IR 05000333/1990009
| ML20217B302 | |
| Person / Time | |
|---|---|
| Site: | FitzPatrick  |
| Issue date: | 02/26/1991 |
| From: | Meyer G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20217B262 | List: |
| References | |
| 50-333-90-09, 50-333-90-9, NUDOCS 9103120055 | |
| Download: ML20217B302 (26) | |
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U. S. NUCLilAR Rl!GULATORY COhihilSSION REGION 1 Report No.:
90-09 Docket No.:
50-333 License No.:
DPR-59 Licensee:
New York Power Authority Post Of0cc Ilox 41 Lycoming, New York 13093 Facility:
James A. FitzPatrick Nuclear Power Plant Location:
Scriba, New York Dates:
December 23,1990 through February 14, 1991*
Inspectors:
W. Schmidt, Senior Resident inspector R. Plasse, Jr., Kesident inspector Approved by:
, #,
f Jfb6
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(ylenn W. hieyer, Chief
/ Date Reactor Projects Section No. til INEITCI' ION SUMMAIE This inspection report discusses routine and reactive inspections of plant activities during day and backshift hours including: plant operations, radiological protection, surveillance and maintenance, security, engineering and technical support, and safety assessment and quality verincation.
- NOTE: The inspection period was lengthened because additional time was needed to evaluate the condition of the torus temperature instruments and the fire barrier penetrations, inspection of these issues ended with the exit on February 14, 1991. Inspection in all other areas ended on Jt.nuary 31, 1991.
INSPECTION RFSUl/I'S The inspector identined apparent violations dealing with; failure to maintain technical speciGeation required torus temperature instrumentation operable and with failure to maintain electrical penetrations in their design conGguration.
An lixecutive Summary and an Outline of Inspection follow.
i 9103120055 910301 DR ADOCK 05000333 g
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RESIDENT INSPECTOlt OFFICE JAMES A. FITZPATRICK NUCLEAll POWER PLANT INSPECTION REPORT 90-09 liSECUTIVE SUS 151 ARY Operations Operators properly responded to the B recirculation pump trip and took required actions to establish single loop operation.
Radiolocical Protection Walkdowns of radiologically controlled areas and review of RWPs identified no deficiencies.
Surveillance antLMaintenance The inspector identified an unresolved item regarding NYPA implementation of the personnel tagging procedure and the practice of mechanics performing maintenance on electrical components without electrical protection. Maintenance activities on ESW check valves and RHR leakage troubleshooting were well planned and controlled.
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Security Adequate performance continued in the security area.
Encineerine and Technical Sunng_rt A request for a temporary waiver of compliance to allow restoration of the B recirculation loop was not approved.
NYPA continued to have difficulty with the operation of the boundary check valves between the safety-related ESW and the non safety-related SW systems. Two valves failed during IST on December 26, due to corrosion and silt buildup.
A core spray system walkdown concluded with no problems identified which could have prevented the system from performing its intended function. Howceer, several weaknesses in work status control, WR review, design control (IST stroke time) and surveillance testing practices were noted.
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Executive Sununary (Continued)
Safety Assessment /Ounlity Verifiention Six apparent violations were identified while reviewing the torus temperaNrc instrumentation inoperability.
Three other apparent violations were identified while reviewing electrical fire barrier 3-hour rated penetration seals non conformances.
The inspector's continued review of NYPA's QA Program identified weaknesses wherein NYPA failed to audit various corrective actions systead ana track audit recommendations that did not reach the level of an AQCR.
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RESIDENT INSPECTOR OFFICE JAMES A. FITZPATRICK NUCLEAR POWER PLANT INSPECTION REPORT 90-09 OUTI,INE OF INSPECTION 1.
Operational / Event Summary 2.
C : rations (MC 71707,93702)
a.
January 26, B recirculation pump trip.
b.
January 9, ESF actuation, determined by PORC to be reportable, c.
Operator actions in response to inoperable service water check valves.
3.
Radiological Protection (MC 71707,92702)
4.
Surveillance and Maintenance (MC 61726, 62703, 92702, 92703)
a.
Review of protective tagout procedure, weaknesses identified in control of work, Unresolved item 90-09-01. Procedure revised to provide guidance to protect out of service equipment from an initiation signal, b.
Maintenance observations of service water check valve repairs.
c.
Maintenance observation of A RHR system PCIV leakage.
d.
Review of maintenance backlog.
5.
Security (MC 71707)
6.
Engineering and Technical Support (MC 90712, 92702)
a.
Request for temporary waiver of compliance, b.
Review of SALP recommended review of engineering staffing levels, c.
(Open) Unresolved item 90-02-06; Review of LER 90-25-01, Failure of service water check valves to shut during IST.
d.
Instrumentation left in torus since Mark I program testing.
c.
LER review.
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Outline of Inspection (Coin.nued)
7.
Engineered Safety Feature System Walkdown (MC 71710)
a.
Detailed walkdown of A core spray system, b.
Minor drawing errors identified, c.
Review of IST program.
d.
Isolated loss of control over IST valve stroke time requirements.
c.
Review of maintenance backlog, f.
Review of instrumentation surveillance program, g.
Conclusions.
h.
(Open) Unresolved Item 90-08-03; Review of operations ST program for core spray system.
8.
Torus Bulk Temperature Instrumentation a.
Chronology b..
Deficiencies c.
Safety Significance d.
Conclusions, Apparent Violation 90-09-02.
9.
Safety Assessment / Quality Verification (MC 40500,92720)
a.
Failure of NYPA to maintain three hour fire barrier electrical penetration seals; failure of NYPA to determine root cause of penetration degradation. Apparent Violation 90-09-03.
b.
(Open) Unresolved item 90-08-04; QA Audit Review.
Attachment A Acronyms iv i
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DETAILS 1.0 OPERATIONAUEVENT SUMMARY On December 26,1990, two boundary check valves between the safety related emergency service water (ESW) and the non-safety related service water (SW) systems failed to close during increased frequency IST (see Sections 2.c,4.c and 6.c). The unit operated at rated power until January 26,1991, when the B recirculation pump tripped because of a voltage regulator fault (see Section 2.a below). Single loop operations continued at approximately 50% power through the end of the period, while NYPA investigated the cause of the pump trip.
