IR 05000333/1992003
| ML20198D597 | |
| Person / Time | |
|---|---|
| Site: | FitzPatrick  |
| Issue date: | 05/05/1992 |
| From: | Haverkamp D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20198D566 | List: |
| References | |
| 50-333-92-03, 50-333-92-3, NUDOCS 9205210090 | |
| Download: ML20198D597 (21) | |
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U.S. NUCLEAR REGCLATORY COMMISSION Region i Report No.:
92-03 Docket No.:
50 333 License No.:
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Licensee:
New York Power Authority Post Off~ ice Box 41
.Lycoming, New York 13093 i
Facility:
James A. FitzPatrick Nuclean Power Plant
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Location':
Scriba, New York Dates:
March 8,1992 through April 18, 1992 inspectors:
W. Cook, Senior Resident inspector -
R. Plasse, Jr., Resident inspector J. Caruso Operations Engineer Examiner A. Finkel, Senior Operations Engineer m [- b f/f/91 l
Approved by:
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Donald R. Haverkamp, fhief Date l
Reactor Projects Section No. IB hispection Sui.mmrl:
Routine NRC resident inspection of plant operations, radiological controls, maintenance, engineering and technical support, and quality assurance / safety verification.
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Results: See Executive Summary
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'9205210090 920513 PDR ADOCK 05000333
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Ihecutive Summuy James A. FitzPatrick Nuclear Power Plant NRC Region 1 Inspection Report No. 50-333/92-03 March 8,1992 - April 18,1992 Plant Operntions The plant remained shutdown throughout the inspection period. The performance of operations department perr.onnel during routine activities was generally good. I'lowever, one non-cited violation is discussed in section 2.3 of this report, where licensed operators failed to implement written procedures and were weak in response to alarm conditions. This poor performance resulted in overheating a motor bearing for the A residual heat removal service water pu'mp.
NYPA completed a thorough, high-quality shutdown risk assessment of the refueling outage.
During March 24-26, 1992, a special review was conducted of the fire protection program improvements to Dre watch training and control of combustibles. The compensatory Ore watches were observed to be well trained. The hot work Dre watch training improved, but the
!icensee concluded further improvements, especially in the area of hot work permits / checklist responsibilities, were necessary. Combustible levels and general plant cleanliness were adequate and improving, and NYPA site management has committed to develop and implement a formal program to maintain this condition.
Endiologieni controls Radiological work practices observed during the performance of maintenance activities and during routine plant tours were appropriate. The health physics technicians conducted good pre-job briefings and maintained good surveillance of work activities. Radiological work areas were generally clean and had appropriate radiological postings.
Maintenance With a few minor exceptions, procedures were followed closely and documentation was kept up-to-date. In addition to the required quality control hold points and verifications, quality assurance personnel were observed conducting surveillances of selected maintenance activities.
Supervisory oversight, procedural adherence and quality veriGcations were generally effective.
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The contrauoi procedure, which is referenced in the hydraulic snubber functional surveillance i
test procedure, does not appear to meet the intent of NYPA's administrative controls for a
" continuous use" procedure. NYPA station management agreed to evaluate this observation and take appropriate action.
Engineerine and Technical Suppnd NYPA has cleared the review backlog coacerning Limitorque valve operator motor pinian key failures dating back to 1981. This was an example of the progress being made on NYPA's commitment to reduce the significant operating events backlog.
Safety Assessment /Ounlity VerificatioD A review of Technical Specification quality assurance audits is:iued in the past six months indicated, overall, that the quality of the audits was good, but the followup of some QA observations (observations not constituting a noncompliance or non-conforming condition) was weak. Adverse quality condition reports (AQCRs) were also reviewed by the inspector, back to July,1989. NYPA performance in the review of the AQCRs was found satisfactory, however, a general weakness was noted in the performance of root cause analysis in those AQCRs which required one.
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TAllLE OF CONTFNI'S 1.0 SUMhiARY OF FACILITY ACTIVITIES I
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1.1 NYPA Activities.................................... I 1.2 N RC Acti vities..................................... I 2.0 PLANT OPERATIONS (71707,71710,93702)
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2.1
"')utine Plant Operations Review........................
I 2.2 Enginected Safety Feature Walkdown of A and C Emergency Diesel Generators
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2.3 Overheating of Residual lleat Removal Service Water Pump hiotor Beari n g s......................................... 3 2.4 Diagnostic Evaluation Team Observation Followup.......
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2.5 Temporary Instruction (TI) 2515/113 - Reliable Decay Heat Removal During outages
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3.0 RADIOLOGICAL CONTROLS (IP 71707)....................
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4.0 hiAINTENANCE (IP 62703)
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4.1 Observation of hiaintenance Activities....................... 6 c
5.0 REVIEW OF FIRE PROTECTION PROGRAhi lhiPROVEhiENTS TO FIRE WATCH TRAINING AND CONTROL OF COhiBUSTIBLES.........,.. I1 6.0 ENGINEERING AND TECHNICAL SUPPORT (9F,'02)..............
6.1 Review of NYPA's Efforts to Evaluate Limitorque Valve Operator hiotor Pinion Key Failures...........................
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7.0
- SAFETY ASSESShiENT/ QUALITY VERIFICATION (71707,93702)....... 16 7.1 Review of Quality Assurance (Q.A) Audits and Adverse Quality Condition Reports ( A QCR s)..................................
8.0 htANAGEhiENT hiEETINGS..............................
NOTE: The NRC inspection manual procedure or temporary instruction that was used as inspection guidance is listed for each applicable report section.
