IR 05000331/1998004
| ML20248J453 | |
| Person / Time | |
|---|---|
| Site: | Duane Arnold  |
| Issue date: | 05/29/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20248J439 | List: |
| References | |
| 50-331-98-04, 50-331-98-4, NUDOCS 9806090138 | |
| Download: ML20248J453 (21) | |
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U.S. NUCLEAR REGULATORY COMMISSION REGION lli Docket No: 50-331 License No: DPR-49 Report No: 50-331/98004(DRP)
Licensee: IES Utilities, In First Street SE P.O. Box 351 Cedar Rapids, lA 52406-0351 Facility: Duane Arnold Energy Center Location: Palo, Iowa Dates: March 18 - April 28,1998 Inspectors: L. Collins, Acting Senior Resident inspector M. Kurth, Resident inspector Approved by: R. D. Lanksbury, Chief Reactor Projects Branch 5 l
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N 138 990529 PDR ADOCK 05000331 PDR l - - - _ _ _ _ _ _ _ . . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _
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EXECUTIVE SUMMARY l
Duane Amold Energy Center NRC Inspection Report 50-331/98004(DRP)
This inspection report included resident inspectors' evaluation of aspects of licensee operations, maintenance, and engineerin Operations l . Operations personnel began the refueling outage on April 2,1998, by performing an error free shutdown. Refueling activities on the refuel bridge and in the control room were also performed without error (Section 01.1).
. Operations personnel demonstrated a lack of planning and coordination by allowing certain maintenance tagout and testing activities to be conducted simultaneously on April 12,1998. This resulted in several control rods drifting into the reactor core during refueling operations (Section 01.2).
. The licensee identified that operators had missed daily routine Technical Specification surveillance tests on two occasions due to the lack of attention to routine activitie Surveillance test intervals were only slightly exceeded and subsequent tests were satisfactory. The corrective actions were appropriate. This resulted in two non-cited violations (Section O1.3).
. Two configuration control issues occurred during the refueling outage involving the mispositioning of the scram discharge drain valve jacking mechanisms, and two hydraulic control unit valves were found in the wrong position. No adverse plant conditions resulted in either case (Section O2.2).
Maintenance
. Five unexpected engineered safety feature (ESF) actuations occurred during the first several weeks of the refueling outage due to communication problems, scheduling and planning deficiencies, and the failure to follow the prerequisites listed on the surveillance test procedures. One ESF actuation resulted in a violation for the failure to follow procedural prerequisites (Section M1.2).
. The method of placing the battery charger in service following maintenance to test its intended function when an alternative method was available for testing without placing it back in service was a concem (Section M1.3).
. Three human performance events occurred during the first several weeks of the refueling outage due to communication problems and not following industry safety practices (Section M1.4).
+ Inadequate work instructions resulted in energizing an out-of-service circuit. Additionally, the calibration procedure was inadequate. Neither the work instructions nor the calibration procedure ensured that leads were lifted to prevent energizing the out-of-service circuit (Section M2.2).
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. The inspectors were concemed that a " reference use" procedure would nct be changed according to the licensee's policy on procedural adherence upon identifying a procedure deficiency during the calibration and replacement of a relay. (Section M2.2)
Enaineerina
. The containment hydrogen / oxygen monitor system was inoperrble due to a design discrepancy that existed since its installation (Section E2.1).
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Rooort Details Summary of Plant Status-
The plant began this inspection period operating at 100 percent power and remained at or near I full power until the April 2,1998, scheduled shutdown to commence refueling outage 15 i
(RFO 15).
