IR 05000315/1994005
| ML17331B378 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 05/09/1994 |
| From: | Kropp W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17331B377 | List: |
| References | |
| 50-315-94-05, 50-315-94-5, 50-316-94-05, 50-316-94-5, NUDOCS 9405170027 | |
| Download: ML17331B378 (28) | |
Text
U.S.
NUCLEAR REGULATORY COMMISSION
REGION III
Report Nos.
50-315/94005(DRP);
50-316/94005(DRP)
Docket Nos.
50-315; 50-316 Licensee:
Indiana Michigan Power Company 1 Riverside Plaza Columbus, OH 43216 License Nos.
DPR-58; DPR-74 Facil.ity Name:
Donald C; Cook Nuclear Power Plant, Units 1 and
Inspection at:.
Donald C.
Cook Site, Bridgman, Michigan Inspection Conducted:
March 12 through April 22, 1994 Inspectors:
J.
A.
Isom D. J'. Hartland Approved By:
r pp,
>e Reactor Projects Section 2A gci i<
ate Ins ection Summar
Ins ection from March
1994 throu h
A ri 1
1994 Re ort Nos.
50-315 94005 DRP '0-316 94005 DRP Areas Ins ected:
Routine, unannounced safety inspection by the resident inspectors of operational safety verification; onsite event follow-up; current material condition; housekeeping and plant cleanliness;'safety assessment/quality verification; maintenance activities; surveillance a'ctivities; engineering
& technical support; and refueling activities.
Results:
Of the nine areas inspected, no violations were identified.
The following is a summary of the licensee's performance during this inspection period:
Plant 0 erations The licensee's performance in this area was adequate.
However, there was a
,weakness identified with the operators'upervision of an engineering department test activity that resulted in inadvertent entry into Technical Specifications (T.S.) 3.0.3.
Also, the operator did not understand that providing cooling water to the auxiliary feedwater pump thrust bearings may potentially hide a high thrust condition.
9405170027 940509 PDR ADOCK 05000315
Maintenance and Surveillance
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~
~
~
The licensee's performance i
En ineerin and Technical Su ort n this area was adequate.
There was a weakness identified in the supervision of the maintenance mechanics involved with the reassembly of a motor-driven auxiliary feedwater (MDAFW) pump internals.
,
Also, the inspectors noted a weakness in the maintenance procedure that resulted in the operation of a MDAFW pump for several hours before post-maintenance testing without adequate bearing temperature monitoring.
The licensee's performance in this area was adequate.
Weakness was identified in the engineering test procedure for the auxiliary building engineered safety feature exhaust fan which contributed to inadvertently placing Unit 2 in Technical Specification 3. DETAILS Persons Contacted:
American Electric Power Service Com an AEPSC
¹*E.
E. Fitzpatrick, Vice President, Nuclear Operations
¹ S. J.
Brewer, Hanager, Nuclear Safety E Licensing Division
¹ P. A. Barrett, Manager, guality Assurance Department Indiana Michi an Power Cook Nuclear Plant
¹*A. A. Blind, Plant Manager
¹*K. R. Baker, Assistant Plant Manager-Production
- L. S. Gibson, Assistant Plant Manager-Projects J.
E. Rutkowski, Assistant Plant Hanager, Technical Support
- T. P. Beilman, Maintenance Superintendent P.
F. Carteaux, Training Superintendent
- D. L. Noble, Radiation Protection Superintendent T. K. Postlewait, Design Changes Superintendent P.
G. Schoepf, Project Engineering Superintendent
¹ J.
S.
Wiebe, Safety
& Assessment Superintendent L. H. Vanginhoven, Site Design Superintendent
- G. 'A. Weber, Plant Engineering Superintendent
¹ H.
E. Barfelz, Nuclear Safety arid Assessment Supervisor
¹ N. A. Wollenslegel, Shift Supervisor
¹ S.
R. Koshar, Senior Reactor Operator
¹ R. Piller, Senior Reactor Operator
¹ H. J.
Schoonheim, Auxiliary Equipment Operator
¹ J.
D. Donnelly, Auxiliary Equipment Operator Nuclear Re ulator Commission
¹J.
B.
¹ H. J.
¹ L. B.
¹ W. J.
¹ J.
A.
¹ C.
N.
¹ D. L.
¹ J.
B.
