IR 05000323/1985045

Insp Rept 50-323/85-45 on 851230-860107.Violation Noted: Inaccurate Reporting of Details in Ler,Failure to Document Surveillance Test & Failure to Document & Followup on Indications of Equipment Failures

ML16341D583
Person / Time
Site:	Diablo Canyon
Issue date:	01/08/1986
From:	Dodds R, Mendonca M, Polich T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML16341D582	List: IR 05000323/1985045 ML16341D581
References
50-323-85-45, NUDOCS 8601290269
Download: ML16341D583 (18)

Text

U. S.

NUCLEAR REGULATORY COMMISSION

REGION V

Report No:

Docket. No:

License No:

50-323/85-45 50-323 DPR-82 Licensee:

Pacific Gas and Electric Company 77 Beale Street, Room 1451 San Francisco, Califo'rnia 94106 Facility Name:

Inspection at:

Diablo Canyon Unit 2 Diablo Canyon Site, San Luis Obispo County, California Inspectors:

M. M. Mendonca, Sr. Resident Xnspector 'te Signed l

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F I'(.

T. J. Polich, Resident Inspector

, Date igned R. T. Dodds, Chief, Reactor Projects Date igned Section

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Summary:

Xns ection from December

1985 throu h Januar

1986 (Re ort No. 50-323/85-45)

Areas Ins ected:

This special inspection was a follow-up of an LER.

Inspection Procedure 92700 was applied during this inspection.

This inspection effort required 81 inspector-hours by two resident inspectors, approximately 35 hours4.050926e-4 days <br />0.00972 hours <br />5.787037e-5 weeks <br />1.33175e-5 months <br /> of which were accomplished during off-shift periods.

Results of Ins ection:

One violation was identified.

The violation was related to the inoperability of one train of the actuation circuit for a Main Steamline Isolation Valve (MSIV), inaccurate reporting of the details in the related Licensee Event Report, failure to document surveillance test conduct, and failure to document and followup on indications of equipment failures.

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DETAILS 1.

Persons Contacted a.

Pacific Gas and Electric Com an t

• R. C. Thornberry, Plant Manager M. N. Norem, Field Construction Manager

• R. Patterson, Plant Superintendent

• J. M. Gisclon, Assistant Plant Manager, Technical J.

A. Sexton, Unit 2 Startup Manager W. G. Crockett, I&C Maintenance Manager L. F.

Womack, Engineering Manager S.

R. Fridley, Acting Operations Manager W. E. Coley, Lead Startup Engineer D. D. Barkley, Shift Foreman M. W. Stephens, I&C General Foreman S.

G. Banton, Senior Powe'r Production Engineer D. S. Wright, Startup Dry Run Test Supervisor T. S. Ohara, Startup Test Supervisor M. R. Evans, Control Operator C.

G. Smith, Assistant Control Operator S.

E. Skaggs, Shift Technical Advisor P.

E. Rigney, Power Production Engineer D. Whalen, former I&C Technician Services b.

Nuclear Re ulator Commission Staff J. L. Crews, Senior Reactor Engineer, Region V

R. F. Huey, Senior Resident Inspector, Region V

R.

S. Waite, former Resident Inspector, Region V

The inspectors interviewed several other licensee employees including shift supervisors, reactor and auxiliary opeiators, maintenance personnel, plant technicians and engineers, quality assurance personnel and general construction/startup personnel.

• Denotes those attending the exit interview.

2.

Summar of S ecial Ins ection on Ino erabilit of Redundant, Actuation Train A to a Main Steamline Isolation Valve This special inspection was a follow-up of Licensee, Event Report (LER)

85-19 on the subject train inoperability; that,.'was attributed,to miswiring of actuation circuitry from the solid state protection system.

LER 85-19 was issued by the licensee on, December',27.1985,

.and was similar to another recent LER, 85-14.

LER 85-14 was,also the sub)ect of a level IV violation that was issued with Inspection iReport 50-323/85-32 on November 26, 1985.

The similarities and the importance'f 'the related topics prompted this special inspectio "443 (s,

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This special inspection identified the following chronology and findings related to the MSIV actuation, circuitry

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A preoperational test in March 1983 'demonstr'atedl that 'the circuitry functioned correctly and would close the main steamline isolation valve on demand.

R After construction work on the subject, circuitry, portions of the preoperational test were repeated in September 1984.

This test, as it turned out, was the last verification that the circuitry actuated on demand from the solid state protection system.

On July 25, 1985, the Unit 2 reactor was placed in operational mode 3 for the first time.

The main steamline isolation actuation circuitry is required to be operable in modes 1 through 3.

On July 27, 1985, the licensee performed a main steamline closure surveillance test.

In the 'remarks'ection of this test data sheet, a blown fuse had been documented as found and replaced before the test could be successfully accomplished.