I. Ooorations 01 Conduct of Operations L 0 General Comments (71707)
L Inspection Scope The inspectors followed the guidance of Inspection Procedure 71707 and conducted frequent reviews of plant operations. This included observing routine control room activities, refueling activities, reviewing system tagouts, attending shift tumovers and crew briefings, and performing panel walkdowns. The inspectors also observed portions of the April 2 through April 3,1998, scheduled shutdown to commence the start of RFO 1 Observations and Findinas Operations personnel began RFO 15 by performing an error free shutdown. Refueling activities on the refuel bridge and in the control room were also performed without erro Control room staffing levels were appropriate and operations personnel were generally knowledgeable of plant conditions. A number of self-revealing events occurred during the first several weeks of RFO 15 due to human errors, communication problems, planning and scheduling deficiencies, and poor procedural adherence. Many of the events are
' described in more detail throughout this repor O1.2 Control Rods Drift in Defueled Cells Inspection Scope (60710. 71707)
The inspectors reviewed circumstances regarding seven control rods that unexpectedly drifted in defueled cells.-~ Licensee and contract personnel were interviewed. Operator logs, Operating Instruction (01) 255, Revision 39, " Control Rod Drive (CRD) Hydraulic System," and associated tagouts for control rod maintenance were reviewe Observations and Findinas On April 12,1998, operations personnel discovered that seven control rods had drifted in defueled cells immediately after inserting a manual scram to test back-up scram valve A total of 17 control rods were tagged out for maintenance, which was unrelated to the re-scheduled back-up scram valve surveillance test. The configuration of the control rods that were tagged out included 7 control rods in defueled cells with cooling water flow
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established to provide cleaning of the mechanisms. The 7 control rod mechanisms were lined up in accordance with 01255, " Control Rod Drive Hydraulic System," Section 8.7,
"CRD Hydraulic Control Unit (HCU) Isolation for a Defueled Cell." The line up isolated charging water and drive water flow with cooling water flow established to eliminate debris from settling in the control rod drive mechanisms. When the manual scram was inserted to test the back-up scram valves,72 control rods with charged accumulators discharged to the under piston area causing their cooling water check valves to sea The 10 control rods tagged out for maintenance in fueled cells had their charging water, drive water, and cooling water isolated in accordance with 01255, Section 8.2, "CRD HCU isolation for Maintenance." Therefore, the cooling water flow was forced through the 7 control rods tagged out for maintenance in the defueled cells which had cooling water flow established. This resulted in increased cooling water flow pressure and caused the control rods to drift into various locations in the reactor cor The drifting control rods were initially fully out of the core at position 48. Three of the control rods drifted to position 00 and the others drifted to positions 02,08,16, and 46, respectively. Two of the position 00 control rods were askew. The other five control rods were vertical. The inspectors observed corrective actions taken to withdraw the control rods back to position 48. A hook attached to a rope was used to guide the top o(the control rods into the control rod guide tubes and eventually to position 48. Underwater cameras were used to ensure the control rods and surrounding fuel bundles were not damaged during the drift or the control rod withdrawal sequence. Long-term corrective actions to prevent control rod drifting consisted of revising Ol 255 to isolate cooling water to control rod mechanisms in defueled cells. The corrective actions appeared to be appropriat Conclusions Operations personnel demonstrated a lack of planning and coordination by allowing certain maintenance tagout and testing activities to be conducted simultaneously which resulted in several control rods drifting into the reactor core during refueling operation .3 Missed Surveillance Tests Inspection Scope The inspectors reviewed the circumstances surrounding two missed daily Technical Specification (TS) surveillance test Observations and Findinas The daily jet pump surveillance test was required to be completed per TS Surveillance Test Requirement 4.6.E.1. Under Surveillance Test Procedure (STP) 46E001, " Daily Jet Pump Operability," operators recorded jet pump flows, speeds, and differential pressures to ensure that parameters remained within the normal operating range. The surveillance test had been satisfactorily completed on March 18,1998, at 3:20 p.m. The TS defined daily as once every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and allowed a maximum extension of 25 percen Therefore, the surveillance test was required to be performed by 9:20 p.m. on March 1 The operator failed to take the required data and the licensee did not have a process for l
verifying that daily surveillance tests were completed. Subsequently, another operator l 5 l
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l discovered that the surveillance test had not been performed at 9:16 p.m. on March 19 and immediately initiated the procedure, which was completed satisfactorily at 9:31 The licensee deterrnined that the failure to complete the surveillance test within the required period was a human performance error and a violation of TS 6.E.1. Longer term corrective actions included a revision to the shift supervisors' tumover sheet to ensure that the shift supervisor verified certain required surveillance tests were complete On April 15,1998, an operations supervisor discovered another missed surveillance test i
while reviewing the completed STP 42A001, " Daily instrument Cnecks." Fuel pool l exhaust radiation monitors were required to be checked daily by TS 4.2 when hand ling l irradiated fuel in secondary containment and during core alterations and operations with a potential for draining the reactor vessel. This was the only required instrument reading in the current plant mode on the procedure page and the operator mistakenly labeled all of the readings as not required. The surveillance test was required to be performed by 1:27 a.m. on April 15. The fact that the test had not been conducted was discovered at approximately 7:18 a.m. when the reading was immediately taken. Core alterations had been in progress from 9:25 p.m. on April 14 to 2:00 a.m. on April 15. Therefore, 33 minutes passed during which the surveillance test interval had expired while the radiation monitors were required to be operable. The TS action statement allowed one hour to take actions to isolate secondary containment and start the standby gas treatment system. As the limiting condition for operation allowed outage time was not exceeded, no licensee event report for the missed surveillance test was required. The surveillance test results, when completed, were satisfactory. The licensee planned to revise the procedure to more clearly indicate which instrument readings were required to be recorded during shutdown condition Although in both cases the surveillance test intervals were only slightly exceeded, the inspectors were concemed that both instances occurred due to the lack of attention to routine activities. The immediate ar.d longer term corrective actions were appropriat The inspectors ciid not consider the second missed surveillance test to be a repeat of the first missed surveillance test because of different circumstances and therefore these non-repetitive, licensee-identified and corrected violations are being treated as non-cited violations, consistent with Section Vll.B.1 of the NRC Enforcement Policy (50-331/98004-01(DRP) and 50-331/98004-02(DRP)). Conclusions Operators missed daily routine TS surveillance tests on two occasions due to the lack of attention to routine activities. The surveillance test intervals were only slightly exceeded (
and subsequent instrument readings were satisfactor Operational Status of Facilities and Equipment O2.1 General Plant Tours and System Walkdowns (71707)
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The inspectors followed the guidance of Inspection Procedure 71707 in walking down accessible portions of several systems:
. Division i 125 Vdc system
. Core spray system
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Equipment operability, material condition, and housekeeping were acceptable in all cases. The inspectors identified no substantive concems as a result of these walkdown I O2.2 Configuration Control Problems inspection Scope (71707)
The inspectors reviewed two configuration control problems that occurred during RFO 1 The inspectors reviewed action requests and tagouts, attended fact finding meetings, and ,
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toured the areas of the plant where the configuration had changed.