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DETAILS 1.0 SUh1 MARY OF FACILITY ACTIVITIES 1.1 NYPA Activities During this inspection period, the plant remained in cold shutdown with the core off loaded to support the 1992 refueling outage activities. NYPA continued to repair various fire barrier electrical penetration de6ciencies. Major work tasks completed or in progress during the inspection period included various diesel generator maintenance and testing activities and B core spray piping replacement.
1.2 NRC Activilin The activities during this report period induded inspection during normal, backshift and weekend hours by the resident staff. There were 53 hours6.134259e-4 days <br />0.0147 hours <br />8.763227e-5 weeks <br />2.01665e-5 months <br /> of backshift (evening shift) and 62 hours7.175926e-4 days <br />0.0172 hours <br />1.025132e-4 weeks <br />2.3591e-5 months <br /> of deep backshift (weekend, holiday and midnight shift) inspections during this period.
A team of headquarters and region-based inspectors conducted a resiew of the Fire Protection / Appendix R Program, March 9-20,1992, as a followup to the Diagnostic Evaluation Team Review in September-October,1991.
A team of region-based inspectors conducted a review of the emergency preparedness program the week of March 23.
A region-based inspector conducted a review of fire watch training and control of combustibles on March 25 27, 1992.
A region-based inspector conducted a review of radiological controls practices during the week of March 30,1992.
A team of headquarters and region based inspectors commenced a review of the service water systems the week of April 13. This inspection will complete the week of Apnl 27,1992.
2.0 PLANT OPERATIONS (71707,71710,93702)
2.1 Routine Plant Operations Review During the inspection period the inspectors observed control room activities including operator
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shift turnovers, shift crew brienngs, panel manipulations and alarm response, and routine safety system and auxiliary system operations conducted in accordance with approved operating
- procedures and administrative guidelines. The inspectors independently veri 5ed safety system operability by review of operator logs, system markups, control panel walkdowns and component status verifications in the neld. Discussions were held with operators and n ' icians in the Deld to assess their familiarity with current system status and personnel response a events during the inspection period. In addition, during plant tours, inspectors reviewed routine radiological control practices. The activities inspected were found acceptable.
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2.1.1 Auxiliary Plant Operator Rounds On March 11,1992, the inspector accompanied an auxiliary plant operator on his routine rounds of the turbine building. On April 14, 1992, he accompanied an operator on routine rounds of the reactor building. The operators were observed to check all operating equipment for proper operation (i.e., parameters within tolerance, no abnormal sounds or vibrations, no all leaks, sump levels proper, breaker, switch and valve positions, as required). The operators were also observed practicing good radiological work practices. In addition, the operators were obsened to be diligent, knowledgeable in all areas questioned, and professional in discharging their duties.
2.1.2 Operational Safety Verification
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The inspector conducted partial control room and in-plant walkdowns of the A emergency-service water and A core spray systems. The inspector concluded that there were no observable problems affecting system performance or operability.
2.2 Engineered Safety Feature Walkdown of A and C Emergency Diesel Generators On April 4-6,1992, the inspector conducted a detailed walkdown of the accessible portions of A and C emergency diesci generators to verify operability. Normal system lineups (i.e., valves, switches, power supplies) were verified correct using operating procedure, F-OP-22.
In addition, the following equipment conditions and items were verified: housekeeping was adequate; valves did not have significant packing leakage, bent stems, missing handwheels or improper labelling; no prohibited ignition sources or flammable materials were present; major system compenents were properly labelled, lubricated, cooled, and no significant oil leakage was observed; instrumentation was properly installed, functioning, and values observed were consistent with normal expected values; support systems essential to system actuation (i.e., lube oil, air start, fuel oil, and ser ice water) were verified operational; and instrument calibration dates were current.
The inspector also reviewed the jumper, lifted lead and temporary modification, the protective tagout request log, and open work requests to verify system condition and operability.
Auxiliary plant operator log sheets for several shifts were reviewed and found to be accurate and complete with one exception. The C lube oil sump, when sounded by an auxiliary operator in the presence of the inspector, indicated over three inches below full on the dip stick, which was
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below the minimum required sump level of two inches below full. The auxiliary operators had been incorrectly logging sump level at two inches below full. The dip sticks did not have
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minimum level lines to aid the operators in determining a condition of low sump level. The shift supervisor indicated that he would initiate a request to have minimum level lines added to the dip sticks to aid the operators in identifying a minimum level condition. This was the only discrepancy noted in reviewing the logs.
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Smpliance with technical specification requirements was also verified. Surveillance test results i
for procedures ST-9A (Fuel Oil Quantity Check), 9B (Fuel lead and Emergency Service Water Pump),9L (Fuel Oil Transfer Pump), and 9M (Starting Air Compressor), were reviewed for the L
past several months. Laboratory analysis reports for Technical Specification required monthly diesel fuel storage tank sampling were also reviewed for the past several months. Analyses test
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results were acceptable. However, the inspector noted that NYPA sent its fuel samples off site for analysis, but had no mechanism to ensure the laboratory analysis reports were returned and reviewed in a timely manner (less than 30 days). NYPA plans to add a line item to the chemistry surveillance schedule to followup and check on lab reports not received in the expected time period.
The inspector concluded that the A and C emergency diesel generators were properly maintained with no obvious defects. Technical specification surveillance testing requirements were satisfied and there were no observable problems impacting system performance or operability.
2.3 Overheating of Residual Heat Removal Service Water Pumn Motor Bearings On April 3,1992, the cooling water discharge isolation valves for the A and C residual heat
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removal service water (RHRSW) pumps were found in the closed position. The normal position
of these valves per operating procedure (OP)-13 was open. These valves were found out of
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position when an operator responded to high bearing temperature alarms on the A RHRSW pump motor. The A RHRSW pump was running to suppi rt emergency diesel generator (EDG)
testing per ST-98. Prerequisite step 4.15 of ST-98 requires emergency service water forebay circulating flow by running either the A or C RHRSW pump.