On January 31,1991, NYPA requested a Temporary Waiver of Compliance, to allow restarting of the B recirculation pump. The Waiver was not approved by Region I and NYPA clected to shut down the plant (see Section 6.a),
2.0 OPERATIONS a.
Following the B recirculation pump trip on January 26 operators performed well and met
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the conditions for single loop operation within the technical specification (TS) time limit of eight
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(8) hours. The inspector determined the operators were familiar with the procedures for single loop operation. With the pump shutdown NYPA determined that the cause of the trip was a motor generator voltage regulator fault but desired to conduct additional troubleshooting after
returning to two loop operation.
NYPA was unable to restart the pump because the TS requirement to have the temperature differential between the reactor coolant system and the reactor vessel bottom head drain line s 145 *F could not be met. NYPA's management decided to continue single loop operation in parallel with evaluation and resolution of the temperature difference, b.
On January 9,1991, a spurious spike of the B containment high radiation monitor caused actuation of the containment ventilation valve isolation relays (the valve were already shut)
during testing of the A train monitor. The Shift Supervisor (SS) issued an occurrence report (OR) and determined that no ESF actuation had occurred since the valves were already in their safe condition and therefore the situation was not reportable. On January 15,1991, the Superintendent of Power (SOP) discussed this occurrence with the inspector.
On January 16, 1991, after further review the PORC determined that this event was an ESF actuation and NYPA made the 10 CFR 50.72 report. NYPA also planned to issue an LER on this event. The Operations Department took adequate short term corrective actions by making a night order book entry to clarify this issue, however, no formal guidance existed. The inspector considered that this was a weakness and planned to review the LER when issued.
c.
The inspector found that the operators took appropriate action to ensure operability of a
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cable tunnel / switch gear room cooler and the west crescent area unit cooler when service water check valves supplying these components failed to shut during increased frequency IST. This included starting the ESW pumps and shutting manual blocking valves until a maintenance plan could be developed.
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3.0 RADIOLOGICAL PROTl!CTION During toutine tours of the plant, including the torus room, the inspector found acceptable radiological conditions. Review of RWPs that were active indicated that they were acceptable.
4.0 SURVlilLLANCl! AND M AINTliNANCE a.
The inspector reviewed NYPA's program for conducting equipment and personnel safety protection isolations to allow maintenance and modifications. WACP 10.1.2, Equipment and Personnel Protective Tagging was evaluated in light of recent procedure changes and recent plant problems associated with implementation. A sample of existing and closed protective tagging requests (PTRs) was reviewed, which included verificat on of tagged equipment i
position / condition in the field, The inspector concluded that, if properly implemented, the procedure was adequate to result in an effective protective tagging program, llowever, implementation appeared weak based on several occurrences detailed below where operators failed to follow the procedure. The inspector also determined that several apparent tagout impic. mentation weaknesses were related to NYPA's policy of performing maintenance without detailed work instructions (i.e. skills possessed). This led to instances where components were not properly electrically isolated because the identified scope of work was mechanical and the electrical interfaces were not documented.
The inspector found that the procedure was followed for the ten (10) PTRs reviewed and that operators interviewed understood the process. One PTR authorized personnel protection with special condition tags rather than hold tags to allow PMs to grease the traveling screens. This process required additional management approval which was received prior to authorization, llowever, the inspector identification a repeat occurrence of cleared tags being left in vicinity of the previously tagged component. WACP 10.1.2 stated that upon SS permission for tag release, removed tags should be returned to the controller who shouhl complete the PTR and destroy the tag, llased on this second observation (the first being noted in Inspection Report 90 07), operators did not appear to follow these instructions. Due to the high percentage of tags hmg in potentially contaminated areas, the licensee stated that accepted practice had been for an operator to remove and destroy the tags without returning them to the controller, inspector review of an event during the previous reporting period and of conditions observed during this period led to a concern about the adequacy of controlling work which required electrical and mechanical interface. _ _ _ _.
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The inspector reviewed the causes for a November 1,1990 reactor building ventilation
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isolation and SBGT start, before NYPA issued LER 90-26 dealing with the same subject.
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He concluded that a blown fuse, caused by failure to adequately electrical isolate a primary containment isolation valve during maintenance caused the isolation.
i Maintenance was necessary on 20 AOV 95 (cutboard drywell equipment sump dischnge line isolation valve) following its failure to stroke closed within the TS required time.
However, because of deficiencies in the description of work to be conducted on the work
request only mechanical isolation was hung.
Mechanics subsequently removed the
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solenoid coil for the air supply valve (20 SOV 95), without it being c'ectrically isolated.
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Upon receipt of a high equipment drain sump level the removed coil energized resulting in coil damage and the blown fuse. NYPA reset the isolation, provided adequate electricalisolation and completed the repairs without further incident. NYPA critique of the incident identified several personnel errors in implementation of the pTR procedure, however tSe LER did not specifically address these errors. In the LER NYPA committed to conduct a formal root cause evaluation of the incident.
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On January 9,1991, during followup on an operator log entry the inspector identified a
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similar situation as part of the non safety related Oil / Water Separator Modification, F1-88-007. This modification package consisted of a mechanical and an electrical installation procedure. The removal of the waste sludge pump suction line was authorized following establishment of mechanical isolation. No electrical isolation was established and no electrical work was approved at that time. NYPA pipefitters removed a section of pipe which included an air operated valve with its associated solenoid valve and indicator limit switches. The piperitters disconnected the SOV and limit switches from the valve without electrical isolation. This caused damage to the energized coil.
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The inspector discussed these concerns about inadequate electrical isolations with the i
Operations Department Superintendent who made a night order entry to address the -
conditions. The inspector also talked with the Acting Superintendent of Power who was not aware of the event and conducted a critiqac on January 21, 1991, to identify the facts.
The root cause analysis performed on the November 1,1990, event was very thorough and excellently prepared, however, the corrective actions were not yet formalized by the PORC as ofJanuary 16, 1991. The January 21,1991, critique of the second instance was poorly prepared and included no proposed corrective actions or assessment of the workers actions. The inspector again discussed this with the Acting Superintendent of Power, who stated that NYPA agreed and planned to reconvene the critique to address these issues.
