M.
Marner'.
T. Conrad F. E. Johnson I.EGEHD
- s
= Shift lead Trainer
$
= Finergency Hedlcal Technlclan
= SRO-Ch SUPERVISORS RO'S AEO'S ItITALON SHIFT BKJKEIHlQ
16
17
SHIFT STAFF ING MATRIX bOTH UNITS IN MODES 1~4 U1 4 U2 NORMAL UNIT 1 FIRE UNIT 2 FIRE U1 U2 COM U1 U2 FB
X X
'-/ x X
US X
X X
RO X
X X
RO RO X
X X
.X X
RO AEO X
AEO X
AEO X
AEO X
X X
X X
X
,-X X
X AEO X
AEO X
TOTAL 6
2
'3".,5'.3
5 1-SS 1-ASS 3-US 4-RO e - RO/AEO FOR AEO TOURS 17 - TOTAL SHIFT COMP LEMENT
J ll
ROOT CAUSE FAILURE TO COMMUNICATE CLEARLY THE BASIS FOR MANNING AND QUALIFICATIONS REQUIRED FOR THE EMERGENCY REMOTE SHUTDOWN PROCEDURE SAFETY SIGNIFICANCE NONE, THE MANNING REQUIREMENTS OF OHI-4011 ENSURE SUFFICIENT NUMBERS AND QUALIFICATIONS OF OPERATORS CORRECTIVE ACTION REVISE OHI-4011, INCLUDE SHIFT MANNING MATRIX TO SHOW ASSIGNMENT OF RESPONSIBILITIES DURING ALL OPERATING CONDITIONS CANCEL OS0.100
HUMAN FACTORS I. REVIEW OF THE CONCERN II. OVERVIEW OF HUMAN FACTORS - INSPECTION HISTORY A)
1982 APPENDIX R INSPECTION B)
1988 EOP INSPECTION C)
1990 APPENDIX R INSPECTION III. CONCLUSION ON THE HUMAN FACTORS TOPIC IV. SAFETY SIGNIFICANCE OF INSPECTION FINDINGS V.
LONG-TERM ACTIONS TO ENHANCE HUMAN FACTORING
II
1982 HUMAN FACTOR OPEN ITEMS o
CONTAINED ERRORS MHICH COULD PRECLUDE SATISFACTORY PERFORMANCE OF THE PROCEDURES o
CAST DOUBTS AS TO THE FEASIBILITY OF THE PROCEDURES o
TECHNICAL IN NATURE ERRONEOUS DIRECTIONS (MRONG UNIT) FOR MODIFICATION OF EQUIPMENT REQUIRED FOR SAFE SHUTDOWN ERRONEOUSLY IDENTIFIED BREAKERS MHICH MOULD HAVE RESULTED IN DEENERGIZING REQUIRED EQUIPMENT UNPROPER SEQUENCING OF PROCEDURE STEPS RESULTING IN INABILITYTO OPERATE EQUIPMENT
PROCEDURE MODIFICATION OF IEP TRANSFORMER DID NOT PROVIDE GUIDANCE AS TO MHICH OPERATING CABINET REQUIRED MODIFICATION AND LABELLING INSIDE OF THE CABINET MADE IT IMPOSSIBLE TO DETERMINE MHICH FUSES TO REMOVE TRIPPING OF BREAKER TllAB IDENTIFIED AS THE
'M'ENT CHARGING PUMP LUBE OIL PUMP MOULD HAVE RESULTED IN DE-ENERGIZXNG THE MEST CENTRIFUGAL CHARGING PP.