NYPA critique of this event identified that during earlier EDG testing, the RHRSW pumps were sprayed with water when workers in the screenwell area uncoupled a large water-filled hose above the emergency pump room. Water from the hose poured over floor plugs above the emergency pump room and leaked through the floor plugs wetting down the RHRSW pumps below. The operators' initial response to this event was to secure the pump and to close the cooling water discharge isolation valves to the A and C pumps.
A review of the critique minutes issued by the operations department, dated April 13, 1992, identified the following operator errors that led to overheating of the A RHRSW pump motor bearings:
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Closing of the cooling motor discharge isolation valves for A and C RHRSW pumps was
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.not tracked per procedure ODSO-18, Equipment Status Control. ODSO-18, section 7.6.3.2 states for situations requiring breaker or valve manipulations, not covered by procedures, changes are permissible provided shift supervisor permission is obtained and the position change is recorded in the nuclear control room operator log and on the last valve line-up coversheet. Contrary to this, a log entry was not made by the nuclear control room operator (i.e., !icensed reactor operator at the controls) on duty at the time.
This resulted in a loss of system status.
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During subsequent operation of the A RHRSW pump (i.e., following satisfactory pump
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motor inspection and post inspection testing) to support EDG testing, at 2:39 p.m.,
bearing high temperature alarms were received and acknowledged by the control room o}arators on A RHRSW pump. The operators shut the pump down and the alarms cleared. However, proper corrective action to investigate the cause of alarms was not initiated.
The A RHRSW pump was restarted at 10:43 p.m. to support further EDG testing. At
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11:08 p.m., A RHRSW pump motor upper and thrust bearings alarmed. The nuclear control room operator (NCO) acknowledged the alarm, but failed to take proper corrective action. Approximately one hour later, the NCO realized the computer points for the A RHRSW pump were still in an alarm status. An auxiliary operator was sent to investigate and discovered the cooling water return valves for both A and C RHRSW pumps closed (C RHRSW pump was not running). The A RHRSW pump was removed from service to allow for inspection of motor bearings.
I The inspector reviewed the following corrective actions specined in the operations department critique:
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The operators involved received counseling for failing to follow provdures properly and for failing to respond properly to computer alarms.
Each operating shift was briefed on the occurrence and lessons learned. The operators
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were reminded to remain vigilant, in spite of the present cold shutdown condition with the core off loaded.
Surveillance testing requiring participation by the shift's entire licensed operator
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complement will no longer be scheduled during peak hours.
Actions will be taken to reduce the number of control room computer points in an alarm
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status.
As discussed above, NYPA licensed operators failed to implement the requirements of ODSO-18 resulting in a loss of control of system status. In addition, inadequate operator response to alarm conditions resulted in RHRSW pump motor bearing overheating and suspected bearing damage.
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A review by the inspector of the critique issued by the operations department indicated that a prompt and thorough assessment of events and a proper identification of root causes and corrective actions was conducted. The safety significance of this event was minimal in that the pump continued to function to provide pump bay circulating flow and the core was off loaded at the time. In that this event was licensee-identified and satisfied the criteria of 10 CFR 2,
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i Appendix C, section V.G., the procedural noncompliances stated above are not being cited. (92-03-01)
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2.4 Diagnostic Evaluation Tom Observation Follows (Closed) DEO. OPS.028 This diagnostic evaluation observation identified an operations procedure backlog of approximately 400 revisions, and only one individual, a licensed reacur operator, was assigned
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to process procedure changes. In response to this concern, a full-time operations department procedures upgrade group was put in place to reduce the procedure revisions backlog and to enhance the overall adequacy of department procedures. The inspector reviewed the procedure upgrade program and concluded the program has adequate guidelines and resources to identify, prioritize, and improve operations procedures necessary to support safe plant' operations. This DEO. OPS.028 is closed.
2.5 Temocrary Instruction (TI) 2515/113 - Reliable Decay Heat Relanval During Qutages This T1 addresses the practices used by licensee 3 to ensure that plant configuration and operations during outages will maintain the continued removal of decay heat from the reactor.
The intent of the TI is to review the licer$ee's current shutdown risk practices and identify any existing safety concerns. The inspector reviewed NYPA's independent outage risk assessment report, the outage scheduling and centrol, and the minimum level of safety system availability established for the outage. The inspector concluded that NYPA completed a thorough review of the outage schedule and followed the guidelines of Nuclear Management and Resources Council (NUMARC) 91-06 for shutdown risk assessment. The inspector determined that an independent risk assessment group provided specific outage recommendations and that their assessment was of high quality. The inspector did not identify any safety concern with NYPA's review of the 1992 refueling outage. The objectives of the risk assessment team included:
determine whether the schedule of outage activities met Technical Specification requirements and i
provided sufficient defense in depth to ensure an adequate margin to safety: identify problem areas where the margin of safety could be reduced by a single failure; determine appropriate contingency plans for specific problem areas; and make recommendations to improve the margin of safety.
The focus of the assessment was the availability of defense in depth for several key safety functions including decay heat removal capability, inventory control, power availability, reactivity control, and containment capability. NYPA used a three-step approach to determine the outage schedule margin of shutdown risk. Initially, NYPA created availability time lines of the various safety systems which form the lines of defense for each key safety function. NYPA then used the time lines to determme the extent of the defense in depth based on the planned safety system availabilities.