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b Based on this review the inspector concluded NYPA implementation of the PTR program was uconsistent with respect to electrical and mechanical interfaces. Further, the use of skills of the l
t'ade instead of clear job specific guidance to describe work which could involve mechanical or ulectrical interfaces was a weakness. The inspector considered that these issues represented an
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Jnresolved item pending NRC review of NYPA's corrective actions. (UNR 90-09-01)
During this review the inspector noted that Section 6.24 of WACP 10.1.2 was changed to
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provided the necessary instruction to ensure positive disabling of safety equipment to prevent inadvertent automatic actuations during maintenance. This resolved item F-1 of Inspection Report 89-11.
b.
The inspector observed that the repair of the two service water check valves which failed IST was acceptable. This included SS verification that entry into the maintenance condition would cause all crescent area unit coolers to be inoperable, which resulted in the declaration of all ECCS systems as inoperable and placed the unit in a 24-hour shutc. awn TS LCO. The inspector reviewed the necessary tagout and observed portions of the work conducted on the cable tunnel check valve, all of which were acceptable.
c.
The inspector observed good coordination on January 9 when the pressure on A residual heat removal (A RHR) sub-system header was increasing indicating possible PCIV back leakage.
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NYPA declared the system inoperable to allow leakage identification. The inspector monitored the VOTES testing and troubleshooting performed on the A RHR injection valve (10 MOV 25 A).
The inspector found this testing well planned and troubleshooting support from operations, engineering and maintenance MOV task force effective and responsive to resolving the leakage, e
it appeared that the increased leakage was caused by leakage past the inside containment air operated check valve. Following several cycles of 10 MOV 25A the leakage appeared to stop, indicating that the check valve had seated.
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The inspector reviewed the backlog of the Engineering Work Requests (EWRs). EWRs made up approximately 20% of the total of approximately 2000 outstanding WRs. This system was L
being used to identify numerous types of concerns (i.e., plant deficiencies, questions, spare parts procurement issues, out of calibration equipment) needing Technical Services engineering review.
The inspector found that Technical Services was not aggressive in reviewing these issues as indicated in Sections 8 and 9, and in closing these once required action or resolution was determined. The inspector discussed the program with the Technical Services Superintendent and department supervisors. The inspector determined that the WR backlog could be reduced significantly by closing WRs where action was complete. NYPA stated that QA planned to perform an audit of the backlog.
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i 5.0 SECURITY During a tour of the protected area, the inspector noted a questionable condition relative to the protected area barrier. This condition was discussed with the security superintendent who committed to review and resolve the condition if necessary. After discussion with Regional security specialists, due to the low significance of this condition, the inspector found this acceptable.
6.0 ENGINEERING AND TECHNICAL SUPPORT a.
On January 31,1991, NYPA requested a regional temporary waiver of compliance to allow the B recirculation pump to.be restarted with a reactor coolant to lower drain line temperature difference greater than the 145*F limit specified in TS 3.6. A.6.a. At that time the temperature difference indicated 175'F. NYPA stated that the larger than expected differential was potentially caused by either thermocouple deficiencies, lagging separation from the pipe, or a flow blockage in the drain line. NYPA proposed to utilize the average of three lower head skin temperature thermocouple readings. NYPA stated that these temperatures were conservative with respect to the actual water temperature in the lower head region. Further, NYPA proposed to allow this temperature reading to be used three times during the rest of the operating cycle.
This request was not approved by NRC Region I, following a conference call with NYPA, because the requested time period was too broad and more technical data and evaluation was needed to allow a determination that a Waiver was appropriate. Subsequently, the licensee elected to shut down the plant, b.
NYPA completed a S ALP recommendation to review its engineering staffing levels. This study, conducted by a outside contractor, reviewed not only engineering staffing but overall staff of NYPA's nuclear facility and nuclear generation department and other areas which concerned NYPA. The other areas were; document control, outage control, maintenance efficiency, station organization and long range planning. The inspector discussed the results with the resident manager and reviewed the study. On January 17, 1991, the Executive Vice President, Nuclear l.
Generation,. issued a memorandum which discussed organizational changes planned to address several concems raised by the study.
c.
(Open) Unresolved Item (90-02-06): LER 90-25-01. Service water check valves fail to close during testing. This was a supplement to the previous LER discussed in Inspection Report l
~90-08 and documented the failure of the two check valves discussed in Sections 2.c and 4.b l
above.
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Following these failures, NYPA replaced the moving valve internals with stainless wel to help prevent the degrading effects of silt and corrosion. These two valves had been found potentially stuck open from silt and corrosion buildup during the 1990 refueling outage and had been repaired. The enhanced IST had not documented any problems with these valves in the six months since the outage. Further, NYPA planned to continue with the increased frequency (twice per month) testing of these valves. NYPA also committed in the LER to replace these valves with ones of a different design during the 1991 refueling outage.
This item rem:6ned open pending review of NYPA's revised submittal to address and review of the further bg term corrective actions relative to corrosion and silt effects on the ESW system.
d.
During a plant tour of the torus room the inspector noted that torus hatch X-200C had a cover installed that had been designed to allow electrical cable penetrations ar.d that the original blank cover was on the grating and not installed. The modified hatch cover was installed to facilitate the transmission of data during testing, following torus modification, to the SRV tee quenchers. The inspector determined that the instrumentation (strain pages and wiring) installed for use during the testing had not been removed. Review oflicensee Safety Evaluation 81-63, indicated that other BWRs of the same vintage as FitzPatrick had removed this instrumentation during the refueling outage after the testing had been completed. The inspector questioned whether an evaluation for leaving these instruments and wiring installed for longer than one cycle due to the potential for fouling ECCS equipment had been completed. NYPA agreed to review this condition, e.
The inspector reviewed LERs 90-26-00 and 90-27-00 and found them acceptable to address the concerns raised during the two reactor scrams in December 1990.