Hartin, Regional Administrator Hiller, Deputy Regional Administrator Harsh, Project Director, PD3-I Kropp, Chief, Section 2A Isom, Senior Resident Inspector Orsini, Reactor Engineer Shepard, Reactor Engineer Hickman, Project Manager
- Denotes those attending the exit interview conducted on April 28, 1994.
¹ Denotes those attending the management meeting on March 24, 1994.
The inspectors also had discussions with other licensee employees, including members of the technical and engineering staffs, reactor and auxiliary operators, shift engineers and foremen, and electrical, mechanical and instrument maintenance personnel, and contract security personnel.
Plant 0 erations Unit 1 remained in the cycle 13-14 refueling outage with the unit in Node 5 at the end of the inspection period.
During the initial roll after the Unit 2 trip on February 21, 1994, the licensee experienced high vibration levels on the generator during the turbine startup.
The unit remained shutdown throughout the inspection period to replace the main generator.
The unit was in NODE 2 at the end of the inspection period.
a ~
0 erational Safet Verification (71707)
The inspectors verified that the facility was being operated in conformance with the licenses and regulatory requirements, and that the licensee's management control system was effective in ensuring safe operation of the plant.
On a sampling basis the inspectors verified proper control room staffing and coordination of plant activities; verified operator adherence with procedures and technical specifications; monitored control room indications for abnormalities and verified that electrical power was available.
The inspectors reviewed applicable logs and conducted discussions with control room operators throughout the inspection period.
The inspectors observed a number of control room shift turnovers.
The turnovers were conducted in a professional manner and included log reviews, panel walkdowns, discussions of maintenance and surveillance activities in progress or planned, and associated LCO time restraints, as applicable.
On April 7, 1994, the inspectors observed the pre-evolution brief given by the unit supervisor before draining the reactor cavity level to about a one foot below the flange level and noted that the briefing was thorough and well-conducted.
The unit supervisor thoroughly discussed the precautions and limitations of procedure
- 01-0HP-4021.002.005, Revision 16,
"RCS Draining," with the operators.
During the inspection period the inspectors reviewed an event where the operators inadvertently entered Technical specification 3.0.3 for inoperability of the Unit 2 auxiliary building engineered safety feature exhaust (AES) fan system.
Unit 2 was in Node 4 during this event.
On April 2, 1994, at about 10:29 a.m.,
the plant engineers requested that the operators run the 0'I AES fan to verify that required airflow could be achieved after a
HEPA filter replacement.
At this time, the
AES fan was considered inoperable until the engineers had satisfactorily completed the surveillance test.
In order to accomplish this test, the engineers requested that the operators place the 0'2 AES fan in the
"off" position to prevent interference with the ¹1 AES fan airflow measurement.
The unit supervisor, a senior reactor operator (SRO)
in charge of the unit, requested that the reactor operator (RO)
realign the AES fans per the engineers request.
Soon after completing the alignment of the AES fans, the, unit supervisor (US)
was relieved by another SRO.
Shortly after assuming the shift, the US realized that the ¹2 AES fan switch was required to be in the
"AUTO" or the
"RUN" position instead of the "off" position to be considered operable.
With the ¹1 AES fan inoperable and the. ¹2 fan inoperable because the control switch was in the "off" position, the operators placed the unit in T.S. 3.0.3.
The US immediately directed the RO to restart ¹2 AES fan, and stop the ¹1
'AES fan.
Unit 2 was in T.S. 3.0.3 for about 6 minutes.
The AES fans exhaust air from the engineered safeguards system equipment rooms to the unit vent stack.
The AES system in combination with other au'xiliary building ventilation systems, function to minimize the spread of airborne radioactive contamination that might be released within the auxiliary building during.an accident.
Normally, one fan control switch is placed in the "run" position and the other fan control switch position is placed in the "auto" position.
In the "auto" start switch position, the standby fan would start if any of the associated engineered safeguards pumps were running, or if there was an ESF signal.
On April 2, 1994, placing the ¹2 AES fan in "auto" would have started this fan because one of the safeguards pumps associated with this fan was running.
Because the engineers needed to have the ¹2 AES fan secured to obtain airflow measurement from the ¹1 AES fan, the operator placed the control switch for the ¹2 AES fan to the "off" position, not realizing that this placed the unit in T.S. 3.0.3.
In order to complete testing on the ¹1 AES fan, the operators started the charging pump associated with the ¹I AES fan and secured the running charging pump.