Based on this review, NYPA deternfned potential areas of weakness. Recommendations were then provided to the planning department to increase the margin of safety. After conclusion of the shutdown risk assessment, NYPA management established rninimum levels of safety system availability for the outage. The inspector concluded the proposed safety system availability met or exceeded the Technical Specification requirements in several cases. The inspector identified no safety concerns in NYPA's shutdown risk review and recommendations. TI 2515/113 is closed.
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3.0 RADIOLOGICAL CONTI!.0LS (IP 71707)
The inspector observed routine radiological work practices during observation of va-ious maintenance activities and in routme tours of the plant. In general, radiological workers seemed to be well trainel and were observed to be using appropriate radiological work practices (i.e.,
bagged tools and ether items, as required, maintained work areas clean, removed protective clothing properly, do:imetry worn properly, and all radiological postings obeyed). The health physics technicians we:
obu"ved to give good pre-job briefings and maintained close surveillarve over the work :avities in their assigned areas. The radiological work areas, in
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general, were well-maintained (i.e., clean with appropriate radiological postings). The inspector concluded that the workers and health physics technicians were w#ing well together to ensure safe and appropriate radiological work practices.
4,0 MAINTENANCE (IP 62703)
4.1 Observation of Maintenance Activities The inspector observed and reviewed selected portions of preventive and corrective maintenana to verify compliance with codes, standards and Technical Specificadons, proper use of administrative and maintenance procedures, proper QA/QC involvement, and appropriate equipment alignment and retest. The following activities were observed:
4.1.1 Work Requests (WR) OU514 & 08751610 MOV-15A & 10 MOV-15C. Residual Heal Removal Valve Operators Work requests 087514 and 087516 were issued to overhaul and/or replace the Limitorque motor operators for valves 10 MOV-15A and 10 MOV-15C. The inspector observed portions of the maintenance conducted on March 13,1992. The work permit request forms specified to remove -
and caerhaul the operators (replace spring pack) reinstall and return to operation.
The requirements were to be accomplished ir accordance with procedure MP-59.41. The inspector noted that the procedure was followed closely and documentation was kept up-to-date. In addition to the required quality control hold points and verifications, quality assurance personnel were observed conducting surveillances of the activity. Good supersisory oversight was noted.
The workers were following good radiological control practices. The inspector concluded that there was effective procedural adherence and quality verification of this work activity.
4.1.2 WR 089445. Snubber Replacement Main Steam and Comrol Rod Drive Hydraulig by1 lcm 3 Vhrk request 089445 was submitted to remove and replace those snubbers whose service life weald be exceeded prior to the end of the next operating cycl __.
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On March 16. 1992, the inspector observed removal and installation of snubbers in the main steam system (i.e.,29-RIL-S-175B and 29-RIK-S-180A) and control rod drive hydraulic systems (i.e., 03-NW-S 14 and 03-NW-S-15).
The work was accomplished in ancordance with procedure MP-100.3. The inspector noted that the procedures were followed closely and the documentation was kept up-to-date. This incle ?cd completion of the procedure sign-off checklist and documentation of denciencies found. Quality control personnel were observed to complete all verifications, as required. Gocxl supervisory oversight was noted. The workers followed appropriate radiological control procedures.
The inspector had one cancern in that work request 089445 was written to cover the removal and replacement of all the.mubbers worked this outage. A review of the Work Control Center filee indicated operations departinent did not have a listing of the snubbers being worked by the n'
nance department. Technical speci0 cation 3.6.1.2 states that with one or more snubbers ir.q rable, within seven days, during cold shutdown or refueling mode, for systems which are required to be operable in these modes, complete one of the following: a) replace or restore the inoperable snubber (s) to operable status or; b) declare the supported system inoperable and follow the appropriate limiting condition for operation statemes t for that system or; c) perform an engineering evaluation to show the inoperable snubbe. is unnecessary to assure operability of the system or to meet the design critern of the system, and remove the snubber from the system.
The maintenance department had been, to the maximum extent possible, replacing snubbers removed the same shift. However, without operatims department having knowledge of which specific snubbers were being worked, the inspector was concerned that a system could be declared operable and yet still not have the required snubber (s) installed. This concern was brought to the nttention of the mechanical maintenance group management and to the work control group supervisor, Prompt corrective action was takui by the maintenance department supervisors and the work control group supenisor to initiate individual work requests covering snubber work in each affected system. Each work request now (and in the future) lists the actual snubbers affected, by number and location, so that the operations department is aware of all snubber work that could have an affect on system operability. In addition, the maintenance supervisor also initiated a temporary change to procedure MP 100.3. The change modifies Figure 10.1.2 for a snubber that cannet or will not be replaced immediately. The change requirc that the maintenance department provide a copy of this form to the Work Activities Control Center for tracking purposes when a snubber is not replaced immediately. The form also requires followup notification after the snubber is reinstalled. The inspector considered this an appropriate defense in depth temedy.
During review of these snubber maintenance activities, the inspector reviewed site quality assurance surveillance report, No.1517, dated February 17, 1992. This surveillance was conducted between January 14-25, 1992 on snubber visual examinations and retagging of snubber location identification labels.
The report documeated five deficiencies where
maintenance department personnel had failed to identify and document defects, that should have l
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f been identified during the snubber visual examinations. Adverse Quality Condition Report (AQCR) nunioer 92-019 was issued to document and tr2ck resolution of these deficiencies. The maintenance department took prompt action to retrain the mechanic involved and to correct the deficiencies identified. Another AQCR, number 92-072, was written requesting an engineering evaluation of these deficient conditions. The engineering evaluation concluded found that although the deficient conditions were unacceptable for long-term service, the snubbers could still perform their intended function and were considered operable.
The inspector concluded that these work activities were effectively conducted and controlled.