7.0 ENGINEERED SAFETY FEATURE SYSTEM WALKDOWN
- The inspector performed a detailed walkdown of the accessible portions of the A Core Spray (A CS) sub-system. During the walkdown the inspector verified that the as-built configuration matched the plant drawing and system in accordance with OP-14 Core Spray System. The inspector reviewed the maintenance work request backlog, the preventive maintenance and IST programs and the TS required surveillance testing for CS. Based on this review the inspector
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a.
Overalkondition of the equipment observed appeared adequate. All valves were in their required positions; valves required to be locked were locked. The inspector noted that all valves were labelled with an embossed credit card size stainless steel tag. Tag information was consistent with the valve lineup sheets, allowing positive identification. ~he inspector did note that PSO-60, Plant Label Program was recently revised to specify that in addition to the stainless steel tags, all MOVs and manual valves six inches and larger be tagged with a 4X8 inch divisional ccMr coded equipment identification tags. This portion of the labelling program had i
not been implen anted.
b.
Two minor a:screpancies with the system drawing were identified.
A drain line, downstream of 14-CS-722A, was observed to be capped while the system drawing shows this line drains to radwaste. The pump casing vent valve was locked closed as required by the system lineup, however, this was not reflect on the system drawing. It appeared that these items would have also applied to the B train. The drawing control supervisor planned to review these items and incorporate any needed changes in the next dnwing t.pdate, following discussions with the inspector, c.
The inspector determined that the backup (from condensate transfer) CS keep full check valves were not included in the IST program. NYPA's IST personnel stated that these valves were not required to be in the program because upstream isolation valves were shut. This statement was true provided the system was not used as allowed by the OP. NYPA was reviewing this situation.
d.
The inspector also identified cases where the control and implementation of the IST stroke times for valves was questionable. The IST engineer determined that the opening Appendix K LOCA analysis stroke times for the CS injection valves (14 MOV-12A and 12-B) was less than 10 seconds. However, the IST acceptance criteria allowed up to 11.7 seconds for MOV-12A and 12.2 seconds for MOV-12B. The engineer identified the necessary change to the Operations Department by a performance engineering memo, which also included other changes. The ST was not changed to reflect the correct time until after the inspector identified the need for the change to Operations. The inspector reviewed the data sheets for the last three performances of ST-3P and all the stroke times were within 10 seconds.
During the performance of ST-3P, Core Spray Flow Rate and IST on January 30,1991, the closure stroke time for 14 MOV-ll A exceeded its proceduralized IST value by.1 seconds After discussion with the IST engineer, operators issued a temporary change to update the stroke time reference value from (6.7-9.6) seconds to (8.6-12.4) seconds. The need to make this change in the ST had been identified by IST engineering in April 1990 following valve modifications.
However, the information was not provided to the Operations Department so that the ST could be updated. This problem was not identified until the January 30, 1991, ST performance because the previous stroke times met the existing IST acceptance criteria.
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The inspector determined that these appeared to be isolated cases of failure to ensure that IST information in use was correct, liowever, the inspector considered that the process for updating these IST requirements was not proceduralized and was left to the good practice of the IST engineer. This appeared to be an IST program weakness, c.
Inspector review of the 28 open work requests for the core spray system indicated that approximately half could have been closed.
This included seven WRs for pipe support inspections with some as old as December 1986, because NYPA elected to initiate a new WR every calendar year but had not completed the required action to close the previous WR packages. Further, two WRs for PMs on two safety related hiOVs (14 hiOV-llB and 14 hiOV-26B), dated in hiay 1990 could not be found, but the computer listed them as open awaiting post work testing. ST-3P had been performed satisfactorily after completion of these Phis, but these WRs were not cleared. A WR to conduct a CS Class 2 Piping Pressure Test of Core Spray, date January 1987, was still open.
It apocated that the package was complete except for documentation of the test on the A CS minimum flow piping. The inspector questioned if this pressure test was required or if it had been performed. WRs for a 1989 CS ISI weld repairs were in a " hold for outage" status, since a snoop test of the weld required a PCILRT. Base on inspector questions NYPA subsequently provided adequate documentation that the weld was retested during the 1990 PCILRT. QC was pursuing closcout of this work package.
The failure to identify the ability to close these WRs indicated that the semi-annual data base audits described in WACP 10.1.1 section 7.8.3 were not completely effective, it appeared that the audit were only a cursory check by clerical personnel and not a critical review by licensed personnel to determine any adverse operability effects from open WRs. Further, the Operations Department review of open WRs necessary if a system was made or found inoperable to ensure operability of other ECCS systems was not effective. TS required that the operability of other sub-systems.or other systems be verified when a system was taken _out or service or found inoperable. On January 3,1991, A CS was declared inoperable for maintenance, ST-3K was performed satisfactorily for A CS but fail.:d to identify the above discrepancy. While NYPA had not given the operators formal guidance on how to complete this review, they have stated that they would provide sufficient controls to detect items that affect operability.
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f.
The inspector while reviewing instrument calibration requirements, identified that two i
i normally inservice gages were indicated as Category II/Ill components. The inspector questioned the appropriateness of having non-safety related gages in service on a safety related system when they were not used. The system engineer was reviewing this issue.
g.
The inspector concluded that A CS would function as designed to mitigate the effects of an accident. Licensee plans to address the deficiencies identified appeared appropriate.
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h.
(Open) Unresolved item 90-08-03. Doing review of the CS surveillance tests the inspector noted another example wherein NYDA did not enter the TS LCO for an inoperabic sub-system when a surveillance test specific.hy prevents the ability of the safety system to perform its intended function. ST-3J, Core Spray initiation Logic Functional Test makes the system inoperable by ensuring that the injection valve was closed and inoperable. The test prerequisites did not require entry into the TS LCO or verification of redundant safety systems operable prior to test performance. This item remained unresolved pending NRC review and guidance on this issue.
8.0 TORUS BULK TEMPERATURE INSTRUMENT On December 7,1990, NYPA identiDed that the two channels of torus water average temperature instrumentation, required by TS Table 3.2-6, were reading non-conservatively low by approximately 5 F. While working to correct a related deficiency noted in April 1990, I&C technicians determined that each channel (composed of 16 inputs) had been receiving and averaging in a downscale (30 F) input, due to one of the 16 RTDs never having been installed into the circuit. This condition was documented on an Occurrence Report (OR)90-325. To correct the condition, NYPA performed Temporary Modification (TM)90-206, which enabled the adjacent, installed RTD to also supply the input for the,mconnected RTD.