' Observations and Findinos Operators were performing STP 438007, " Scram Discharge Volume Valve Time
. Quarterly Test," when the scram discharge volume drain isolation valves failed to close i as expected. In the field, operators found that the jacking mechanisms used to l i
mechanically drive the valves open or closed were in the open position instead of the required neutral position that allows automatic closure. Operators repositioned the J Jacking mechanisms which took approximately ten tums of the handwheel for each valve, ar'd the surveillance test was performed satisfactoril The pocitions of both drain isolation valves and the jacking mechanisms were checked and verified by operators performing a valve line-up the day before the surveillance tes Each valve had a different jacking mechanism that performed the same function. For the
"B" valve, the neutral position was easily read from an indicator. The "A" valve had a jacking collar that had to be positioned in the middle of the travel range of the valve stem, which was difficult to verif No maintenance work of tagouts had been performed on these valves during the outag The operators who performed the valve lineup remembered leaving the "B" valve in the neutral position, but could not accurately recall the as-left position of the "A" valve. The valves normally close on a scram signal to minimize reactor pressura vessel coolant los There was no safety consequence as a result of the mispositioned valves since the reactor was shutdown with all rods inserted and the scram function reset. The licensee could not determine when the valves were mispositioned, but as a corrective action, locked the jacking mechanisms in the neutral positio On April 26,1998, an operator noticed that the cooling water and exhaust valves associated with HCU 30-19 were closed when the required position was open. Operators repositioned the two valves and verified all valves for all HCUs were properly positione An action request was generated to determine how and when the valves were close The control rod remained inserted at all time No adverse plant conditions resulted in either case; however, the mispositioned valves and jacking mechanisms were the result of inadequate configuration control. The licensee's investigation and the inspectors' review were not complete at the end of the inspection period. Since the event occurred shortly before the end of the inspection period and the inspection was not completed, this configuration controlissue is an unresolved item pending further review of the details of the event to determine the significance and applicability to requirements (50-331/98004-03(DRP)).
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- . Conclusions Two configuration controlissues occurred during the refueling outage. Scram discharge volume drain valve jacking mechanisms were mispositioned which was discovered during
' surveillance testing. An operator found two valves associated with HCU 30-19 in the wrong position. No adverse plant effects resulted in either case.- This issue is an unresolved item pending further review of the events and corrective actions to prevent recurrenc . Maintenance M1 Conduct of Maintenance M1,1 General Comments l lasDeCliOM SCoDe (62707) (61726)
The inspectors observed or reviewed all or portions of the following work activities:
. STP 3.8.4-03, " Service Discharge Test of 1D2125 VDC Battery"
. STP 44A002-CY, "SBLC (Standby Liquid Control) System Manual Initiation, Explosion Valve Test, and Relief Valve Test" Observations and Findinos The inspectors observed adequate maintenance practices, appropriate use of procedures, and good coordination among department M12 Unexpected Enaineered Safety Feature Actuations Inspection Scope (62707. 71707)
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The inspectors reviewed five unexpected engineered safety feature (ESF) actuations that occurred during the first several weeks of the refueling outag Observations and Findinas -
The list below briefly describes the circumstances surrounding each actuation:
- On April 13 1998, while de-energizing electrical loads on the Division i 125 Vdc distribution system for maintenance activities, a primary containment isolation system (PCIS) Group 3 primary containment ventilation isolation occurred. When the supply breaker to the "A" standby gas treatment system panel was tumed off, the reactor building ventilation shaft radiation monitor auxiliary relay was de-energized causing the PCIS Group 3 isolatio . On April 10,1998, while removing one (regulating transformer) of two power sources to the Division i 125 Vdc system per the operating instructions, an unexpected momentary loss of power to the Division I instrument panel was
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experienced. The momentary power loss caused an unplanned PCIS Group 3 isolation, which isolated primary and secondary containment ventilation. System engineers were unable to determine the cause of the momentary power loss but continued to investigate the occurrenc . On April 8,1998, the automatic depressurization system logic functional test was re-scheduled and performed concurrently with inboard main steam isolation valve (MSIV) localleak rate testing (LLRT). This caused several safety relief valves to open and relieve the LLRT test pressure (approximately 40 psi) to the suppression pool. Neither of the work groups were aware of the other group's activitie . On April 4,1998, concurrent turbine control valve response time testing (simulates power greater than 30 percent) and removal of the turbine lube oil system from service resulted in a turbine trip signal and reactor protection system actuation. The reactor was shutdown and no rod motion occurre . On April 3,1998, a Group I isolation occurred during turbine bypass valve response time testing. The MSIVs were already closed but the ESF actuation resulted in the closure of recirculation sample valves. One valve failed to close (see Section M1.3).