The actions taken by the maintenance department to improve work control and to correct quality
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ad effective site surveillance of this maintenance activity and the surveillance report was
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. R 86177. Hydraulic Snubber Maintenance and Functional Testing
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aquest 86177 was issued to rebuild and functionally test hydraulic snubbers.
On mn 16 and 30,1992, the inspector observed testing of three snubbers in accordance with
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procedure MST-100,1, Hydraulic Snubber Functional Surveil'ance Test. On h1 arch 17 and 30,1992, the inspector observed portions of the rebuilding and maintenance work performed on four hydraulic snubber units. The work was accomplished in accordance with procedure hip-102, hiaintenance Procedure for Bergen-Paterson Hydraulic Snubbers. Filling and vacuum purging of the units were performed per reference document Entertech Procedure No. PA-94658. The inspector noted that the procedure was followed and the documentation (i.e., sign-off checklist) was kept up-to-date. For both the maintenance and testing activities, quality con:rol personnel were observed to complete all verifications as required. In essence, they reviewed all phases of the work and testing performed. Good supervisory and quality control oversight-was noted.
The individual mechanics were found to be knowledgeable and professional in performing their work.
The inspector reviewed site quality assurance surveillance report number 92-015, dated F:bruary 18, 1992. The purpose of the surveillance was to determine the adequacy of procedure and program compliance of Entertech Company personnel during the rebuilding and functional testing of plant snubbers. The surveillance had no findings and found the individuals to be kn3wledgeable about testing and rebuilding parameters. Inspector review of this surveillance-concluded that the site quality assurance department had conducted an effective site surveillance of this maintenance activity. Overa11, the inspector concluded that there was effective procedural adherence and quality verification of this work activity. However, the inspector did have one
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observation concerning the snubber test procedure that was discussed with station management for their review and resolution.
Test procedure h1ST-100.1 was written primarily for use with the JAF test machine #5434-3.
The only portions of this procedure that were used to test these Bergen-Paterson hydri.alic
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snubbers were the acceptance criteria and Data Sheet 11.3. The procedure provides no testing
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instmetions for using the contractor's test machine (STADAS 4120 Tester), but references the comractor's p:ocedure, Entertech Procedure No. PA-91814, Rev. C, Functional Testing of Hydraulic Snubbers. Procedure MST-100.1 is a " continuous use" procedure. Procedure AP 1.14 requires that for " continuous use procedures: each step be read before performing it; performed as written; performed in sequence; and signed off, if required, before the next step is begun. The contractor's procedure (PA-91814)is a portion of the technical mancal and does not appear to satisfy the intent of a " continuous use" written maintenance procedure as outlined in procedure AP 1.14.
The inspector interviewed the work activity supervisor and test machine operator and observed that the machine was controlled by a computer program, which was menu driven, and the program provided the operator directions and optioris through various menu choices. The inspector concluded that although the contractor's pro:edure does not appear to racet the irtent
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of procedure AP 1.14 for " continuous use" procedures, the testing appeared to be satisfactorily controlled, conducted and documented. The inspector presented this observation to senior NYPA management regarding the application of the guidelines established in procedure AP-1.14 to the implementation test procedure MST-100.1 NYPA station management agreed to evaluate the inspector's observation and take appropriate action.
4.1.4 WR 049466.10MOV-18. Residual Heat Removal Shutdown Cooling _ Inboard Isolation
.Y.al.vc During performance of local leak rate testing of containment penetrations, in accordance with procedure ST-398, valve 10MOV-18 had excessive leakage. Work request 099466 was written to document this problem and schedule repairs. A work permit request form was submitted by the mechanical maintenance group to disassemble 10MOV-18, inspect seats for damage, repair (as necessary), and reassemble the valve.
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The inspector observed portions of the maintenance conducted on March 27 and 31,1992. The work permit request form specified that repairs were to be accomplished in accordance with procedures MP 59.60 and MP 59.9. A review of the work package documentation indicated that it had been maintained up-to-date. Good supervisory oversight was noted. The workers were observed to be following appropriate radiological control procedures. The inspector concluded that there was effective procedural adherence and quality verification of this work activity.
4.1.5 WR 088545. B Core Spray Piping Reolacement (14-10-W23-1504-58)
Work request 088545 was issued to perform core spray piping (14-10-W23-1504-5B) and safe-end removal and replacement in accordance with modification F1-82-017. Fuur pipe supports were removed and approximately 10 feet of piping from the reactor vessel nozzle to valve 14 CSP-14B were replaced. This request covered all aspects of the modification, including demolition of piping, refurbishment, and pre-operational testing.
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The inspector observed portions of this modification conducted on March 24, 28, 31, and April 1,1992. The work permit request form specified that core spray system piping and sefe-end replacement were to be accomplished in accordance with installation procedure F1-82-017, IP #1. A review of the work package documentation indicated that it had been maintained up-to-
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date, with one exception. On April 1,1992 the inspector observed that two weld card verifications (i.e., for proper purge prior to welding and for proper root weld) for the root weld on the pipe to valve 14 CSP-14B made on backshift the night before, were not completed at the time the work was accomplished. The signatures were subsequently obtained from the workers.
This appeared to be an isolated case. Quality control personnel were observed to complete verifications, as required. In addition to the required quality control verifications, site quality assurance personnel were maintaining surveillance of this job. Good supervisory oversight was noted including the oversight of the welding engineer. The workers and supervisors appeared
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to be well-trained and to function ~ ell as a team. The workers were following appropriate radiological control procedures. Le inspector concluded that there was effective procedural adherence and quality verification of this work activity.