No Action Request was prepared as prescribed by the licensee's administrative procedures to track equipment failures.

On August 14, 1985, an NRC inspector observed a blown fuse in the same circuitry.

The fuse was replaced, and a continuity check of the circuitry was performed to verify operability.

The performance of this continuity check was not documented as required by the licensee's administrative procedures.

On August 31, 1985, the licensee's trouble-shooting of a reactor trip/safety injection event found another blown fuse in the circuitry and also determined that there was a "shorted-out" solenoid in the circuitry.

The main steamline isolation valve was declared inoperable and the action requirements of Technical Specifications were followed.

On September 6,

1985, the licensee replaced the "shorted>>out" solenoid.

The technician that performed this corrective maintenance did not verify the adequacy of this change-out, since a

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post-maintenance test was to be done at a later time.

On October 3, 1985, post-maintenance testing for the change-out of the "shorted-out" solenoid was successfully accomplished.

On October 7,

1985, the reactor was again placed in operational mode 3.

On November 6, 1985, Channel B was taken out of service for approximately 30 minutes during the performance of a surveillance test required by the Technical Specifications.

On November 26, 1985, a violation was issued on the inoperablity of a miswired feedwater isolation valve circuitry that was similar to the main steamline isolation valve miswiring which was eventually

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discovered on November 27. 'ne o'f this violation's concerns was the failure of equipment history tracking that could have earlier identified the feedwater isolation valve miswiring.

On November 27, 1985, the licensee in trouble-shooting a reactor trip/safety injection that occurred on the previous day found that the circuitry was miswired.

The licensee corrected the miswiring and tested all main steamline isolation valves.

On December 27, 1985, the licensee issued a licensee event report on the miswired circuit.

The licensee had identified the cause of the miswiring as the September 6, solenoid replacement.

The licensee had not considered the evidence of the July 27 blown fuse or discussed the solenoid change-out with the involved technician.

Based on the evidence available, the inspectors conclude that the latest evidence indicated that the circuitry was properly wired in September 1984.

To summarize, this special inspection identified deviations from administrative procedures.

Further, because the licensee failed to correct the main steamline isolation valve actuation circuitry miswiring in a timely fashion, and there appeared to be adequate equipment history to indicate a problem in the August 14 time frame, the inoperability of the MSIV circuitry is considered an apparent violation of the Technical Specifications.

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Au ust 14 Fuse Failure On August 13 or 14, 1985, an NRC inspector, on an enhanced team inspection of Unit 2, identified a blown fuse in the train A actuation circuitry for Solenoid Valve 306 (SV-306).

This solenoid valve, on actuation from a Solid State Protection System (SSPS) train A slave relay was designed to close one Main Steamline Isolation Valve (MSIV), FCV-44.

Another, similarly actuated solenoid valve associated with SSPS train B

was designed to provide a totally independent isolation of the same MSIV.

Licensee personnel and an NRC inspector recalled that the fuse was replaced, and that a continuity check, Surveillance Test Procedure (STP)

M-16P, of the circuit was performed.

This Technical Specification (TS)

required test was a determination of MSIV operability by verification of a continuous circuit through the SSPS slave relay and actuation coil for, the solenoid valve.

Action Request (AR) number A0004496 was also generated by the licensee on August 14, to identify and follow-up on the fuse failure.

FCV-44 was not declared inoperable on the discovery of the August 14 fuse failure.

The reasons that FCV-44 was not declared inoperable, according to licensee personnel and a

NRC inspector's recollections, were that:

train B of the SSPS had always been operable and would have closed the MSIVs if called upon; the train A fuse failure was considered a random component failure as verified by the continuity check of the circuit; the MSIVs were closed at this time and so had fulfilled their safety function of steamline isolation; and the licensee was following with an A ll~, 0 I<<k JK Il')

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The fact that train B was considered operable presupposed that there was nothing else wrong with the circuit. If, as later determined, there was something wrong with the circuit, then the train A actuation circuit was inoperable beyond TS 3.3.2 action requirements.

Further, whenever train B was removed from service, there was no operable isolation mechanism for FCV-44.

From the review of shift foreman logs, train B was removed from service for approximately 32 minutes during the conduct of STP I-16B on November 6, 1985 while the reactor was in mode 1.

These conditions along with the ultimately discovered miswiring of the main A solenoid placed the reactor in TS 3.0.3 which was not recognized at this time or in the licensee's subsequent evaluations.

The continuity check of the circuit on August 14 added credence to the operator's finding that there was nothing wrong with the circuit and it was a random component failure.

However, there was no documentation of this continuity test.

The operator stated that he neglected to document this surveillance or verify its conduct with the shift foreman.

Subsequently, licensee management stated that the continuity check had not been performed because of a problem in the SSPS.