Afterwards, the operators placed the ¹1 AES fan in the "run" position and the ¹2 AES fan in the "auto" position.
The inspectors reviewed this event and had the following concerns:
~
There was inadequate supervision by the US of the test activity.
Although generally aware of the requirement to have the ¹2 AES fan in the. "auto" or "run" position to maintain the fan operability, the US did not recall the requirement at the time he directed the RO to realign the AES fans for the test.
During discussion with the inspectors, the US indicated familiarity with the effect the control switch positions had on fan operability.
The inspectors determined that procedure, 02-0HP-4030.STP.025B, Revision 5, 12/21/93, titled, "Engineered Safety Features Fan ¹2 (2-HV-AES-2) Ventilation Exhaust Air Filter Train Test," contained caution statements warning the operators to
maintain the switches for the AES fans in the
"AUTO" or
"RUN'osition to maintain operability.
This operations procedure also contained a statement that when the contro'1 switch for either ¹1 or ¹2 AES fans is left in the stop position, the associated fan should be considered inoperable.
The engineering department procedure,
"AES Fan Testing,"
- 12 THP 4030 STP.228, Revision 8, June 11, 1993, was not consistent with the operations procedure.
There were no warnings on the effect of fan operability from the control switch positions.
Also the engineering procedure did not reference the operations surveillance procedure that alerts the operators to the importance of control switch positions.
The licensee initiated condition report 94-0658 to document this discrepancy.
Onsite Event Follow-u (93702)
On March 21, 1994, the licensee had an event which required prompt notification of the NRC pursuant to
CFR 50.72.
The inspectors pursued the event onsite with licensee and other NRC officials.
The inspectors verified that any required notification was correct and timely and verified that the licensee initiated prompt and appropriate actions.
During performance of a radiograph inspection of a portion of the ESW supply line to the Unit 1 "West" HDAFW pumps, the licensee identified a potential blockage consisting of sand, silt, and some zebra mussels in the section of the 4-inch piping where it branched off from the 20-inch main "East" ESW header.
The inspectors reviewed this event in detail and documented the results in inspection report 50-315/94008(DRP);
50-316/94008(DRP).
Current Material Condition (71707)
The inspectors performed general plant as well as selected system and component walkdowns to assess the general and specific material condition of the plant, to verify that work requests had been initiated For identified equipment problems, and to evaluate housekeeping.
Walkdowns included an assessment of the buildings, components, and systems for proper identification and tagging, accessibility, fire and security door integrity, scaffolding, radiological controls, and any unusual conditions.
Unusual conditions included but were not limited to water, oil, or other liquids on the floor or equipment; indications of leakage through ceiling, walls or floors; loose insulation; corrosion; excessive noise; unusual temperatures; and abnormal ventilation and lighting.
The inspectors had the following concerns:
On March 14, 1994, during a routine tour of the Unit 2 HDAFW pump areas, the inspector observed that the outboard bearing
housing on the Unit 2 "E" HDAFW pump was warm to the touch.
The inspectors noted that the inboard bearing housing on this pump, as well as both the inboard and outboard bearing housing temperatures on the
"W" HDAFW pump, were below room temperature.
The inspector'informed the Shift Supervisor and the System Engineer of the apparent discrepancy.
The licensee later informed the inspector that the difference in bearing housing temperatures was because non-essential service water (NESW) was valved into the bearings that were below room temperature.
The HDAFW pumps were designed to operate satisfactorily without NESW cooling.
Flow would be provided to these bearings if the bearing temperatures became elevated.
The licensee could not determine, why there was no NESW cooling flow to unit 2 "E" MDAFW pump outboard bearing.
The cooling water flow to the other bearings was believed provided to ensure that adequate bearing temperatures were maintained during extended pump operation.
The pumps were running for an extended period of time for decay heat removal, with the unit in Node 3 for the main generator rotor replacement.
The inspector determined, based on discussion with the licensee and a review of licensee procedure
"Operation of Auxiliary Feed Pumps During Plant Startup and Shutdown",
2 OHP-4021.056.002, Revision 8, that the operating procedure required operators to supply cooling to the bearings only if required to maintain bearing housing temperatures below 160 degrees Fahrenheit.
Although providing cooling water did not appear to affect the pump performance, if provided when not required, cooling water could mask degradation of the bearings that would be identified by elevated temperatures.