4.1.6 WR 99235.10MOV-17. Residual Heat P.emoval Shutdown Cooling Outboard Isolation Valve Work request 99235 was issued to replace 10 MOV-17 in accordance with installation procedure IP-1 for modification F1-89-027. The inspector observed portions of the work on March 30-31, and April 2-3,1992. A review of the work package documentation indicated that it had been maintained up to date with the following exceptions. Two systems (i.e., nitrogen for the containment air dilution (CAD) system and condensate transfer) that had been cut and partially removed to facilitate 10 MOV-17 installation required installation of temporary pipe caps followed oy performance of satisfactory leak tests. These tests were not verified as complete in the procedure.
The inspector determined from discussions with the maintenance general supervisor that-downstream work, subsequently approved on the CAD system, had prevented the performance of the required leak test (or step 1.2, perform inservice leak test per AP 2.6) of the associated i
pipe as indicated on drawing SK-F1-89-027-001. The maintenance general supervisor had discussed this with the operations shift supervisor at the time.
When questioned by the inspector, the operations work control supervisot was aware that this leak test had been sequenced by other work. A pipe cap had been installed as a contingency to allow system operation, if required. _ This was a good example of maintenance and operations departments keeping each other informed and coordinating their efforts to manage this outage activity. The other temporary pipe cap was on a 4-inch condensate transfer line (WCP 151-53 per FP-14G, Rev.15B). The leak test (procedure step 8.2.8.2, perform in-service leak test per AP-2.6) was performed previously and failed. The system was pressurized at the time the inspector mr.de this observation. When this was brought to the attention of the maintenance supervisor, the test was reperformed satisfactorily and the signoff made. This missed inservice leak test appeared to be an isolated case.
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11 The inspector concluded the supervisory oversight was generally good, particularly oversight by the system engineer who was observed to be closely monitoring this work activity. The workers were observed to be following appropriate radiological procedures under the continual surveillar, of radiation protection technicYns.
4.1.7 WR '085617.10 AOV-68B. Residual Heat Removal Low Pressure Core Iniection
. Testable Check Valve Work Request 085617 was issued to repair valve 10 AOV-68B which was leaking approximately twenty drops per minute. Contamination on the lagging below the valve was approximately four million disintegrations per minute.
The inspector observeo portions of the-naintenance conducted on April 1-2, 1992. The valve disassembly and reassembly was in accor;ance with procedure MP-59.46. A review of the work package documentation indicated that it had been maintained up-to-date. Good supervisory oversight was noted. The workers were observed to be following appropriate radiological control procedures. The inspector concluded that there was effective procedural adherence and quality verification of this work activity.
5.0
- REVIEW OF FIRE PROTECTION PROGRAM IMPROVEMENTS TO FIRE WATCII TR.AINING AND CONTROL OF COMBUSTlHLES At approximately 9:00 p.m. on March 18,-1992, senior NYPA management placed a stop work order on all station activities. The basis for this action was to ensure the adequacy of their station fire protection and prevention program. An NRC Fire Protection / Appendix R team onsite between March 9-20, 1992, identified a broad spectrum of concerns involving the
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adequacy of firewatch and fire brigade training, the operability of fire suppression systems and
- fire fighting equipment, the acceptability of combustible leading in the plant and deficiencies in their safe shutdown capabilities. : An interim exit meeti.ng held by the team with station
- management on March 16, 1992 resulted in a stop work ordct for all hot work (welding, grinding and open flame type work). Subsequent review of the issues by NYPA, on March 18, 1992, gave them reason to halt all refueling outage work to ensure the full scope of their fire protection program deficiencies were known and compensatory measures taken Site management authorized resumption of refueling outage work on March.24,1992.
This authorization was preceded by: plant inspections, cleanup and removal of combustibles to an acceptable level throughout the plant (final plant cleanup and removal of combustibles continued through March 31,1992); retraining of fire watches; reverification of fire brigade training and qualifications; and resolution of immediate fire equipment concerns. Hot work was initially authorized by NVPA management only in selected areas.
L The inspector reviewed NYPA actions to improve fire watch training and control of l-Lcombustibles in the plant between March 24-26,1992. The fire watch program at the site consists of two separate tasks described as either compensatory or welding and cutting fire
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Compensatory Fire Watches-The compensatory fire watches have been trained to patrol an assigned area and repon to the control room if there is a fire or indication of smoke. The inspector interviewed fiftecc compensatory fire watch personnel and determined that they were trained and were knowledgeable of actions required of them in the event they encountered a fire during their
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watch.
Welding and Cutting Fire Watches The personnel assigned as welding and cutting fire watches are generally craft personnel. These fire watch personnel have been retrained to perform hot work fire responsibilities using a revised lesson plan (FP-13.16) and Welding Support Procedure (WAP-04). In reviewing this training the inspector had the follow observations:
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The revised training added a written examination and a practical examination (e.g.,
demonstrate ability to identify various fire hazards and the proper use of a carbon dioxide fire extinguisher). The addition of these examinations to this training program was viewed by the inspector as a program improvement.
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A list of retrained personnel has been distributed to site managers and supervisors by the fire protection training instructor.
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The hot work permit checklist used to authorize welding / cutting / grinding was previously-a separate qualification. The work permit and checklist had been verified by the responsible supervisor for welding and cutting under the old guidelines. The most recent change to WAP-04, issued on March 18,1992, allowed the fire watch to complete and issue the hot work permit / checklist. The revised fire watch training now qualifies the fire watch to complete the hot work checklist, in addition to the normal fire watch responsibilities. This change raised the question as to whether the fire watch was qualified to make all these verifications.
A subsequent review by senior NYPA management of the hot work permit and checklist requirements resulted in the general manager of operations issuing an interim guidance memorandum on March 26, 1992.