Upon review of the installation, design, and modification of the torus average water temperature monitoring system, the inspector noted several deficiencies with regard to the engineering evaluation of modifications, the adequacy of surveillances, the timeliness of corrective actions for identified deficiencies, the reportability of an identified inoperable condition, and NYPA's review for corrective actions. The cumulative effect of these deficiencies indicated that NYPA had failed to identify modification errors, had failed to correct errors in a timely manner once identified, and had performed an ineffective review to identify the root causes of the problem.
a.
Chronology The following chronology provides a sequence of events related to this issue.
J182 Additional thermowells for installation of RTDs were installed in the torus wall to be consistent with a 1980 NUREG-0661 safety evaluation report for the Mark I containment long-term program. During installation, a drill bit broke off in one of the thermowells preventing installation of an RTD. Efforts to remove the bit failed and were discontinued as the torus had been refilled. Engineering analysis justified operation with 15 instead of 16 RTDs. The electronic program for calculating the torus water temperature was modified to average only the remaining 15 RTD inputs. The cabling had been run but was left unconnected at the non-functional RTD location. This instrumentation supplied a back panel data logger in the control roo i l
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.L12 Torus water temperature instrumentation was modified to be consistent with TMI Action Plan post-accident monitoring instrumentation guidance (Reg. Guide 1.97), i.e., modified to provide two independent channels each with 16 inputs from the dual element RTDs.
The modification was intended to provide for monitoring of torus water temperature during both normal and accident conditions, including inputs to the SPDS computer and an SPDS and annunciated alarm at 95 F for use in EOPs and for TS required mon.ioring
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of torus temperature. The torus was not drained so the damaged thermowell was not repaired as part of the modincation and thus cach channel was left with 15 functional RTD inputs. Pre-operational testing of the modification verified that two RTD signals were not present. The calculation program for the instrumentation was not modified to account for the use of 15 instead of 16 RTDs However, the system was designed by NYPA with a function which would remove a failed RTD from scan at a point where it deviated from the average by 10%. Thus the two non-functional RTD values were removed.
This circuit also provided for a two second alarm of the High Torus
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Temperature annunciated alarm, followed by renash if the circuit was removing an RTD from scan, 12/88 NYPA recognized that rejection of a temperature signal that deviated by 10% or greater may have resulted in the rejection of a valid temperature signal (when an SRV discharged
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or HPCI or RCIC steam supplies exhaust to the torus). The safety evaluation for the modification was subsequently modified to allow the rejection of signals which deviated from the average by 1100% but substantiating rationale for the change was not provided in the safety evaluation. (This change assumed that the missing RTD would provide a deviation signal of greater than 100% and would therefore be eliminated from the calculation. This assumption was later found to be incorrect).
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10/89 The torus water temperature calculation circuit was reprogrammed using a work request to include the 1100% deviation. At this point the instrumentation provided an average I
temperature reading that was ron conservatively low by approximately 5 F. The post-modification testing used ISP-28, Suppression Pool Temperature Calibration, and was signed off as satisfactory to meet TS requirements, it was noted that the " Torus Bulk Temperature High" control room annunciator would not actuate on an open or shorted RTD reading and that a 100% deviation was not possible. An engineering work request was written for technical services to follow up on this problem. (The engineering work request had not been acted upon at discovery of the problem in December 1990.)
11/89 NYPA received TS Amendment 144 which, in part, changed the requirements for torus temperature monitoring instrumentation to be the two instrument channels discussed above.
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4/90 During performance of the normal TS required :libration per ISP-28, the same and alarm problem noted in October 1989 was documented, and the October 1989 WR 9BD was referenced.
Again, these STs were signed off as satisfactory to meet TS requirements. Further, downscale readings for one of the 16 RTDs to each instrument channel were noted as deficiencies and an April 1990 WR was written for I&C to investigate.
12/7/90 Troubleshooting under the April 1990 WR found that both channels of the temperature monitor in question were inputting a false value of 30 F to the temperature averaging circuit. This was documented in OR 90-325, and NYPA performed TM 90-206 which allowed the adjacent, installed RTD to supply a second input, thus making 16 total inputs to each instrument.
L2K PORC determined that the inoperable condition of these instruments was not reportable due to a Technical Specification interpretation which indicated that alternate instrumentation could be used in place of the inoperable temperature monitor. The PORC review concluded that the deficicacy occurred because of inadequate review of the setpoint change made in October 1989 and that the calibration procedure was deficient.
PORC also reviewed the TM and determined that it was acceptable.
1/14/91 NYPA classified the issue as a reportable event following a discussion with the resident inspector over the use of the TS interpretation.
2/13/91 NYPA submitted LER N029 on the inoperable torus water average temperature instrumentation.
The NYPA investigation uncovered an initially weak engineering review of how these instruments functioned with respect to removing a failed instrument from scan. Rather than comparing the percentage deviation of an individual instrument reading to the average values, the instrument actually compared an individual reading to the average reading as a percentage of instrument scale (200*F).
b.
Deficiencies:
1.
During the OR review NYPA identified that there was inadequate engineering work on the modification to the temperature averaging circuit to change the setpoint for removal of invalid inputs from 10% to 100%. The error in this modification resulted in the torus water average temperature being non-conservatively low and rendered this instrumentation inoperable when the modification was installed in October 1989.
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2.
During the OR review NYPA identined that the calibration procedure (ISP-28) used for post-modi 6 cation testing and biannual TS-required calibration was inadequate and did not determine that the torus water average temperature was reading low. On three ocassions, the procedure was completed and signed as satisfactory and the inaccurate average temperatures were not detected. Specifically, the procedure calibrated each RTD but did not independently calculate the average of the RTD readings and compare this calculated average temperature to the average temperature output of the instrument. The inspector evneluded that the repeated use of an inadequate procedure appeared to indicate the lack of a questioning attitude by the !&C technicians and reviewers.
3.
Following the October 1989 modification, NYPA demonstrated poor evaluation and followup to the problems identified during the post modification testing. As stated above, the calibration procedure used during post modification testing was inadequate in that it did not independently calculate an average temperature and compare the instrument output against it.