REQUIRED FOR SAFE SHUTDOMN PROCEDURE ORGANIZATION MAS AMKMARD, STEPS MERE NOT PRIORXTIZED TO ENSURE STABLE SHUTDOMN CONDITIONS COULD BE MAINTAINED
1988 HUMAN FACTOR OPEN ITEMS o
LABELLING HATCHING PROCEDURAL GUIDANCE VERBATIM o
THE USE OF VALVE NOUN NAMES MITH VALVE NUMBERS o
PROCEDURE FORMAT
- NOTES AND CAUTIONS PLACED PRIOR TO ASSOCIATED
~ STEPS
- USE OF DOUBLE NEGATIVES IN PROCEDURE GUIDANCE
- IMPROPER BRANCHING AND/OR REFERENCING MITHIN PROCEDURE
1990 HUMAN FACTORS OPEN ITEMS o
FIVE HUMAN FACTOR CONCERNS MERE IDENTIFIED DURING THIS INSPECTION:
LACK OF A DEDICATED LADDER OF ARRI VALVES D/G AIR RECEIVER OUTLETS VALVES INCORRECTLY IDENTIFIED IN THE PROCEDURE IMPLIED LOCATION OF 345KV CIRCUIT BREAKER DEDICATED JUMPER NOT RESIDENT AT TDAFP LOCAL CONTROL PANEL DEDICATED MRENCH NOT AVAILABLEAT CA-2515 AND CA-2480
ERS PROCEDURE HUMAN FACTOR ENHANCEMENTS o
REORGANIZATION OF ERS PROCEDURE o
DEYELOPMENT OF ERS STATUS TRACKING SHEET o
INCORPORATION OF EOP HUMAN FACTORING GUIDELINES INTO EMERGENCY REMOTE SHUTDOMN PROCEDURE
SAFETY SIGNIFICANCE THE ITEMS IDENTIFIED DURING THE INSPECTION WERE
'DETERMINED NOT TO BE OF SAFETY SIGNIFICANCE.
THE PROCEDURAL GUIDANCE PROVIDED DID NOT PRECLUDE SUCCESSFUL COMPLETION OF THE PROCEDURES AND THE ITEMS IDENTIFIED MERE NOT REQUIRED TO ACHIEVE HOT SHUTDOWN CONDITION LONG-TERM ENHANCEMENTS o
CORRECTION OF INSPECTION
FINDINGS-COMPLETED - 11/15/90 o
INSTALLATION OF YENTS AT 1-CA-2515 AND 1-CA-2480 o
INSTALLATION OF DEDICATED TOOL BOX AT TDAFPs SCHEDULED - 12/15/90 SCHEDULED - 12/15/90 o
COMPLETE PROCEDURE> MALKDOMN TO BE FACTORED INTO A MANUAL ACTION STUDY (BOTH UNITS)
SCHEDULED -
2/15/91
DESIGN CONTROL CONTROL ROON HVAC PROBLEM INVESTIGATION ROOT CAUSE SAFETY SIGNIFICANCE CORRECTIVE ACTION PREVENTATIVE ACTION
CONTROL ROOM HVAC PROBLEM EXRE INDUCED LOSS OF CONTROL ROOM HYAC NOT COVERED BY EMERGENCY RESPONSE PROCEDURE
CONTROL ROOM HYAC INVESTIGATION BLACKOUT CALCULATXON PREFORMED
,l ASSUMING LXGHTXNG AVAXL'ABLE 120OF AT 2 HOURS OTHER SCENARXOS USING BLACKOUT CALCULATION BASE WITH DOORS OPEN WXTH DOORS AND HATCHES OPEN WITH/WITHOUT NORMAL LXGHTXNG WITH PORTABLE FANS RESULTS 120OF REACHED BETWEEN 3 AND 21 HOURS
CONTROL ROOM HVAC ROOT CauSE INAPPRDPRxATE AssuMPTxoN QN MAGNxTUDE 0F C0NTR0L RDQM HEAT LOADXNGS
CONTROL ROOM HVAC SAFETY SIGN Z FICANCE HOT STANDBY ACHIEVED
- MINIMALHUMAN DISCOMFORT 120 F DRY BULB = 80 F MET BULB EQUIPMENT LONG TERM -
COLD SHUTDOWN
- CONTROL ROOM INDICATION OPERABLE AT 120 F
- LOCAL INDICATION IS AVAILABLE EXCEPTION RHR AMMETER HOWEVERS CONTROL ROOM RHR INDICATION CAPABLE OF 149 F
COLD SHUTDOWN ACHIEVABLE WITH REASONABLE OPERATOR ACTIONS