The memorandum placed the responsibility for review and approval of-all hot work permits / checklists on the site fire protection supervisor or the outage coordinator, in his absence. The work supervisor still has the overall responsibility for safety on the work site. This direction will remain in effect until' superseded by a new Work Activity Control Procedure currently under development.
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~ A review of the student comment sheets on training (received as of March 25, 1992)
indicated programmatic weaknesses may still exist in WAP-04 9nd the associated lesson plan used to conduct this training. NYPA has recognized the aced to make further improvements to WAP-04 and is in the process of revising this procedure and will conduct followup training, as required.
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The site fire protection supervisor had not reviewed the revised instructor's lesson plan for training the hot work fire watches hnd was not aware of the student feedback received to date on ret aining the fire watches. The inspector brought this to the attention of the
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fire protection supervisor and NYPA management. Management's review of the student comment sheets prompted initiation of further changes to the procedure used for training the fire watches.
Control of Combustibles Control of combustible and plant cleanuo was verified by conducting tours of the turbine and reactor buildings. NYPA has invested considerable time and effort between March 17 and 31 into plant cleanup and into reducing the amount of combustibles in the plant to an acceptable level. The inspector observed the condition cf the plant with respect to cleanliness and combustibles to have been acceptable and improving.
Tie responsibility for maintaining the plant in a clean condition has been assigned to the building and groun.is manager. Eventually (i.e., after additional personnel are hired to support the fire
- protection' supervisor), this responsibility will be assigned to the site fire protection supervisor.
The building and grounds staff will continue to be used as a resource to maintain plant cleanliness. The general manager for maintenance and administration was developing a plan and updating plant procedures to ensure that the present conditions of the plant are maintained.
. These new or revised procedures to maintain the plant in a clean condition will incorporate area fire loading values, as well as lessons learned during the present plant cleaning task employed by the mechanical maintenance general supervisor, summary, the compensatory fire watches were observed to be well trained. The hot work o
ri.c watch training improved, but the licensee concluded further improvements, especially in the area of hot work permits / checklist responsibilities, were necessary. Combustible levels and -
general plant cleanliness were adequate and improving, and-NYPA site management has committed to develop and implement a formal program to maintain this condition, i-I i
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6.0 ENGINEERING AND TECifNICAL SUPPORT (93702)
6.1 Review of NYPA's Efforts to Fyaluate Limitoique Valve Operator Motor Pinion Key Failures The inspector reviewed three Operating Experience Review (OER) reports issued in late December 1991. These OERs evaluated industry problems experienced between 1981 and 1990 regarding pinion gear-to-shatt key Limitorque Motor Actuator failures for applicability at FitzPatrick.
6.1.1 Review of NYPA Operating Experience Review Report P712 The inspector reviewed NYPA Operating Experience Review (OER) report P712, issued December 26,1991. This OER report evaluated the following for applicability at FitzPatrick:
NRC Information Notice 81-08, kepetitive Failures of Limitorque Operator SMB-4 Motor-to-Shaft Key; General Electric Service Information Letter (SIL) 378, dated June 1982, Limitorque Valve Operator Motor Pinion Key Failures; and INPO OE 1898, which reported Tennessee Valley Authority's discovery of deformed motor pinion keys in SB-3 units equipped with 100 foot-pound motors. The OER report stated that a review had identified fourteen MOVs (i.e.
ten cater,ory I and three category II/III) which were appli,; t)le and required motor pinion key replacement, The inspector reviewed NYPA actions to replace the motor pinion keys in the fourteen MOVs identified. Three have been completa and the rest are either working or scheduled to be completed this outage. One of the MOVs identified in OER report P721 as needing motor pinion key replacement was 10MOV-27B.
NYPA Occurrence Report (OR)92-106, dated Mar.h 16,1992, reported that the 10MOV-27B (residual heat removal low pressure coolant injection outboard injection valve) operator motor pinion key was found failed (i.e., severed) during pinion removal. The motor pinion key was replaced with a new key from stock. There was no indication of a valve operability problem prior to discovery of the failed pinion key.
In summary, NYPA industry event review per OER report P712 was satisfactory. However, OER report P712 was not issued until December 26, 1991, approximately ten years after industry problems were first identified. Evidence indicates that NYPA apparently started to take actions back in 1981 and 1982 to evaluate these industry problems. Records show replacement parts were ordered and received in 1982, howevt, the parts were never replaced. NYPA's recent efforts to review industry problems for applicability at FitzPatrick appears to be thorough.
However, this review was not timely given the potential safety significance, and has been the subject of previous NRC assessment (reference DET report).
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6.1.2 Review of NYPA Operating Experience Review Report 88N62 The inspector reviewed Operating Experience Review (OER) report 880462, dated December 17, 1991. This OER report evaluated NRC Information Notice 88-84, Defective biotor Shaft Keys in Limitorque hiotor Actuators, for applicability. The report indicated that a review of the database revealed only one documented case of mour pinion key shearing at FitzPatrick (i.e.,1978, valve 14 h10V-llB). The OER report also stated that files were reviewed to determine which motor operated valves (hiOVs) could potentially be equipped with improper motor pinion keys. The results of this review identified fifteen h10Vs (i.e., four category I and eleven category 11/111) which required motor pinion key replacement. The inspector reviewed NYPA actions to replace the motor pinion keys and identified that eight have
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been completed this outage and the rest are planned (i.e., work requests are written and
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scheduled) and will be completed before the end of this outage. Valve 10h10V-12B was one of the fifteen h10Vs identified in the OER report as needing motor key replacement.