The operator's failure to understand that a
need to provide cooling flow to lower a bearing temperature could be an indication of a degraded pump condition.
This contributed to the failure of the Unit 1 "E" NDAFW pump later in the month.
The inspectors discussed the details of this maintenance evolution in paragraph 4 of this inspection report.
As immediate corrective action, the licensee placed caution tags on the NESW supply valves to the bearings to prevent opening the valves unless bearing housing temperatures reach 140 degrees Fahrenheit.
In addition, the licensee initiated a procedure change request to clarify the requirements in the "Operation of Auxiliary Feed Pumps During Plant Startup and Shutdown" procedure.
Although the actions taken to clarify the use of NESW in the operating procedure were good, the inspectors noted that the same procedure did not warn the operators of a potential for masking pump problems through the use of NESW coolin Elevated temperatures of 140 to 160 degrees Fahrenheit might mean higher than desirable thrust was being placed on the bearings and engineering involvement may be warranted.
The inspectors review of the surveillance data for the MDAFW pumps found that most bearing temperatures were in the low 100 degrees Fahrenheit region and would not ordinarily require that NESW flow be provided to cool the bearings.
On March 21, 1994, the inspector accompanied the System Engineer 'to the Unit 2 MDAFW pump area to follow-up on a
report of excessive leakage of oil from the outboard bearing of the "E" MDAFW pump.
Upon arrival, the System Engineer lifted the cap on the bearing housing and observed excessive frothing/foaming of the oil inside the housing.
In response, the System Engineer immediately notified the control room, and actions were taken to shut down the pump to investigate the problem.
The licensee sampled the oil and did not find any evidence of water intrusion or other contaminants that would indicate any bearing damage.
The sample was taken at that time to verify the oil was not contaminated after water was discovered spraying on the bearing housing from the pump packing.
The licensee determined that the excessive frothing was due to the overfilling of the housing with oil.
The inspector was informed that the bearing housing became overfilled as a result of a minor leak in the oil drain cap.
The leak caused air bubbles to be formed in the housing which caused over addition'of oil from the bubbler to the oil reservoir.
The inspector noted from review of auxiliary equipment operator (AEO) turnover logs that the licensee subsequently.
added oil to the bearing housing bubbler on a shiftly basis until th'e condition was identified by the System Engineer on March 21.
The frothing of the oil inside the housing apparently caused the oil to leak from the housing cap.
. Operations shift personnel apparently did not take action to investigate the cause of the frequent oil additions.
As corrective action to related problems, the licensee had previously developed OSO 114, "Lubricating Oil in Safety and Non-Safety Related Rotating Equipment," Revision 0, which provided guidance to the shifts regarding the monitoring of oil inventory in plant equipment.
During a routine tour of the Unit 2 turbine-driven auxiliary feedwater (TDAFW) pump area on March 16, 1993, the inspector observed steam blowing from the packing area of the trip and throttle valve (T&TV). After several minutes, the leakage ceased after the packing apparently adjusted itself.
An AEO was also present and notified the control room of the condition.
As a precautionary measure, the licensee
performed T&TV testing as detailed in "Turbine Driven Auxiliary Feedwater System Test," procedure, 2-OHP-4030.STP. 17T, Revision 10, to verify valve operability.
The licensee was also evaluating the prioritization of AR
¹47097, which was initiated on July 7, 1993, to repair-the packing leak.
d.
Housekee in and Plant Cleanliness The inspectors monitored the status of housekeeping and plant cleanliness for fire protection and protection of safety-related equipment from intrusion of foreign matter.
The inspectors toured the Unit 2 containment on March 15, 1994, and observed miscellaneous trash and debris in the basement level and poor housekeeping at unoccupied reactor coolant pump work areas.
The inspector notified the Plant Manager, who was present in containment.
No violations or deviations were identified.
Safet Asse'ssment ualit Verification (40500 and 92700)
The inspector reviewed the following condition reports (CRs) to monitor the conditions related to plant or personnel performance, potential trends, and also to ensure that they were generated appropriately and dispositioned in a manner consistent with the applicable procedures.
CRs 94-0118; 94-0224; 94-0299 94-300; 94-0306; 94-0336; and 94-0368.
The inspectors found no problems and no 'violations or deviations were identified.