Nonetheless, during the testing NYPA identi6ed that the alarm would not actuate when an RTD was removed from the circuit. Subsequent troubleshooting identined and documented on an engineering work request that "it is not possible to achieve 100% differential between bulk and individual RTD readings". In effect this observation rendered the modification a failure, in that the 100% differential had been implemented to remove failed RTDs (having greater than a 100% differential) from the averaging circuit. The engineering WR written in October 1989 remained open at the end of the report period.
Desp te the identined problem, NYPA proceeded to accept the modification. There appeared to be no immediate effort to evaluate whether the problem could affect the operability of the instrumentation. Accordingly, the post modification test was signed off as satisfactory and meeting TS requirements, and supervisory review of the test agreed with this conclusion. The inspector concluded that the initial acceptance of the Gawed modification and the lengthy delay in troubleshooting the identined problem represented an unacceptable approach to ensuring the operability of a safety system.
In addition, the inspector concluded that NYPA also demonstrated untimely corrective action regaiding the second WR, written in April 1990 to troubleshoot a downscale RTD _(the uninstalled RTD) following the biannual calibration. While this WR was the method by which the deficiency was eventually identified, this WR had been open for approximately eight months.
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4.
PORC incorrectly determined that the inoperable instrumentation was not reportable based
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on an inappropriate TS interpretation for TS Table 3.2-6. which required that these two instruments be operable. Tojustify that redundant equipment was available, NYPA implemented TS interpretation No.17, which stated that two other single point RTDs, with indications located on a panel in the relay room, were suitable replacements for these two averaging instruments. The inspector stated that because the alternate instruments did not meet the requirements described in the SER accompanying TS Amendment No.144, this position did not appear to be appropriate. After the inspector discussed this and the reporting requirements of 10 CFR 50.73 with the Superintendent of Power on January 14,1991, he decided to submit an LER.
5.
The inspector concluded that NYPA ocmonstrated a weak review and evaluation process following the identification of the inoperable instrumentation. Specifically, the discovery of the inoperable instrumentation showed that an incorrect temperature was being input into the average circuit and that the invalid temperature input was not being removed from the circuit. Regarding the incorrect temperature input, NYPA installed the input from the adjacent RTD to correct this.
However, the safety evaluation for this change (Th190-206) was deficient in that did not address the basic change to use the adjr. cec' RTD for two inputs. The safety evaluation used the FS AR's discussion of 16 RTDs as a basis, but the change related to one RYD supplying two inputs. The safety evaluation used the 1987 safety evaluation as a basis, but that design used 15 inputs as the 10% differential removed the sixteenth from the circuit. Also, the Thi safety did not address how many RTDs were required to be operable for the instrument channels to be operable.
Further, the safety evaluation did not address the aspect that a failed RTD would not be removed from the circuit or alarmed to operators, incorrectly assumed in the previous modification but now obviously in error. The fact that PORC subsequently approved this Th1 and its associated safety evaluation, based on the inadequate information provided on the Thi, indicated a weak review was conducted.
Further, the inability to remove failed RTDs and to alarm such a failure to operators was not corrected or compensated. At the end cf the period the averaging circuit retained the 100%
differential known io be incorrect. TS Table 4.2-6 requires that a daily instrument check be performed on the torus water temperature instrumcats; however, the procedure for logging these
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temperatures had not been able to detect a failed RTD, in that there was no acceptance criteria for comparing the two channels to each other and the individual RTD readings were not logged.
The inspector also questioned how an operator or an I&C technician taking a reading for a specific RTD at the local panel would know that the Thi was in effect since a tag to inform the
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operator of the altered condition was not included. In late January, the inspector discussed these concerns with the operations superintendent, who then changed the daily log for monitoring TS instruments (ST-40D) to log each RTD reading separately to ensure that a failed RTD would be identified. He also added a special condition tag to the local monitoring switches to indicate that
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one RTD was not installed and that one RTD was supplying two signals.
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6.
The inspector found that NYPA did not provide accurate information on the status of the
degraded condition of the torus awage temperature monitoring system to plant personnel.
Specifically, the only open documentation, apparent to the inspector, indicating that the RTD was not installed was WR 53379, dated April 15, 1987, to repair or replace the thermowell for 161 RTD 136 during the next outage. Plant electrica! drawings (FE-3GR ar.d FE-3UE), instrument loop drawings (LP-16-1-52 and LP-16-1-57), and mechanical drawing (FM 44 A) indicated that the 16 RTDs were installed. There was no ron-conformance written to document the situation, and there was no temporary modification o' caution tag indicating that the system was actually different from what was shown on the drawings following compktion of the modification, c.
Safety Significanct The inspector concluded that the safety si :nificance of the temperature averaging error was that it affected the instruments necessary to en.ure compliance with torns temperature limit specified r
in TS 3.7. A.c and entry and controlling c mditions in the EOPs which utilize torus temperature.
The error affected the subsections of TS 3.7.A.c in the following ways (the calculated torus temperature when the indicated temperature was at the TS limit are provided in parentheses);
(1)
TS specifies that torus temperature shall be less than 95 F (99 F).
(2)
TS allows the temperature to rise to 105 F (110 F) during testing.
(3)
TS requires that the plant be scrammed at i10 F (115 F).
(4)
TS requires depressurization of the reactor vessel if isolated with a torus
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temperature of 120 F (125 F).
The error introduced would have affected the use of the EOPs in the following ways; 1)
Torus water at 95 F (99'F)is an entry condition to EOP-4, Primary Containment Control, l
2)
Torus temperatures ranging from i10 F (115 F) to 137 F (143*F) are used in a graphical form in EO"-4 to determine if boron Mjection should be utilized.
i 3)
Torus temperature in the range of 100 F (104 F) to 220 F (232 F) are used to determine the primary containment temperature limit.
In LER 90-029 NYPA evaluated the safety significance of this condition as being minimal,-but there was no documented basis for making this statement. Also, NYPA noted that the actual torus temperature had never exceeded 95 degrees F, the temperature at which the above specifications would have applied.
d.
Conclusions:
The inspector concluded the following.