- OPEN DOOR AND PROVIDE PORTABLE FANS ROOM TEMPERATURE 132 F AT 72 HOURS HUMAN
F ADDITIONALACTIONS
- REPOWER FANS AND'STABLISH ESW COOLING ROOM TEMPERATURE 117 F AT 72 HOURS HUMAN LOWER THAN 80 F
EXPECT NORMAL SHUTDOWN AT 30 HRS ~
NO SIGNIFICANT HAZARD TO HEALTH AND SAFETY OF PUBLIC
CONTROL ROOM HVAC CORRECTXVE ACTXON IMMEDXATE ESTABLXSH FZRE MATCHES INTERMEDXATE REVXSXNG ERS PROCEDURES PROVXDZNG REPAXR ITEMS FOR COLD SHUTDOWN INFORMXNG PERSONNEL
CONTROL ROOM HVAC PREVENTATXVE ACTIONS LONG TERM REROUTE HVAC FAN CABLING CURRENT ENGXNEERXNG AND DESIGN PROCEDURES REQUXRE MORE EXHAUSTXVE REVXEM OF DESXGN XNPUTS
DESIGN CONTROL ESM 5 CCM ISOLATION RELAY CIRCUITRY o
PROBLEM o
INVESTIGATION o
ROOT CAUSE o
SAFETY SIGNIFICANCE o
CORRECTIVE ACTIONS o
PREVENTATIVE ACTIONS
~
~
aSRa
~
~
~ -
~
Q
~
~ 0
~
DESIGN CONTROL ESW 5 CCM ISOLATION RELAY CIRCUITRY INVESTXGATXON:
DESXGN L4AS XNAPPROPRXATEI.Y TRANSLATED TO E LEMENTARY DRAMXNGS
DESIGN CONTROL ESW
CCW ISOLATION RELAY CIRCUITRY ROOT CAUSE:
INAPPROPRXATE ENGXNEERXNG 5 DESXGN CHECKING OF DRAhfXNGS XN 1983
DESIGN CONTROL ESW 5 CCW ISOLATION RELAY CIRCUITRY SAFETY SXGNXFXCANCE:
EFFECTS MANUAL RESTART SHORT ON ALL 4 CABLES XNTERNALLY REQUXRED ONE ESW PUMP REQUXRED ONE CCW PUMP REQUXRED FOR CSD PROCEDURE ADEQUATELY ADDRESSES LOCAL MANUAL RESTART OF THE PUMPS NO SAFETY SXGNXFXCANCE
DESIGN CONTROL ESW 5 CCW ISOLATION RELAY CIRCUITRY CORRECTIVE ACTXONS:
IMMEDXATE REPLACE EXISTING 10 AMP.
FUSE WITH 5 AMP.
LONG TERM RESTORE CIRCUXT TO AS-DESXGNED CONFIGURATION
~ ~
~
~
~
~
~
~
~
~
~-
~ -
~
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~ 0
~
DESIGN CONTROL ESM 5 CCM ISOLATION RELAY CIRCUITRY.
PREYENTATXVE.ACTXONS:
PROCEDURE CHANGES MERE MADE XN 1985
ELECTRICAL CABLE ROUTING ERRORS
OUTLINE I.
HISTORY II.
ROOT CAUSE III.
SAFETY SIGNIFICANCE IV.
ACTIONS TO PREVENT RECURRENCE
HISTORY REVIEW OF APPENDIX.R SAFE SHUTDOWN CABLE ROUTES BY FIRE ZONE IDENTIFIED A NUMBER OF INSTANCES WHERE THE
.ACTUAL CABLE ROUTE DIFFERED FROM THE ROUTE DETERMINED IN SUPPORT OF PLANT MODIFICATIONS WITH POTENTIAL APPENDIX R IMPACT.
OF THESE INSTANCES, TWO WERE DETERMINED TO VIOLATE APPENDIX R CABLE SEPARATION/
PROTECTION CRITERIA:
1.
CABLE 1-29685G RUNNING BETWEEN LOCAL SHUTDOWN INDICATION (LSI) PANELS 1-LSI-6 AND 1-LSI-6X; 2.
CABLES 1-1936R/2-12467 1-1936R
= UNIT 1 ALTERNATE POWER SOURCE CABLE TO THE UNIT 2 LSI PANELS 2-12467
= UNIT 2 NORMAL LSI POWER SOURCE CABLE
BOTH OF THE ABOVE INSTANCES CREATED A POSSIBILITY FOR A FIRE-INDUCED LOSS OF PROCESS MONITORING INSTRUMENTATION REQUIRED BY PROCEDURES.
THE LSI CABLE ROUTING DISCREPANCIES WERE REPORTED IN LER NO.90-010 AND WERE REITERATED BY INSPECTION REPORT NO.