Several factors contributed to the events including communication problems, scheduling and planning deficiencies, and the failure to follow the prerequisites listed on the surveillance test procedures. In the April 8 event, precedural prerequisites were signed off but were not adequately completed which resulted in the unexpected actuation. The failure to properly implement the procedure prerequisite was a violation of TS 6.8, ' Plant Operating Procedures"(50-331/98004-04(DRP)), as described in the attached NOV. On April 8, the operations manager instituted additional controls over surveillance tests and LLRTs which included a pre-job brief prior to all surveillance tests, explicit discussion of special precautions, and a required peer check of all prerequisites. These corrective
actions appeared to be appropriate. No furtherinstances of the failure to meet prerequisites prior to test initiation were note Conclusions i
Five unexpected ESF actuations occurred during the first several weeks of the refueling outage due to communication problems, scheduling and planning deficiencies, and the failure to follow the prerequisites listed on the surveillance test procedure M1.3 inadeouate Post-Maintenance Testina Inscection Scope (62707)
The inspectors reviewed post-maintenance festing instructions for several maintenance activities. Licensee personnel were interviewed and Management Directive (MD) 24, Revision 12, " Post Maintenance Testing Program," was reviewed.
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b. Observations and Findinas On December 16,1997, work was performed per corrective maintenance action request (CMAR) A38252 which provided instructions for licensee personnel to replace relay coils for several safety related relays, including the PCIS Group i relay (71B-K057) for the recirculation sample line outboard valve. When the maintenance work was completed, in accordance with the post-maintenance testing instructions, the licensee was to verify that the relay contacts would be in the desired position (closed) when energized. The post-maintenance test was completed and the relay was retumed to service; however, the function of the relay was to deener0 i ze when a Group i isolation signal was initiated which would cause the relay contacts to open and the associated isolation valve to clos On April 3,1998, as discussed in Section M1.2 cf this report, relay A71B-K057 failed to perform its intended function and deenergize after initiation of a PCIS Group i isolation l signal. Therefore, the associated recirculation sample line outboard valve did not automatically close. The redundant inboard isolation valve did close as required. The licensee determined that mechanical binding prevented the relay from dropping out. The mechanical binding was due to improper retainer replacement during the reassembly of i the relay on December 16,1997. Therefore, the recirculation sample line outboard valve was considered inoperable by both the inspectors and the licensee from December 16, 1997, until April 3,1998. The relay was replaced on April 3,199 The April 3,1998, ESF actuation occurred after corrective maintenance was performed on the relay. Management Directive 24 provided instructions to be used by shift supervisors, and maintenance coordinators, planners, and supervisors in specifying and reviewing post-maintenance testing. The significance of this issue was not evaluated before the end of the inspection. This issue is considered an unresolved item until the significance is determined and the ability of the inboard isolation valve to perform the safety function of providing primary containment is assessed (50-331/9G004-05(DRP)).