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TS 3.2.6, which requires that at least one channel of torus water temperature instrumentation be operable, was not met from November 1989 (when TS Amendment 144 was implemented) until December 7,1990. This represented an apparent violation. Both channels
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were inoperable in that the average temperature reading was non-conservatively low by approximately 5*F.
2.
TS 4.2.6, which requires that the torus water temperature instrumentation be calibrated on a biannual basis to confirm operability, was not met and represented an apparent violation.
Although the calibration was performed biannually, the procedure was inadequate to determine that the average temperature was non-conservatively low by approximately 5 degrees.
3.
The engineering error in the modification of the temperature averaging circuit to have a 100% setpoint on deletion of invalid inputs represented an apparent violation of 10 CFR 50, Appendix B, Criterion 3 regarding design control and verification of design adequacy. In
. addition, the post-modification testing accepted the modification despite apparently identifying the desin error.
4.
The untimely corrective action for the identified deficiencies regarding the impossibility of achieving a 100% differential and the inability of the alarm to actuate for a disabled RTD input represented an apparent violation of 10 CFR 50, Appendix B, Criterion XVI regarding corrective action. Specifically, an engineering work request written in October 1989 identined the inherent error in the 100% setpoint had not been acted upon in December 1990 when the inoperable condition was identified. Further, the work request (WR) for troubleshooting a downscale RTD was initiated in April 1990 but work on the WR was not begun until December
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1990. This represented untimely corrective action to an indentified deficiency on safety related equipment. Although the identified deficiencies (alarm and RTD) had less signincance than the inaccurate average temperature, the alarm represented a symptom of the temperature problem, and its slow resolution delayed the identification of the temperature problem.
5.
The NYPA decision that the identined instrument problem was not reportable was incorrect and represented an apparent violation of 10 CPR 50.73. The operation of the plant in a condition prohibited by TS necesitate(' a written report (LER) that was not submitted within the 30 days permitted. NYPA identi6eu the inoperable condition on December 7,1990, the l_
inspector discussed the decision not to submit an LER on January 14, 1991, at which point NYPA decided to submit an LER, and LER 90-029 was submitted on February 13. As discussed above in Deficiency 4, the use of an inappropriate NYPA TS interpretation was involved in the incorrect decision.
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The NYPA safety evaluation and safety review process on the TM in December 1990 did not provide an acceptable basis for the TM, Accordingly,10 CFR 50.59 and NYPn procedure WACP 10.1.3, Control of Jumpers. Lifted Leads and Temporary Modifications were not met and this represented an apparent violation. Specifically, the TM safety evaluation did not address the acceptability of using an adjacent RTD input or the instrumentation's inability to indicate any RTDs failures to operators.
The above apparent violations of NRC requirements will be tracked es APP VIO 90-09-02, 9.0 SAFETY ASSESSMENT AND QUALITY VERIFICATION The inspector concluded based on review of non-conformances on electrical fire barrier a.
penetrations that NYPA's control of fire barrier penetration acals was inadequate. This led to penetration seals which were degraded to various nonconforming conditions. It appeared that there was a lack of plant management involvement because the de6ciencies failed to rise to a level where timely corrective action was taken.
The inspector reviewed the installation procedures, design configuration drawings for electrical fire barrier penetrations and a sample of the QC visualinspection sheets for modification F1-80-007. The inspector determined the penetrations were initially built to documented, tested conditions and verified by QC during post-installation visual inspections. Further, NYPA's procedure for performing the TS required visual inspections of and repairs to electrical fire barrier penetrations were reviewed. The inspector determined the following:
Two surveillance procedures with differing acceptance criteria existed for conducting the 18 month fire barrier penetration visual inspections (required by TS 4.12.F.1.a) on electrical penetrations.
The operations department procedure (ST-76Z) required that all seals be determined intact visually with no damage or air flow through the penetration. The maintenance department procedure (MST-76.ll) required verification of conformance with the as built configuration for electrical penetrations only, if a non-intact penetration was found, ST-76Z directed establishment of a continuous Orc watch within one hour, as required by TS 3.12.F.1.b.
The MST-76.11 only required that a WR be generated to correct any deficiencies noted. ST-76Z and MST-76.11 were performed in parallel between May and November 1990. ST-76Z was
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signed off as satisfactory on November 14, while MST-76.11 had identified numerous non-conforming conditions in electrical fire barrier penetrations.
The requirements for the installation of damming material in the current procedure for installing ar.d opening and scaling electrical penetration seals (I-SE-03) were inconsistent. The procedure provided for implementation of the original as-built onfigurations and for a different updated con 6gura%n The inspector determined NYPA failed to resolve this conflict during previous IS-E-03 ;
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On August 1,1990, the maintenance department wrote AQCR 90-169 (classified stanaard significance) to document numerous non-conforming conditions identined during MST 76.11 performance.
This also identiGed the discrepancy noted in the installation procedure requirements above. QA sent the AQCR to technical services with a recommendation that the acceptability of the non-conforming conditions be evaluated. An occurrence report was not written at that time to document the non conformance, so that compliance with TS 3.12.F.1 could be assessed.
Technical services responded on October 11,1990 stating that the conditions were acceptable based on other tested configurations, overconservative barrier rating testing, low combustible
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loads, low percentage of seals affected and excess foam depth above the design requirements.
Further, it was stated that the significance of the non-conformances would be reviewed by the corporate office by December 12, 1990. Technical services also identified that the root cause of the non-conformance needed to be determined.
AQCR 90-169, Rev.1, dated December 7,1990, initiated by QC documented the fact that MST 76.11 visual inspection identified hpproximately 118 penetrations where inadequate damming materic.l existed. Further, it was documented that step 7.4 of MST 76.11 required a work request to be initiated to document the unsatisfactory condition. On December 6, the WR had been initiated, QA again recommended engineering determine acceptability of the non-conforming penetrations and stated no violations of " seal integrity" existed.
QA also recommended that inspection criteria be reviewed to address the TS surveillance requirements.
The original AQCR was closed three days later by the same QA individual who signed for initiator and reviewer of that document. Rev. I of this AQCR again failed to address the cause of the non conformances from the as-built configuration.