Failure to document the check had it been performed and to verify operability in lieu thereof appears contrary to program requirements.

Also, there was no evidence that the operators tried to evaluate how long the fuse had been blown.

Since there was no immediate evidence of valve failure, as the inspectors verified, the filing of an AR appeared to be an acceptable resolution.

The fact that an AR documented this fuse failure provided assurance that the licensee would followup and, as it turned out, was instrumental in the licensee's identification of a

"shorted out" solenoid on August 31.

The fact that the MSIVs were closed for at least portions of this time could also be inferred from the review of the shift foremen and control operator logs, in that the 10Z dumps were being used for reactor coolant system temperature control.

Review of operator logs showed that Unit 2 had entered mode 3 operations on July 25 at 4:34 a.m.; from August 14 through August 20, the reactor was maintained in mode 3; and was in modes 2 or 3 following initial criticality on August 20 through August 29.

Au ust 31 Fuse Failure On August 29, 1985 a Unit 2 reactor trip and safety injection signal occurred (LER 85-07).

The licensee in their post-event followup found that a fuse was burned out on the same actuation circuitry as in the August 14 finding.

This fuse failure was attributed to the safety injection signal with a "shorted-out",, solenoid.

The fuse was replaced, a

continuity check of the SSPS actuation circuitry,, STP M-16P, was again performed and indicated acceptable results on August 31 at 5:10 p.m.

At about the same time as this continuity test, the licensee's trouble-shooting determined that SV-306 was "shorted-out" and, therefore, FCV-44 was declared inoperable at 5:12 p.m.

on August 31.

The 3,icensee complied with Technical Specification 3.3.2; Table 3.3-3 Action 22 by~

establishing mode 4 at 8:34 p.m.

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Another AR, A0005898, was prepared on September 3, to follow the August 29 event's fuse failure.

This AR was eventually resolved in the August 14 AR's followup.

The "shorted-out" solenoid valve was attributed as the cause of the August 14 and 29 fuse failures in the licensee's followup and in the subsequent LER, 85-19.

The unit was subsequently taken to mode 5 and maintained in mode 5 through September.

The licensee should have initially reported the identified "failed solenoid" within 30 days in accordance with 10 CFR 50.73.

Se tember 6 "Shorted-Out" Solenoid Re lacement On September 6,

SV-306 was replaced'n accordance with shopwork follower TI-2-85-451 that had quality control review and hold points (the wiring of the solenoid valve was not identified for'uality control observation).

The hold points"were consistent with Quality Control procedural requirements of NPAP, C-800 and C-800S1; and the shopwork follower indicated the conduce of the work on'nvironmentally, qualified equipment to be in accordance with NPAP C-40 and C-40S1.

In LER 85-19, the licensee reported a"wiring error wa's made during the September 6 replacement of SV-306.. This wiring error.was not discovered until late November in the followup of a safety'njection event.

The wiring error bypassed the actuating coil for SV-, 306; so that the MSIV train A actuation signal would not; initiate main steamline is'olation, but would result in a blown fuse on. SSPS actuation.

Xt appears'hat the licensee misinterpreted a miswired solenoid as a shorted solenoid.

On October 3, a continuity check and valve closure time test (STPs M16-P and V-8, respectively)

were performed for FCV-44 that verified valve operability but does not verify individual train response.

The licensee thought that the V-8 test satisfied post-maintenance testing requirements from the September 6 solenoid valve replacement in accordance with requirements of the associated Clearance No. 4-15025-85.

NPAP C-40 specified that "The responsibilities and requirements for conducting post-maintenance tests are prescribed in Nuclear Plant Administrative Procedures C-3 and C-6."

NPAP C-3 and its supplements specify surveillance requirements in accordance with TSs for main steamline isolation trip actuation device and slave relays as STPs V-8, V-3R2, and M-16P.

NPAP C-6 Supplement 3, "Post Maintenance Testing,"

specifies STP V-8 as the test to verify MSIV function after maintenance.

Therefore, the licensee's post-maintenance testing for the September

solenoid replacement appears to be in conformance with plant administrative procedures.

Further, the specification of V-8 for post-maintenance testing on the replacement of SV-306 appears to be technically acceptable, based on what leads should have been lifted to perform the work and discussions of the work conduct with the involved technician.

To establish the exact conduct of the September 6 SV-306 replacement that was credited with the miswiring, the inspectors discussed the job with a former IGC Technician who performed the gob and is now at another plant.

This former licensee employee recalled lifting only the two leads that were required for replacement of the solenoid, which would be logical and

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Additionally, the technician did not,,'check the circuit or the replaced solenoid valve after the work was completed.

This check may have identified the miswiring at this time.,'Although there are no requirements for such checking when a post,-maintenance functional test is planned, it is good practice that'as,been'followed where" practicable.