90018 ITEM 4.C.
ACTIONS HAVE BEEN TAKEN TO CORRECT BOTH PROBLEM To 1-LSI-5 1-LSI-6 To 1-LSI-2 Power Load Norm. Alt.
5.0 Amp.
Fuse Cable 1-29685G thr ough Fire Zones 12,11,10,4 1,~~52,49-through Fire Areas 11,10,9,40,~~3 1-LSI-6X (
Amp.
ELSC Br eaker Unit 2 Alternate Sour ce Load (i.e., R/I', I/I',...)
2-LSI-&XX Containnen Tray 2CT-C32 with 1-1936R Fire ZOne 23 5 F'eet Fire Zone
Fire Zone 25 Condo't 2-12467 To 1-LSJ-6 ice'i)
~ it Feet~
Notei 1.
Drawing is not to scale.
2.
lnfornation Frori th's drawing is Fr on drawings 2-1418 L 2-1427.
To Panel 2-ELSC
II.
ROOT CAUSE INSUFFICIENT CONTROLS WERE IN PLACE TO ENSURE THAT NEW CABLES ADDED TO THE PLANT COMPLIED WITH APPENDIX R REQUIREMENT III. SAFETY SIGNIFICANCE THE UNIT 1 LSI PANEL CABLE ROUTING ERROR CREATED THE POSSIBILITY FOR A FIRE IN FIRE AREAS 48 AND 49 TO DISABLE BOTH THE UNIT 1 CONTROL ROOM AND LSI PANEL PROCESS MONITORING INSTRUMENTATION.
THE UNIT 2 LSI PANEL CABLE ROUTING ERROR CREATED THE POSSIBILITY FOR A FIRE IN FIRE ZONE 24 TO DISABLE THE UNIT 2 LSI PANEL PROCESS MONITORING INSTRUMENTATION AND A PORTION OF THE CONTROL ROOM INSTRUMENTATION.
SINCE FIRES PROPAGATE AT.A FINITE RATE AND FIRE DETECTION AND SUPPRESSION IS PROVIDED IN THE AREAS OF CONCERN, ME CONCLUDED THAT THE CONDITION DID NOT ADVERSELY IMPACT THE HEALTH AND SAFETY OF THE PUBLI IV.
ACTIONS TO PREVENT RECURRENCE OUR PROGRAM FOR ENSURING CONTINUED APPENDIX R COMPLIANCE MILL BE REVISED TO CORRECT THE CONDITIONS
.THAT LED TO APPENDIX R NON-COMPLIANCE FOR SAFE SHUTDOWN CABLES. 'REVENTIVE ACTIONS INCLUDE:
o ENHANCE PROCEDURES FOR ROUTING SAFE SHUTDOWN CABLES o
USE A 'DATA BASE SOFTWARE PROGRAM AND SAFE SHUTDOWN LOGIC DIAGRAMS TO VERIFY THAT NEW CABLES ARE ROUTED IN ACCORDANCE WITH APPENDIX R REQUIREMENTS o
PROVIDE APPENDIX R COMPOSITE DRAWINGS o
CONFIRM THE ACCURACY OF SAFE SHUTDOWN CABLE ROUTES o
ENHANCE TRAINING FOR NUCLEAR ENGINEERING/DESIGN DEPARTMENTS
HISTORY OF COOK LIGHTING CONCERNS 4/82 -
12/82 NRC INSr ECTXON FXNDXNGS
AREAS DXD NOT HAVE EMERGENCY LXGHTXNG BATTERXES NOT RATED FOR
HOURS COOK REPLACES 25 MATT MXTH 12 MATT LAMPS REPLACE BATTERY PACKS RETAXN CONSULTANT TO REVIEW LXGHTXNG
HISTORY OE COOK LIGHTING CONCERNS (CONTn)
1/83 -
3/84 SCOPXNG OF APPENDXX. R DESIGN CHANGES AND LIGHTING SCHEDULE FOR COMPLETXON OF III.a3 TXED TO COMPLETXON OF III.G COMPLXANCE EXTENDED TO END OF 1985 UNXT 2 REFUELXNG OUTAGE
HISTORY OF COOK LIGHTING CONCERNS (CoNT D)
4/84 -
7/84 EMERGENCY LXGHTXNG MALKED DOWN* FOR OPERABILITY
'I EMERGENCY LXGHTXNG WALKED DOWN* FOR CIRCUIT XDENTIFXCATION
HISTORY OF COOK LIGHTING CONCERNS (CONT'D)
3/85 -
9/85 APPROXXMATELY 65 NEW BATTERY PACKS WERE XDENTTFXED AS SEXNG NEEDED FOR THE DRAFT EMERGENCY REMOTE SHUTDOWN PROCEDURE.