Maintenance Surveillance (62703
& 61726)
a
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Maintenance Activities (62703)
Routinely, station maintenance activities were observed and/or reviewed to ascertain that they were conducted in accordance with approved procedures, regulatory guides and industry codes or standards, and in conformance with technical specifications.
The following items were also considered during this review:
limiting conditions for operation were met while components or systems were removed from service; approvals were obtained prior to initiating the work; functional testing and/or calibrations were performed prior to returning components or systems to service; quality control records were maintained; and activities were accomplished by qualified personne The inspectors observed the following activities with no problems identified:
JO¹ R0020811, Unit 2 "CD" EDG Aftercooler Inspection JO¹ R0026192, Unit 2 "E" HDAFW Pump Rotor Inspection (in progress)
On March 27, 1994, the Unit 1 "East" motor-driven auxiliary feedwater (HDAFW) pump was damaged during a maintenance run.
The inspectors determined that the cause of the damage was a
combination of improper assembly and installation of the pump that resulted in excessive thrust on the outboard pump bearings.
The inspectors learned that temperature readings of the packing gland and the bearing housing were being taken during the last 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> befor'e pump failure by operators and maintenance personnel.
During this time the outboard bearing housing temperature indicated about 140 degrees Fahrenheit, which was above normal.
The operators and maintenance personnel did not realize that this higher temperature could be an indication of a high bearing load condition.
As a result, after the pump operated for about 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> over the period of 2 days, while the mechanics made adjustments to the pump packing, the outboard bearing was severely damaged, and the pump shaft was sufficiently damaged to require replacement.
The inspectors interviewed several mechanics and first level supervisors and found that repacking of the pump was performed several times over the weekend.
Also, the inspectors learned through interviews that about 1 to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> of pump operation was required to properly run-in the packing.
Maintenance department procedure
- 12-MHP-5021.056.001, revision 5, Change 8, "Hotor-Driven Auxiliary Feed Pump Maintenance,"
requires packing run-in be completed before the post-maintenance test (PHT).
Therefore, the pump could be run for several hours to allow the mechanics to complete the packing adjustments before the PHT.
Unlike PHT procedure,
"East Motor-Driven Auxiliary Feedwater System Test,"
- 1-OHP4030.STP.017E, the maintenance procedure did not require that the pump be run without bearing cooling water until stable conditions were seen in the bearing temperatures.
Therefore, the equipment operators were not alerted to the significance of the observed elevated outboard bearing temperatures.
Although proper actions were taken to provide cooling water flow to the bearings in order to maintain the bearing temperature below 160 degrees Fahrenheit, the operators did not realize that the need to provide cooling water to the bearings could imply an abnormal bearing condition.
The inspector determined that one of the two mechanical crews involved in the pump reassembly did not have prior experience with the reassembly of auxiliary feedwater pump internals.
Also, the inspectors determined that the supervision of pump internal reassembly was weak.
The first level supervisor in charge of this
work activity did not have a mechanical background and therefore, could not provide assistance to the mechanics who had questions on the pump internal reassembly.
Through discussions with the operator, the inspectors determined that the operator was called away from the HDAFW pump room shortly before pump failure.
A mechanic, also in the room to monitor the packing performance, detected signs of an abnormal bearing temperature condition and requested that the operators secure the pump.
b.
Surveillance Activities (61726)
During the inspection period, the inspectors observed technical specification required surveillance testing and verified that testing was performed in accordance with adequate procedures, that test instrumentation was calibrated, that results conformed with technical specifications and procedure requirements and were reviewed, and that any deficiencies identified during the testing were properly resolved.
The i'nspectors witnessed portions of the following surveillance:
~
On Harch 25, 1994, the inspectors observed portions of the Unit
"CD" diesel generator run and noted that some of the diesel generator engine parameters were outside the bands stated on the data sheet.
The inspectors discussed these apparent discrepancies with the system engineer..
The inspectors also noted various minor oil leaks from the following parts of the diesel generator or its support systems:
2.
3.
oil leak from diesel generator lube oil filter, 1-gT-112-CD, flange oil leak from full flow lube oil strainers transfer valve, 1-gP-59-CD slight oil leak from most cylinder covers These material deficiencies were discussed with the system engineer.
The system engineers stated that most of these minor oil leaks will be reviewed by the scheduling group to determine when to schedule the necessary corrective job orders.'he inspector also checked on the status of job order
¹24867, written on July 3, 1992, which documented a lube oil leak from the air drain fitting on the engine driven fuel oil pump.