As part of the maintenance activities, seven additional relays had their coils replace The licensee verified that no mechanical binding problems existed with the relays after the April 3,1998, incident. Also, the licensee deenergized the relays during scheduled outage activities and verified that the relay contacts dropped out when deenergized, thereby verifying the proper function of the relays. The immediate corrective actions taken appeared to be appropriat In addition, on November 19,1997, as detailed in inspection Report 97017, Section M1.3, electricians performed maintenance on the Division i 125 Vdc battery charger (1D12) by replacing several circuit boards in accordance with CMAR A36453. When the maintenance was completed, post-maintenance instructions directed that the battery charger be placed back in service and confirmed that it was operating within specifications. Operations personnel attempted to place the charger back in service and it failed to operat The licensee conducted a root cause investigation and concluded that effective post-maintenance testing was not specified in MD 24 or in CMAR A36453. Engineering and electrical maintenance personnel later developed an attemative post-maintenance test to apply an electrical load to the charger prior to placing it back in service to verify it functioned properly. Corrective actions were taken to provide training to engineering and
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operations personnel on the requirements of MD 24. Also, MD 24, Attachment 1," Post Maintenance Testing That Should Be Considered For Selected Maintenance Activities,"
was to be updated to include 125 Vdc battery charger maintenance. The corrective actions appeared to be appropriat Conclusions Two post-maintenance testing deficiencies were identified. An assessment of the safety significance of the failure of a PCIV to close was not complete. This failure was not identified through post-maintenance testing following replacement of an associated rela Testing the battery charger by placing it in service following maintenance is a concem, since attemative testing could have been performe M1.4 Human Performance Concerns Inspection Scope (62707)
The inspectors reviewed the circumstances surrounding thrce human performance events that occurred during the first several weeks of the refueling outage, Observations. and Findinas The list below describes the circumstances surrounding each human performance event:
. On April 8,1998, a main generator to exciter coupling weighing 350 to 500 pounds was dropped approximately 5 feet onto the turbine floor due to improper rigging techniques. No one was injured. The couplity/as being removed so that tests could be performed on adjacent components; however, the licensee's project leader instructed certain individuals during a tumover not to remove the coupling and that altemative methods to test the adjacent component needed to be pursued. The coupling was not supposed to be removed because industry data showed that future turbine generator vibration problems may occu The turbine workers were focussed on completing the component test and were unaware that the coupling was not to be remove . On April 20,1998, while rigging, lifting, and moving a steel panel in the turbine building, a worker was injured. As the panel was lifted approximately 18 inches off the floor, one of the two slings used on the lift shifted, causing the panel to lunge forward and cut the worker's leg. The injured person, acting as a crane signal-man and a helper to guide the panel to its desired location, was positioned within severalinches of the panel during the lift. A contributing factor to the injury was that the worker was standing within a roped off radiologically " Clean-Clean"
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zone that surrounded the panel. The working area was somewhat limited, therefore, the " Clean-Clean" zone only provided a one foot clearance between the roped boundary and the panel. The worker treated the boundary as an invisible wall and thought that he could not work outside the " Clean-Clean" zone to make the lift. The worker did not question whether the boundary could be extende Also, the riggers indicated that it was normal for slings to creep or walk several inches during a lift; however, only one sling was free to creep and the other had a physical restriction (steel framing) that did not allow it to mov l l
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. On April 21,1998, a contract electrician was nearly injured while attempting to connect temporary power lines into a 480 Volt portable breaker panel. The electrician was using a rachet to tighten a lug in the breaker panel when it contacted a 480 Volt,1000 amp energized bus bar. The path to ground was not through the electrician, therefore, he was not injured. The electrician, along with two other electricians who were responsible for connecting the temporary power source, were instructed at the start of the work day to take certain safety precautions, such as using insulating blankets, face shields, and safety glove The safety precautions were not used. The licensee evaluated this industrial safety event per Occupational Safety Health Administration (OSHA) requirements and determined that it was not reportabl Several factors contributed to the human performance events including communication problems and not adhering to industry safety practices. Fact finding meetings were held for the events and common themes discussed included workers being comfortable with the work that was performed and the common practice to work this way. Licensee and contract personnel verbally committed at each fact finding meeting that increased safety precautions would be taken to prevent future events. Also, management planned to spend more time in the field and approach workers if safety concems exis Conclusions Three human performance events occurred during the first several weeks of the refueling outage due to communication problems and not adhering to industry safety practice M2 Maintenance and Material Condition of Facilities and Equipment M Plant Materiel Condition Inspection Scope (62707)
The inspectors reviewed several emergent work items to ensure appropriate operal..ay evaluations were performed, TS were met, repairs were made, and root causes were determined where appropriat Observations and Findinas The inspectors noted that there were several emergent equipment issues during the inspection period. The examples are listed below:
. On March 23,1998, the torus temperature indicator failed during surveillance testing. Repairs were completed on March 25 and the 30 day limiting condition for
operation (LCO) was exited.
l l . On March 25,1998, the "B" containment atmosphere monitor torus sample valve, SV 81088, was declared inoperable due to slow closing times. Operators followed the TS action statement and isolated the sample line and entered a 30-day LCO. The valve was repaired and retumed to service on March 3 !