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Corrective Action on Previous Violation At about th6 same time as the~MSIV miswiring was conjectured to have occurred, a very, similar miswir'ing on a feedwater isolation valve was observed.'his was reported in LER 85-14 and was the subject of a level IV violation (Inspection Report 85-32).

Included as a resolution topic of the LER was that adequate pose-maintenance tests should be conducted for components that are normally only tested with continuity checks during operations, e.g.,

MSIVs and feedwater isolation valves.

The licensee's corrective action, for the feedwater isolation valve LER and violation, included verification that the MSIVs had previously responded correctly to an actuation signal.

This was the case for FCV-44 since the B train of the SSPS had performed its function.

This corrective action for the feedwater isolation valve miswiring would not have prevented or found the MSIV miswiring. If a test of MSIV actuation logic had been done on finding the feedwater isolation valve miswiring, the MSIV miswiring would have been discovered and prevented t'e recurrence of a similar violation. It is not apparent that t'e licensee took timely corrective action in this case.

E ui ment Histor Trackin The violation on the LER 85-14 topic also included a concern that the licensee's response to finding fuse failures did not include an acceptable search of equipment history.

The LER 85-19 follow-up included review by the inspectors of related ARs, Nuclear Plant Problem Reports (NPPRs),

clearances, equipment history and STPs, since turnover of the system to operations by the Startup Department.

The inspectors reviewed the chronological files of the applicable STPs and found the forms acceptably completed for the required TS modes.

This review also found no indication of equipment problems that could have provided information on the SV-306 miswiring discovered in late November; except review of STP V-8 files found mention of a blown fuse and bad fuse indicator light that were replaced on July 27, 1985 for FCV-44.

The fact of a blown fuse in July should significantly change the conclusions of LER 85-19.

This replacement of the fuse in FCV-44's Train A actuation circuit and the subsequent passing of a STP V<<8 indicate that the solenoid was not "shorted-out" on July 27.

There was no documentation to indicate a main steamline isolation actuation that could have produced the August 14 fuse failure, or the previously unconsidered July 27 fuse failure.

The licensee had considered in LER 85-19 that the fuse failures of August 14 and 29 were caused by the "shorted-out" solenoid.

The licensee should have determined that the three fuse failures in a matter of about one

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month with a successful V-8 indicated a problem'ther than a'shorted-out" solenoid.

The inspectors discussed the finding o'f the" blown fuse and subsequ'ent V-8 test with the licensed operator involved,,gn the test and with a power production engineer that reviewed the, test data.

The blown fuse was considered an anomoly worth a remark in 'the STP, according to the operator.

No thought was given to drafting an AR,. however it was considered that a power production engineer should be aware of the fuse failure and given an opportunit'y to prepare an AR.

The power production engineer noted the failur'e, but considered it a simple random failure in light of the successful STP V-8.

In contrast, an AR was prepared by the shift foreman for the August 14 failure.

The inspectors concluded that an AR should have been prepared for the July 27 fuse failure to assure that this equipment failure would be tracked, and on subsequent failures, e.g.,

August 14, considered.

This AR could have aided in the identification of the miswiring problem around August 14; since the August 14 failure would have then been the second documented fuse failure and the successful STP V-8 on July 27 would have indicated potential problems other than a "shorted-out" solenoid.

Therefore, the inspectors considered it reasonable that the miswiring could have been identified and corrected around August 14, 1985.

Further, the failure to identify the July 27 blown fuse in an AR or other document is contrary to NPAP C-40S2.

Independently, in response to an Instrumentation and Control (ISC)

request the Operations Department issued a Shift Order on January 3,

1986 and a Shift Foremen Memo on January 6,

1986, to require that all blown fuse indications be documented in an AR.

Problem Resolution Pro ram and Efforts The July 27 fuse failure in conjunction with a successful STP V-8 and the other two fuse failures were not considered by the licensee.

Also, the facts that the solenoid replacement was unlikely to have resulted in the miswiring and that the solenoid was never verified to be the source of the fuse failures were not considered by the licensee.

These facts indicate that, the miswiring probably did not occur on the September

replacement and, as later indicated, may have occurred as early a September of 1984.

The licensee did not discuss the identified causal event with the involved individual.

A generic concern that arises from failure to discuss the event with the involved individual relates to the Technical Review Group's (TRGs)

effectiveness; an issue that has been previously raised in inspection reports 85-32, 85-22 and others.

This generic concern is reinforced by the TRGs failure to accurately identify the cause or time frame of the miswiring in the evaluation of LER 85-19.

In the violation issued in Inspection Report 85-32 on the LER 85-14 topic, another issue was the licensee's failure to review equipment history cards until questioned by an NRC inspector.

Although documentation of equipment history should be in ARs as previously

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