The inspector found that the maintenance had been performed and was closed in the maintenance computer, but the job order tag had not been removed.
~
On April 8, 1994, the inspectors witnessed portions of the,
"DGCD Load Shedding and Performance,"
- 1 EHP 4030 STP.217A, revision 1, Change 1,
and noted that the preparation and conduct of this section the licensee's blackout testing was well-conducted and no ECCS equipment anomalies were noted.
During a plant tour during the blackout testing, the inspectors found an appendix R emergency light, 1-BATLIT-8, that was not working.
This was discussed with the shift supervisor.
Subsequent investigation by the appendix R
engineer found that the lighting pack was defective and he wrote a priority 20 action request
¹A68377 to have the light repaired.
Later in the month, the lighting pack was repaired and returned to service.
The inspectors discussion with the Appendix R engineer found that inoperability of this emergency light had a minimal effect on the operator performance in this area because the light provided general area lighting.
The other appendix R emergency light, which was noted as operating in the control rod drive room, provided illumination of the equipment which required operator manipulation.
~
'he inspectors observed
"Pressurizer Level Protection Set
Functional Test and Calibr'ation" surveillance procedure I-'IHP-4030.SHP. 108, Revision 0.
No problems were identified.
No violations or deviations were identified.
En ineerin 8 Technical Su ort (37700)
The inspector monitored engineering and technical support activities at the site including any support from the corporate office.
The purpose 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.
The inspectors reviewed the licensee's safety review to justify continued oper ation of Unit 1 with loss of one of the 640 bolts that bolt through the core barrel into the former plates.
During the licensee's video inspection of the core plate for debris prior to core reload for Unit 1 cycle 14, a 3-1/2" stainless bolt was found.
The bolt was removed from the reactor vessel prior to core reload.
The licensee requested that the vendor perform a safety review to justify operation of Unit 1 with one of these bolts missing, not knowing which of. the 640 bolts came loose, and not knowing the condition of the remaining 639 core barrel/former bolts.
The licensee reviewed the vendor analysis and agreed with the evaluation that one missing core barrel/former bolt was acceptable and did not pose an undue risk to public health and safety.
The inspectors review of the analysis found that from a structural integrity aspect, the missing bolt did not appear to impose an immediate safety problem.
Additionally, the inspector's
discussion with the engineers found that fuel damage from another loose bolt was probably unlikely since the bottom nozzle of the fuel assembly would block the bolt from coming in contact with the fuel rod.
The inspectors were informed that the licensee plans to inspect the condition of the remaining 639 bolts during the next refueling outage in 1995 to determine their condition.
The licensee will also identify the original location of the bolt which was found during this outage.
No violations or deviations were identified.
6.
Refuelin Activities (60710)
During the refueling outage, the inspectors observed the licensee's fuel handling operations and discussed refueling operations with plant operators and fuel handling personnel.
The licensee used approved procedures for= fuel accountability and movements.
Communications between the control room and fuel handlers were established and effective.
The inspectors witnessed fuel handling operations during several shifts from the control room, in the fuel building, and in containment.
During this Unit 1 outage, all of the fuel was loaded to the reactor.
The refueling activity was initiated on schedule, completed essentially on schedule and proceeded in accordance with the plan and requirements.
No violations or deviations were identified.
7.
Meetin s
and Other Activities a.
Mana ement Meetin s
(30702)
On March 24, 1994, there was management meeting between NRC and the licensee to discuss the operator log falsification issues and operator performance issues during the reactor coolant draindown to reduced inventory condition.
A copy of the material used by the licensee to discuss these matters is attached.
b.
Exit Interview (30703)
The inspectors met with the licensee representatives denoted in paragraph 1 during the inspection period and at the conclusion of the inspection on April 28, 1994.
The inspectors summarized the scope and results of the inspection and discussed the likely content of this inspection report.
The licensee acknowledged the information and did not,indicate that any of the information disclosed during the inspection could be considered proprietary in nature.
Attachment:
Senior Management Slides'
Gondu, Operations Assessment of corrective action effectiveness
~ Focused self-assessment and trend analysis initiatives
~ Monthly analysis of Operations related operating experience
~ Semi-annual Corrective Action Program Trend Analysis Report
~ Error-Free Refueling Program
~ Monthly Plant Performance Monitoring Program
~ Quarterly Performance Overview Program
~ QA/Qc independent assessments
~ Audit/surveillance activities
~ Special assessments (during RCS flood-up and unit startup, etc.)