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. On March 27,1998, the reactor building exhaust damper,1V-AD-138, failed to I close within 10 seconds as required. Operators followed the TS action statemen The damper was repaired and returned to service on March 2 . On March 31,1998, a containment atmosphere sample pump,1C-218B, failed while in service. The pump was replaced and retumed to service on April Conclusions The licensee promptly resolved emergent equipment material condition issues that were identified during the inspection period. All of these equipment problems were resolved well within the associated TS allowable outage time M2.2 Circuit Inadvertentiv Eneroized Durino Maintenance Work Inspection Scope The inspectors reviewed procedure Relay-A109-1, "Agastat Timing Relays," and preventive maintenance action request 1102482, used to replace and calibrate PCIS relay A718-K065, after an instrument and control (l&C) technician inadvertently energized the out-of-service circuit during the wor Observations and Findinos An l&C technician was replacing and calibrating relay A718-K065, which was used in the primary containment isolation system for steam leak detection in the reactor water cleanup system. The circuit was normally powered by the "A" reactor protection system bus which was tagged out-of-service. The technician connected a test power source to the relay without disconnecting the coil leads from the rest of the circuit which resulted in energizing other portions of the circuit. The individual noted that something unexpected had occurred and stopped work to evaluate. The licensee determined that the work instructions were deficient in that they did not require leads to be lifted per MD 37,
" Electrical Termination Sheet." Immediate corrective actions included revising the work instructions to include instructions for lifting the coil leads per MD 37. Energizing a circuit that was intended to be deenergized and out-of-service could have posed a hazard to others working within the out-of-service boundary; however, at the time the event occurred, no other work was in progres The licensee initiated an action request and held a fact finding meeting to discuss the event. The licensee identified that the procedure used to calibrate the relay, Relay-A109-01, "Agastat Relays," contained three sections, each which addressed a
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different model relay. The section used in this case did not specifically direct that the power leads be disconnected. The other two sections did provide those directions. The ,
licensee planned to revise the procedure. During the rneeting, the licensee also noted that the pre-job brief did not include a discussion on precautions to prevent energizing the circuit. A revision to the administrative control procedure (ACP) for pre-job briefings was also planned. Inadequate work instructions and procedures is considered a violation of 10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings" (50-331/98004-06(DRP)), as described in the attached NOV. Neither the work
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instructions for installing the relay or procedure Relay-A109-1 required lifting leads to prevent energizing an out-of-service circuit.
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l The inspectors agreed with the conclusions that the procedure and the pre-job briefing were deficient but also had several other concems. After the technician inadvertently energized the circuit, although the work instruction was revised, a procedure change as specified by ACP 101.01, " Procedure Use and Adherence," was not immediately initiate Since the calibration procedure was a " reference use" procedure, the work instruction I was immediately revised per MD 37 instead of processing a temporary procedure {
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change. The inspectors were concemed that workers might not pursue a procedure change immediately upon discovery because the procedure was considered to be
" reference use" which allows segments of procedures to be performed from memory. As such, the procedure had been at the work site but not in use at the time the event occurred. Previously, the inspectors documented concems with the licensee's use of
" reference use" procedures. This is considered an unresolved inspection item (50-331/98004 07(DRP)) pending a determination if the licensee's procedure use practices satisfy 10 CFR Part 50, Appendix B, Criterion V (refer to Section E8.1 for further discussion on procedure use concerns). Conclusions An l&C technician inadvertently energized an out-of-service circuit during calibration and replacement of a relay. No other work within the out-of-service boundary was in progress ;
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at the time. The procedure and the pre-job brief were deficient. The inspectors had a concem that " reference use" procedures were not changed in accordance with the licensee's policy on procedure adherenc (
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M8 Miscellaneous Maintenance issues (92902) j M8.1 (Closed) Licensee Event Report 50-331/97-11-00 and Unresolved item (URI)
50-331/97014-01: Inadequate TS Required Surveillance test Procedure. The inspectors reviewed primary containment isolation system valve functional test results and concluded all valves operated within the allowable time limit. Administrative changes were made to surveillance test procedures to satisfy future closure timing requirement The licensee determined, based on a review of previous data, that the valve isolation logic was tested satisfactorily. The inspectors had no further concems. These items are close M8.2 (Closed) Inspection Followup Item (IFI) 50-331/97017-02: Inoperable 125 Vdc Battery Chargers Following Preventive Maintenance. The inspectors reviewed the root cause investigation findings. As detailed in Section M1.3, the method of placing a component back in service following maintenance for testing purposes when an alternative method was available for testing without placing it in service is a concem. The root cause findings and corrective actions appeared to be appropriate. This item is close _ _
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Ill. Enaineerina E2 Engineering Support of Facilities and Equipment E Containment Hydrooen/Oxvoen Monitors Inoperable (37551) Inspection Scope The inspectors reviewed several action requests and vendor information regarding the effects of condensation on the accuracy of the containment hydrogen / oxygen monitor system. The inspectors reviewed the Updated Final Safety Analysis Report (UFSAR),
NUREG-0737," Clarification of TMI(Three Mile Island) Action Plan Requirements," and the TS for this syste Observations and Findinos in 1996, the licensee discovered a discrepancy between the design specification and plant drawings for the containment hydrogen / oxygen monitor system. The General Electric specification and the UFSAR (12.3.4.2.3) stated that the gas sample lines shall be insulated with electrical heat tracing sized to hold a minimum gas sample temperature of 250*F (Fahrenheit). Common gas sample lines for both the containment hydrogen / oxygen monitors and the post-accident sampling system did not have insulation and were heat traced to maintain 95'F. With sample lines at a lower temperature than containment atmosphere during post-accident conditions, condensation could form and could affect the hydrogen / oxygen monitorindications. In March 1998, the vendor provided new information on the effects of condensation which showed that, over the range of temperatures in which the system is designed to operate (100* to 300*F),
indicated hydrogen / oxygen concentrations would be two to four times higher than actua Engineers performed an operability assessment and provided a correction factor chart to operators as an aid to convert indicated hydrogen and oxygen concentration to actual concentrations based on torus temperature. The evaluation concluded that drywell sample lines to the monitors were short and would quickly reach ambient temperatures such that condensation would not affect the accuracy of the monitors. However, the
~ torus sample lines were long and would be affected by condensation without the require .