An OR was written December 12,1990, and two hour fire patrols were initiated until the ton-conformances were corrected. There was no documented determinations of the ability of these penetrations to perform their three (3) hour fire barrier rating. Thejustification for not necoing the continuous fire watch was not clearly documented, but it appeared that it was based on the technical services October 1i response to the original AQCR discussed above.
Since December 12,1990, six additional ors and various work requests were issued identifying 164 non-conforming penetrations. NYPA has not determined safety significance, reportability or root c. case of the non-conformances.
WPO technical evaluation of the non-conformances, ACTS item 1975, due December 1,1990 was extended to February 1,1991. NYPA long term corrective actions and reinspection were awaiting this evaluation.
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Based on this review the inspector concluded that NYPA's fire protection program failed to maintain electrical fire barrier penetrations in the tested three hour fire resistance rating required
by Facility Operating License, section 2.C(3). The inspector also concluded that NYPA failed to take timely corrective actions to determine the cause of the program degradation required by 10 CFR 50, Appendix B, Criteria XVI. Further, when compensatory actions were taken they did not comply with the actions required by TS 3.12.F.1.b. The inspector considereo that these represented apparent violations of NRC requirements. APP VIO 90-09-03
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The inspector reviewed Information Notice 88-56, Potential Problems with silicone foam fire barrier penetration seals, including NYPA's evaluation 9ER 880286) dated April 1989. This notice ide:.ified non-conforming conditions in fire penett ion seals due n. lack of shrinkage of
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fill material. Technical Services recommended that no ack.'tional inspection of penetrations at
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FitzPatrick be conducted because of: NYPA personnel training, proper installation procedures which reduce the probability of nonconforming seals, and visual surveillance tests performed every 18 months verifying the integrity of seals. This OER was still open and the inspector considered this present evaluation inadequate based on the identified problems to date.
b.
(Open) Unresolved item (90-08-04):
The inspector continued to review NYPA's corrective action systems. The inspector reviewed NYPA's QA audit program and several audits conducted during 1990. The portions of the TS required audits conducted by the onsite QA staff and the methods of conducting these audits were specified in QA pncedure 18.4-Audit Program implementation and QA procedure 18.1, QA Audit Program, respectively. The inspector found that the program laid out in QAP 18.4 met the TS requirements for audits and that all audits have been completed on schedule. However, the inspector noted that several methods which NYPA used to identify and correct dcficiencies in equipment, structures, systems or methods of operation were not specified as requiring auditing. Not included were standard AQCRs, Work Requests, Action / Commitment Tracking System, Occurrence Reports, review of actions on
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industry events and performance and system engineering memorandums. Failure to audit these systems to ensure that identified deficiencies were resolved properly appeared to be a weakness in the QA program.
The inspector reviewed four audits in depth. One was a TS required audit of deficiency corrective actions. The other three were program audits that were not specified as required by TS.
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Audit 712, TS required corrective actions audit, dated July 13, 1990. This audit was a follow-on to the previous audits, also reviewed, which were conducted in this area. The inspector determined that these audits only concerned themselves with LERs, NRC violations and NYPA responses to NRC bulletins. There has been no audit conducted
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to specifically review the functioning of the other deficiency identification systems,
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discussed above, during the last year. This was the apparent result of a resident manager request to track these issues following the 1987 overexposure on the refuel floor.
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Further, although this audit was very broad in scope there was no specific checklist or objectives to indicate how the effectiveness of corrective actions was evaluated. The inspector found no documentation of the type of assessment that was applied to each of these items. These audits appeared only to document and track these issues, not to review the suitability of the corrective actions.
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Audit 715 (Review of EOP Administrative Controls), dated August 17,1990. This audit was well prepared and presented several well defined recommendations to improve the controls and documentation of EOPs.
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Audit 708 (Inservice Testing Program Implementation). This audit was well laid out with the attributes that were to be audited and very good observations. When the observations indicated that an attribute had not been met or was indeterminate, the issue was included on an AQCR to ensure corrective actions. This audit identified numerous weaknesses in the IST program.
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Audit 90-06 (Smihber Controls), dated June 6,1990. NYPA site personnel had requested that QA conduct this audit. The audit was of good quality and documented numerous
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deficiencies with the snubber control and testing program.
This item remains open pending further NRC review.
10.0 OTHER INSPECTIONS The programmatic engineering and technical services inspection was conducted between January 28 and 31,1991, as documented in Inspection Report 91-04.
I 1.0 EXIT INTERVIEW At periodic intervals during the course of this inspect:an, meetings were held with senior facility management to discuss inspection scope and findings. In addition, at the end of the period, the
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NITACllMENT A James A. FitzPatrick Nuclent Power Plimt Acronyms Action Commitment Tracking System ACTS
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American Nuclear Insurers AOV
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Air Operated Valve AQCR
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Adverse Quality Condition Report CS
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Core Spray System ECCS
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Emergency Core Cooling System ESF
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Engineered Safety Feature EOP
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Emergency Operating Procedures ESW
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Emergency Service Water FSAR
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Final Safety Analysis Report IP3
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Indian Point 3 I&C
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Instrumentation and Control In-Service inspection ISI
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In-Service Testing LCO
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Limiting Condition of Operation LER
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Licensee Event Report LPRM
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Local Power Range Monitor MOV
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Motor Operated Valve NRC
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Nuclear Regulatory Commission NYPA
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New York Power Authority OP
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Operating Procedure OR
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Occurrence Report PCIV
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Primary Containment Isolation Valve PM
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Preventive Maintenance PORC
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Plant Operations Review Committee PSO
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Plant Standing Order PTR
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Protective Tagout Request Quality Assurance QA
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Quality Control RAP
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Reactor Analyst Procedure RHR
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Residual Heat Removal System RTD
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Resistance Temperature Detector Radiation Work Permit RWP
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Safety Evaluation SER
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Safety Evaluation Report SOP
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Superintendent of Power SOV
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Solenoid Operated Valve SPDS
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Attachment A (Continued)
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Shift Supervisor Surveillance Test ST
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Temporary Modincation TS
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Technical Specification WACP
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Work Activity Control Procedure WCC
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Work Control Center WPO
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White Plains OfRec WR
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Work Request
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