Page 11 of 11
Refueling Error Precursors Refueling Preparation Reactor Disassembly ~
Spent Fuel Pit Cleaning
14
o
c
0 E
Precursors to:
8 Damaged Fuel H Mlsposltloned Fuel 0 Damaged Equipment l3 Breakdown In Work Process 8 Health and Safety
~ Lost oblect
2
4
6
8
10
12 Week ft Management Initiatives: (week of 3/18/94)
Department Head action to ensure inclusion of the following subjects during first line supervision job briefings:
~ PMI-4080 Foreign Material Exclusion Zones
~ PMSO.145 Tool Accountability with Reactor Head removed
~ PMP.2291.001.001 Work Control Process (Jobsite Cleanliness)
~ PMSO.129 Transient Material Restraint Trends: (as of 3/18/94)
40 precursors to date.
Foreign material in the Spent Fuel Pool and Reactor Cavity continue to be a problem.
~ Spent Fuel Pool debris remains under the control of PMI-4080.
~ Reactor Cavity debris: While Reactor Head is installed, foreign material control is expected to be controlled under the normal work process control. This direction is found in PMP.2291.001.001 8. PMSO.129. A letter to Department Heads willbe issued.
The content of this letter reiterates the reliance on these procedures to control transient tools and materials in the Containment.
East Hoist of the Spent Fuel Pool crane failure. May be the single most significant precursor to date.
This event remains under investigation. Spent Fuel Pool vacuuming operations have been halted pending investigation result Conduct of Operations
~ Feedback to Senior Management
~ Corrective Actions
~ Assessment of the. Effectiveness of Corrective Actions Page 1 of 11
Conduc Operations Feedback to Senior Manage t
December 1993 Corrective Action Program Trend Report
~ Comments:
~ Weak pre-job preparation, planning, and organization
~ Over-reliance on counselling as a corrective action versus process improvement
~ Recommendations:
~ Examine processes used by support staff and supervision
~ De-emphasize use of counselling as sole corrective action Page 2 of 11
Condu Operations Feedback to Senior Manag February 1994 Self-Assessment
~ Gomment:
~ Ineffective reinforcement of Operations policies and expectation leads to inconsistent results
~ Recommendations:
~ Operations management should reinforce policies and expectations to each working level
~ On-shift and staff supervisors should routinely conduct oversight/coaching activities of plant operator tours Page 3 of 11
Conduc Operations Feedback to Senior Manage t
Recent In-house Operating Experience
~ Unit One RCS Inventory ManagementNessel Level Indication Event
~ Operator Tour Discrepancies
~ Chronology of Recent Events related to Conduct of Operations Page 4 of 11
Condu Operations Feedback to Senior Manag t Recent In-house Operating Experie RCS Inventory ManagementNessel Level Indication Event on February 17/18, 1994
~ RCS Draining procedure in progress
~ Isolation of pressure equalization path for eductor installation
~ Eductor tested, pressure released from vessel head, level instruments indicate low
~ PRT vented, indicated RCS level increases
~ RCS inventory drained to restore level, expected volume calculated, desired level reestablished Page 5 of 11
Condu Operations Feedback to Senior Manag t Recent In-house Operating Experie Tour Investigation
~ 25,213 door checks were performed, which resulted in 85 identified discrepancies.
50'/o of these discrepancies were attributed to 3 operators.
~ The standards and accountability for operator tour performance have not been effectively established by Operations Department management.
~ The process for Operations Department management monitoring of operator tour performance has been ineffective in identifying performance deficiencies.
~ The process used by Operations Department management to direct the performance of operator tours was ineffective in providing the necessary guidance.
Page 6 of 11
Condu Operations Feedback to Senior Manag t Recent In-house Operating Experie Chronology of Recent Events related to Conduct of Operations
~ 3/19/94-Contamination of Large Areas of the AuxiliaryBuilding due to Personnel Error during a CVCS Resin Sluice. Procedure deficiencies contributed
.
~ 3/16/94-AC Power was Inadvertently Secured to Approximately 100 Appendix R Emergency Lights due to Personnel Error during Planning and Execution of a Clearance Permit.