heat tracing and insulatio The inspectors questioned past operability and deportability (under 10 CFR 50.73)
decisions given the discovered inaccuracy of the monitors >The licensee's operability assessment concluded that the monitors were operable in the past because under design basis loss of coolant accident conditions, using realistic (not design bar:is) assumptions of oxygen and hydrogen concentration in containment, indicated hydrogen and oxygen concentrations would be below the emergency operating procedure flarftmability ]
concentrations. Therefore, premature venting of containment would not occur. The inspectors concluded that this assessment of past operability was not adequately justified. Technical Specification 3.2.H required the containment hydrogen / oxygen monitors to be operable. The TS bases stated that the instrumentation listed in TS 3. was designed to provide plant status for accidents that exceed the design basis accident conditions discussed in Chapter 15 of the UFSAR and was specifically added to comply with the requirements of NUREG-0737 and Generic Letter 83-36. These misleading
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indications would not have allowed operators to accurately monitor the containment atmosphere during accHent conditions and could have resulted in premature venting of containment under beyond design basis accident condition After several discussions on the subject, the IL ensee agreed to submit a licensee event report for the past inoperability of the containment hydrogen / oxygen monitor system. The inspectors concluded that the system had been inoperable from the date when the TS requirement for operability was initially incorporated in September 1984 until March 20,1998, when the correction factor chart was generated for use by operator Since the limiting condition for operation for the monitors was exceeded, this past inoperability condition constituted a violation of TS 3.2.H (50-331/98004-08(DRP)) as described in the attached NO Corrective actions for this nonconformance were repeatedly delayed despite recommendations from the system engineer in 1997 to restore the system to the original intended design. However, at the end of the inspection period the licensee had developed a schedule for completing the required modification c. Conclusions The containment hydrogen / oxygen monitor system was inoperable due to a design discrepancy which existed since initialinstallation. Corrective actions to restore the system were repeatedly delayed. The licensee initially performed a poor assessment of past operability but ultimately concluded that the system had been inoperabl E8 Miscellaneous Engineering issues (92902)
E (Closed) URI 50-331/970 w 4 Procedure Usage Requirements During Modification During a modification of the high pressure coolant injection system the inspectors had observed that work was completed but the job steps not signed off. The licensee considered the work package instructions to be " reference use" rather than " continuous use." Upon further review of the licensee's procedure use and adherence procedure, ACP 101.01, the inspectors found that many procedures could be treated as " reference use." Only surveillance test and special test procedures were specified to be " continuous use." A reference use procedure was not required to be at the job site and steps (if in small segments)could be performed from memory and signed off at a later tim Accordingly, as the work package for the HPCI modification was a " reference use" procedure and the work had been performed satisfactorily, no violation was identifie This specific item is close Additionally, the procedure use and adherence policies dictated that steps be performed in sequence, but numerous exceptions were pro tided which gave latitude to workers using procedures. In all, given the large number of " reference use" procedures and the latitude to perform steps out-of-sequence in many cases, the inspectors concluded that the procedure adherence policy was liberal. Although no violations were identified, the inspectors remained concemed that liberal policies regarding procedural use and adherence could result in future unintended plant effects. Additional concems with
" reference use" procedures are discussed in Section M2.2 of this report. Unresolved item 50-331/98004-06 was issued to document these concem .'