IDENTXFXCATXON DONE BY WALKDOWN*
HISTORY OF COOK LIGHTING CONCERNS (CONTD)
10/85 - 10/86 COMPLETXON OF ONGOXNG APPENDXX R MODXFXCATXONS FXNAL WALKDOWN* OF EMERGENCY LXGHTXNG, 5 ADDXTXONAL BATTERY PACKS XNSTALLED NRC XNsr EcTxoN FDUND 2 LOCATXONS MHERE EMERGENCY LXGHTXNG XS NEEDED
HISTORY OF COOK LIGHTING CONCERNS (CONTD)
4/88 MERGER OF ERS PROCEDURE MXTH ALTERNATE SHUTDOMN AND COOLDOMN PROCEDURE
HISTORY OF COOK LIGHTING CONCERNS (CDNTn)
4/90 -
8/90
MALKDOMNS OF ERS PROCEDURE (REV. 8)
FXRST USE OF LXGHTXNG LEVEL ACCEPTANCE CRXTERXON INADEQUATE LXGHTXNG XDENTXFXED XN 61 LOCATXONS CORRECTXVE ACTXON XNXTXATED
- MXNERS HATS INSTALLATXON OF ADDXTXONAL LXGHTXNG
-. COMPLETXON BY AUGUST 30, 1990
ROOT CAUSE CONCLUSIONS WHILE EARLY MALKDOMNS MERE CONDUCTED s SUBJECTXVE ACCEPTANCE CRXTERXA USED UNTIL 199Q NO MALKDOWN XN 1988 OF REVISION 8 TO ERS PROCEDURE RESPONSXBXLXTY FOR APPENDXX R LXGHTXNG ACCEPTABXLXTY MAS FRAGMENTED
SAFETY SIGNIFICANCE ABXLXTY TO SAFELY SHUTDOWN WAS NOT IMPACTED BECAUSE:
INADEQUATELY LXGHTED AREAS RANDOMLY LOCATED OPERATORS CARRY FLASHLXGHTS AND MOULD HAVE, USED THEM OPERATORS VERY FAMXLXAR WXTH PLANT LAYOUT AND WXTH ERS PROCEDURE
CORRECTIVE ACTION REVXSXONS TO ERS PROCEDURE L4lLL BE EVALUATED FOR LXGHTXNG XMPACT PRXOR TO XSSUANCE RESPONSXBXLXTY OF PLANT APPENDXX R ENGXNEER NEMLY CREATED POSXTXON OF NEO APPENDXX R ENGXNEER TO ASSURE RFC S
ARE REVXEMED FOR APPENDXX R
LXGHTXNG XMPACT
SUMMARY EXTENSXVE APPENDXX R MORK DONE OVER A PERXOD OF 8 YEARS EXPECTED DECLXNE XN ENGXNEERXNG L4ORK/PROCEDURE DEVELOPMENT AFTER 1986 FRAGMENTED RESPONSIBILITIES FOR LXGHTXNG ACCEPTABXLXTY NONE OF VXOLATXONS MOULD HAVE LED TO A CONDXTXON WHERE PLANT COULD NOT BE SAFELY SHUTDOWN CORRECTIVE ACTXONS ADDRESS ALL VXOLATXONS PREVENT RECURRENCE
II I'
t
$ UNMARY (CONT'D)
MAJOR CORRECTIVE ACTXONS ARE ESTABLISHMENT OF CORPORATE APPENDIX R ENGINEER ESTABLISHMENT OF PLANT APPENDIX R ENGINEER PREPARATXON OF APPENDIX R DRAWXNGS CONFXRM THE ACCURACY OF SAFE SHUTDOWN CABLE ROUTES PERFORM MANUAL ACTION STUDY TO g XF POSSXBLE g REDUCE DEPENDENCE ON OPERATOR ACTXON DESIGN CHANGES TO ADDRESS LOSS OF CONTROL ROOM HVAC