~ 2/26/94-Manual Trip of 1E CCP for low VCT due to Inadequate Command and Control during Temporary Relief of a Reactor Operator.
~ 2/21/94-Unexpected Closure of 1-ICM-129 due to Personnel Error during Outage Planning/Coordination.
~ 2/18/94-RCS Inventory Management/Vessel Level Indication Event Page 7 of 11
Conduc Operations '- Feedback to Senior Manage t Recent In-house Operating Experien Chronology of Recent Events related to Conduct of Operations (continued)
~ 1/4/94 U1 West CCW Pump Cavitated due to Inadequate Command and Control, and Inadequate Job Briefing, during Restoration from Maintenance (System Design contributed to the event).
~ 9/29/93-Inadvertent Transfer of 1600 Gals. of Glycol to the Wrong Monitor Tank due to Failure to Use the Procedure, and Inadequate Job Briefing, during a Routine Waste Operation.
~ 9/24/93 Inabilityto Drain the RCDT due to Personnel Error, and Poor Command and Control, while Placing the Boric Acid Evaporator in Service.
~ 9/2/93 Failure to Immediately Restore Oil Level in the U2 TDAFP Pump Bearing due to Poor Command and Control Following Sampling of the Oil~
~ 9/2/93-Failure to Recognize the Inoperability of the TDAFP due to Procedural Deficiencies during ISI Testing.
Page 8 of 11
Conduc Operations Feedback to Senior Manage t Recent In-house Operating Experien Chronology of Recent Events related to Conduct of Operations (continued)
~ 8/16/93 Rod Sequence Violation Annunciator became Litand Remained Unacknowledge for Two Hours due to Personnel Error during Routine Control Rod Surveillance. There were two errors, failure to followthe procedure, and then failing to acknowledge the consequential annunciator.
~ 8/5/93 Draining of the U2 RCS to a Lower Level than Anticipated due to Procedural Deficiency during Draindown for Conoseal Repairs.
~ 7/16/93-400 Gals. of Glycol was Spilled in Containment due to Personnel Error during Routine System Realignment. Absence of a Pre-job Brief Contributed.
~ 4/11/93 Incomplete Boration of a CVCS Mixed Bed Demineralizer Results in Inadvertent Increase in RCS Temperature due to Procedural Deficiencies and Inadequate Pre-job Briefing.
Page 9 of 11
Cond uc Operations Corrective Actions
~ Revised Guidance
~ OHI-4013 "Operators Authorities and Responsibilities"
~ Tour Procedure
~ Miscellaneous normal operation procedures
~ New Guidance
~ OSO.113 "Operations Standards"
~ OHI-7011 "Operator Tour Verification Program"
~ OHI-2001 "Procedure Use and Adherence"
~ Initiatives
~ Establish and Communicate Operations Standards
~ Improve Supervisory Involvement
~ Improve Supervisor Training Page 10 of 11
p
~
Ot'- fee 8 Ue jg)
Refueling Error Precursors Refueling Preparation Reactor Disassembly ~ Spent Fuel Pit Cleaning
14
o
C e
E
Precursors to:
~ Damaged Fuel H Mlsposltloned Fuel C3 Damaged Equipment 8 Breakdown In Work Process
~ Health and Safety
~ Lost obiect
2
4
6
8
10
12 Week ft Management Initiatives: (week of 3/18/94)
Department Head action to ensure inclusion of the following subjects during first line supervision job briefings:
~ PMI-4080 Foreign Material Exclusion Zones
~ PMSO.145 Tool Accountability with Reactor Head removed
~ PMP.2291.001.001 Work Control Process (Jobsite Cleanliness)
~ PMSO.129 Transient Material Restraint Trends: (as of 3/18/94)
40 precursors to date.
Foreign material in the Spent Fuel Pool and Reactor Cavity continue to be a problem.
~ Spent Fuel Pool debris remains under the control of PMI-4080.
~ Reactor Cavity debris: While Reactor Head is installed, foreign material control is expected to be controlled under the normal work process control. This direction is found in PMP.2291.001.001
& PMSO.129. A letter to Department Heads willbe issued.
The content of this letter reiterates the reliance on these procedures to control transient tools and materials in the Containment.
East Hoist of the Spent Fuel Pool crane failure. May be the single most significant precursor to date.
This event remains under investigation.'pent Fuel Pool vacuuming operations have been halted pending investigation results.