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IV. Plant Support <
R8 Miscellaneous Radioloalcal Protection issues (83526) i (Closed) URI 331/97016-04: Criticality Monitoring of Shipping Containers. This issue l R '
involved the failure to have in place either a criticality monitoring system for storage and handling of new (non-irradiated) fuel or an NRC approved exemption to this requirement contained in 10 CFR 70.2 CFR 70.24 requires that each licensee authorized to possess more than a small amount of special nuclear material (SNM), maintain in each area in which such material is handled, used, or stored, a criticality monitoring system which will energize clearly audible alarm signals if accidental criticality occurs. The purpose of 10 CFR 70.24 is to ensure that, if a criticality were to occur during the handling of SNM, personnel would be alerted to that fact and would take appropriate actio Most licensees were granted exemptions from 10 CFR 70.24 during the construction of nuclear power plants as part of the Part 70 license issued to permit the receipt of the
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initial core. Generally, these exemptions were not explicitly renewed when the Part 50 l operating license was issued, which contained the combined Part 50 and Part 70 l authority. In August 1981, the Tennessee Valley Authority (TVA), in the course of l
reviewing the operating licenses for its Browns Ferry facilities, noted that the exemption I to 10 CFR 70.24 that had been granted during the construction phase had not been explicitly granted in the operating license. By letters dated August 11,1981, and August 31,1987, TVA requested an exemption from 10 CFR 70.24. On May 11,1988, the NRC informed TVA that "the previously issued exemptions are still in effect even j
though the specific provisions of the Part 70 licenses were not incorporated into the
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Part 50 license." Notwithstanding the correspondence with TVA, the NRC had determined that, in cases where a licensee received the exemption as part of the Part 70 i
license issued during the construction phase, both the Part 70 and Part 50 licenses l
should be examined to determine the status of the exemption. The NRC view now is that unless a licensee's licensir g basis specifies otherwise, an exemption expires with the i expiration of the Part 70 license. The NRC intends to amend 10 CFR 70.24 to provide for I administrative controls in lieu of criticality monitor The NRC had concluded that a violation of 10 CFR 70.24 existed. The NRC has also determined that numerous other licensees have similar circumstances that were caused by confusion regarding the continuation of an exemption to 10 CFR 70.24 originally issued prior to issuance of the Part 50 license. After considering s!! the factors that resulted in these violations, the NRC has concluded that while a violation did exist, it is appropriate to exercise enforcement discretion for Violations involving Special Circumstances in accordance with Section Vll.B.6 of the " General Statement of Policy and Procedures for NRC Enforcement Actions" (Enforcement Policy), NUREG-160 Pending the amendment to 10 CFR 70.24, further enforcement action will not be taken for failure to meet 10 CFR 70.24 provided an exemption to this regulation is obtained before the next receipt of fresh fuel or before the next planned movement of fresh fuel. This item is close . _ _ _ _ _ _ _ _ _
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V. Manaoement Meetinas X1 Exit Meeting Summary The inspectors presented the inspection results to members of licensee management at the
- conclusion of the inspection on April 28,1998. The licensee acknowledged the findings
) presented. The inspectors asked the licensee whether any materials examined during the l
inspection should be considered proprietary. No proprietary information was identifie I
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PARTIAL LIST OF PERSONS CONTACTED Licensee J. Franz, Vice President Nuclear G. Van Middlesworth, Plant Manager R. Anderson, Manager, Outage and Support i
J. Bjorseth, Maintenance Superintendent
! D. Curtland, Operations Manager R. Hite, Manager, Radiation Protection M. McDermott, Manager, Engineering K. Peveler, Manager, Regulatory Performance
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INSPECTION PROCEDURES USED IP 37551: Onsite Engineering IP 60710: Refueling Activities IP 61726: Surveillance test Observation IP 62707: Maintenance Observation IP 71707: Plant Operations IP 83526: Control of Radioactive Materials and Contamination, Surveys, and Monitoring IP 92902: Followup - Engineering ITEMS OPENED AND CLOSED Opened 50-331/98004-01 NCV Failure to complete surveillance test in required time period 50-331/98004-02 NCV Failure to complete surveillance test in required time period 50-331/98004-03 URI Mispositioned valves 50-331/98004-04 NOV Failure to properly implement procedure prerequisite 50-331/98004-05 URI Adequacy of verifying a relay was able to perform intended function 50-331/98004-06 NOV Inadequate work instruction and procedure 50-331/98004-07 URI " Reference use" procedures meeting 10 CFR Part 50 50-331/98004-08 NOV Limiting condition for operation for monitors was exceeded Closed 50-331/07011-00 LER inadequate TS required surveillance test orocedure 50-331/97014-01 URI Inadequate TS required surveillance test procedure 50-331/97016-03 URI Procedure usage requirements during modifications 50-331/97016-04 URI Criticality monitoring of shipping containers 50-331/98004-01 NCV Failure to complete surveillance test in required time period 50-331/98004-02 NCV Failure to complete surveillance test in required time period
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LIST OF ACRONYMS USED ACP Administrative Control Procedure CFR Code of Federal Regulations CMAR Corrective Maintenance Action Request CRD Control rod drive DAEC Duane Amold Energy Center ESF Engineered safety feature HCU Hydraulic control unit l&C Instrument and Control i IFl Inspection followup item
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IP Inspection procedure IR Inspection report LCO Limiting Condition for Operation LER Licensee Event Report LLRT Localleak rate testing MD Maintenance Directive MSIV Main steam isolation valve NCV Non-cited violation NOV Notice of violation NRC Nuclear Regulatory Commission Ol Operating instruction PCIS Primary containment isolation system RFO Refuel Outage SNM Special nuclear material STP Surveillance Test Procedure TS Technical Specification TVA Tennessee Valley Authority UFSAR Updated Final Safety Analysis Report URI Unresolved item
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