NYPA Occurrence Report (OR)92-113, dated h1 arch 20,1992, reported that the valve 10 h10V-12B (residual heat removal heat exchanger outlet isolation) operator motor pinion key was found sheared during removal. The OR also reported that no demand failure of the operator had occurred. The key was replaced with a new key from stock. Initial analysis of the failed key material composition was conducted by NYPA. The analysis results indicated type 1018 steel.
NYPA plans to send the failed key off to an independent testing facility for more comprehensive analysis. The inspector determined that Licensee Event Report 92-002-00, htOV Deficiencies Related to Generic Letter 89-10, will be revised to incorporate this problem along with other h10V deficiencies identified during this outage.
In summary, NYPA OER repor' 880462 appeared to be adequate in content and appropriately identified 10hiOV-12B as needing corrective action. However, this review was not conducted
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until December 1991, approximately three years after the NRC Information Notice was issued.
As discussed above, NYPA's recent efforts to review industry problems for applicability and to initiate corrective actions is commendable, however, this review was not timely.
6.1.3 Review of NYPA Operating Exoerience Review Report 9002D4 NRC Information Notice 90-37, Sheared Pinion Gear-to-Shaft Keys in Limitorque hiotor Actuators, identified failures in high-speed (3600 rpm) Limitorque, Sh1B-0 actuators, with 25 ft.-lb. of torque. NYPA issued Operating Experience Review (OER) report 900204 to document review of this notice. This report identified thr-.:ategory II/III circulating water valves (36 h10V-100A, B, C) that were similar in design characteristics. The report stated that these
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valves do not appear to be subject to the severe impact loading described in the NRC notice and do not have a history of pinion key failure. However, replacement of the pinion keys with a harder material (ASThi 4140) was recommended and would increase equipment reliability. It would also preclude personnel exposure in the event of motor pinion key failure during plant operation. The inspector verified NYPA completed replacement of the motor pinion keys in 36 h10V-100A, B, and C. The inspector noted that NYPA's evaluation and corrective actions in this case were timely and appropriate.
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6.1.4 Summarv of Findings The inspector concluded that NYPA has responded to clear the review backlog conceming Limitorque valve operator motor pinion key failures. The inspector noted that three OERs were issued in late December 1991, that evaluated industry problems experienced between 1981 and 1990 for applicability at FitzPatrick. NYPA has either already completed or is planning to complete motor key replacement on those identified motor operators before the end of this outage. It was also noteworthy that several of the valve operators identified in the OERs were found failed upon disassembly. Although the timeliness of these reviews was in two cases poor, especially OER report P712 which addressed problems identiGed over ten years before, NYI A has demonstrated a desire to appropriately respond to this concern raised hst year by the NRC-Diagnostic Evaluation Team.
7.0 SAFETY ASSESSMENT / QUALITY VERIFICATION (71707,91/02)
7.1 Review of Ourlity Assurance (OA) Audits and Adverse Ouality Condition Reports (AOCRs)
As a means of assessing the NYPA QA department's ability to identify problems at the FitzPatrick site and track their resolution, the inspector reviewed all Technical Specification (TS)
QA audits completed in the October 1991 through March 1992 time frame and a sampling of adverse quality condition reports (AQCRs) that had been closed since January 1,1992. QA audits of facility activities are required by Technical Specification (TS) 6.5.2.8 and are controlled by procedure QAP 18.4, Audit Program Implementation. The AQCR process exists
- to assure that adverse quality conditions are identified, tracked and resolved, including root cause determination, and is controlled by procedure QAP 15.2, Implementation and Control of the AQCR Program.
The inspector reviewed ten TS audit reports and determined that the audits met the requirements of QAP 18.4 and that the audit subject and frequency requirements specified in the TS had been satisfied. The overall quality of the audits was good, yet the inspector noted there was no clear-cut criteria for determining when an audit checklist attribute was satisfactory or not. There appeared to be variance in whether a negative audit observation resulted in an " unsatisfactory" on the audit checklist, a QA recommendation, and/or the generation of an AQCR. The inspector also determined that unless an AQCR was generated, there was no means of tracking any corrective action for a negative finding until the next QA audit in the same area re-inspects the identified weakness.
The inspector concluded that NYPA performance in the review of the recently completed AQCRs was acceptable. The reviewed AQCRs had been initiated as far back as July 1989, and the inspector discerned an improvement in the preparation and resolution of the newer reports.
However, the inspector noted a general weakness in the performance of the root cause analysis m the AQCRs which required one. In many cases, the QA department had accepted root cause
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analyses that were simple causal factor statements or in some instances, a re-worded statement of the identified problem with-vague corrective actions. A deficiency was identified by the inspector concerning one AQCR (No.91-093, involving a HPCI survcillance test) that had been closed by QA after corrective actions had only been proposed. No verification of the corrective action implementation or completion had been completed. When brought to the attention of station management, this AQCR was reopened by site QA. This appeared to be an isolated -
oversight.
The inspector discussed his findings with the site QA manager, who acknowledged the inspector's concerns and stated that weaknesses in the QA audit corrective actions were being addressed in a new, comprehensive corrective action process being developed by NYPA. Also, weaknesses in the AQCR root cause analyses were being addressed by an ongoing, expanding root cause training program. The identified weaknesses notwithstanding, the inspector concluded that FitzPatrick QA audit and AQCR programs were adequate.
NYPA initiatives for improvement were considered appropriate to resolve the identified weaknesses.
8.0 MANAGEMENT MEETINGS At periodic intervals during the course of this inspection, meetings were held with senior facility management to discuss inspection scope and findings. In addition, at the end of the period, the r
inspectors met with licensee representatives and summarized the scope and findings of the inspection as they are described in this report.
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