IR 05000334/1999002
| ML20195C456 | |
| Person / Time | |
|---|---|
| Site: | Beaver Valley |
| Issue date: | 05/21/1999 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20195C452 | List: |
| References | |
| 50-334-99-02, 50-334-99-2, 50-412-99-02, 50-412-99-2, NUDOCS 9906080170 | |
| Download: ML20195C456 (23) | |
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- U. S. NUCLEAR REGULATORY COMMISSION
REGION I
License No DPR-66, NPF-73 Report No /99-02,50-412/99-02 Docket Nos.~ 50-334,50-412 Licensee: Duquesne Light Company Post Office Box 4 Shippingport, PA 15077 Facility: Beaver Valley Power Station, Units 1 and 2 Inspection Period: March 21,1999 through May 1,1999 Inspectors: D. Kern, Senior Resident inspecto G. Dentel, Resident Inspector G. Wertz, Resident inspector J. Furia, Senior Radiation Specialist W. Maier, Emergency Preparedness Specialist Approved by: P. Eselgroth, Chief Division of Reactor Projects 9906000170 990521 PDR
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EXECUTIVE SUMMARY Beaver Valley Power Station, Units 1 & 2 NRC Inspection Report 50-334/99-02 & 50-412/99-02 This integrated inspection included aspects of licensee operations, engineering, maintenance, ;
and plant support. The report covers a 6-week period of resident inspection; in addition, it includes the results of announced inspections by a regional radiation specialist and by an emergency preparedness specialist evaluating technical specification surveillance procedural control Ooerations
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On March 29,'while shutdown, a 4 kV supply breaker tripped resulting in a loss of offsite power to the Unit 2 "A" train emergency bus. The emergency diesel generator started and reenergized the emergency bus as designed. System engineer confusion and communication deficiencies delayed operators from removing a degraded battery charger, which caused the event, from service. This increased the likelihood of a repeat
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event. (Section 01.2)
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Acceptable progress to eliminate significant operator workarounds was achieved during
. the Unit 2 refueling outage. The cumulative impact of the Unit 2 operator workarounds, bases for continued operability, and control room deficiencies was minimal. (Section O2,1)
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Corrective actions in response to the violation for failure to implement procedures were comprehensive and effective. Senior station management recognized and responded well to human performance problems during the Unit 2 refueling outage. (Section 08.1)
Significant overtime was worked for the Unit 2 refueling outage, but hours were carefully tracked in accordance with procedures. While no events were attributed to fatigue or excessive workload, management of evertime, especially for operators (20 to 32 percent overtime), continued to be a challenge. (Section 08.2)
Maintenance
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Maintenance activities were generally performed well. However, maintenance and a design modification did not resolve Unit 2 main feedwater regulating valve (MFRV)
performance problems. The MFRV oscillations during unit restart and power ascension were more predominant than those experienced prior to the corrective maintenanc Steam generator levels were maintained in their proper bands by constant operator control and monitoring. (Section M1.1)
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Twelve surveillance tests were performed well with strong preevolution briefings. In most cases, operators successfully identified and compensated for procedure deficiencies prior to performing the surveillance test. (Section M1.2 and M3.1) j
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Surveillance procedure deficiencies involving incomplete precautions, initial conditions, and acceptance criteria continued to challenge the operating staff. . (Section M1.2 and M3.1)
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Corrective actions to eliminate scheduling problems associated with missed technical specification surveillances were properly implemented. The establishment of the surveillance coordinator positions and the surveillance tracking database created additional barriers for preventing missed surveillances. (Section M3.2)
- - Work activities were safely coordinated through the one-stop-shop during the Unit 2 refueling and Unit 1 surveillance testing outages. The improved work activity coordination effectively reduced burden on the control room staff. The reduced burden enabled the nuclear shift supervisors to focus more directly on maintaining safe shutdown plant conditions and contributed to improved human performance. (Section M4.1)
- Post-maintenance test (PMT) requirements were properly specified and performed following equipment maintenance during the Unit 2 refueling outage and the Unit 1 surveillance testing outage. Senior reactor operators assigned to the one-stop-shop j effectively managed PMT schedule implementation and ensured equipment was j promptly restored to service following planned maintenance. (Section M1.3)
Enoineerina i Good root-cause assessment by system engineers and maintenance personnel provided timely corrective actions for several safety-related Unit 2 refueling outage equipment problems. A system engineer was aggressive in his resolve to identify and correct a Unit 1 repetitive breaker problem. (Section E2.1)
Plant Suooort
The radiation protection program was effective during the Unit 2 refueling outag Appropriate controls for personnel radiation protection were established in the radiologically controlled areas. Enhanced informational postings, especially in the containment, aided in maintaining occupational exposures as low as is reasonably achievable (ALARA). (Section R1)
- Housekeeping, including storage of equipment, boric acid leaks, and structural support condition, was good for the Unit 1 containment at the conclusion of Unit 1 surveillance outage activities. (Section R2.1)
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The scope and depth of Quality Services Unit surveillances conducted for the Unit 2 refueling outage, and as part of the annual health physics program audit, were acequate to identify and document program deficiencies. All identified deficiencies were entered into the condition report program and tracked through resolution. (Section R7)
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y TABLE OF CONTENTS Page EXECUTIVE SUMMARY . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . li TABLE OF CONTENTS . . . . .. . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lv
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' t,'~ Operations . . . . . . . . . . . . . . .-. . .............................................. 1
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01 Conduct of 0perations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 01.1 General Comments (71707) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 01.2 Partial Loss of Unit 2 Offsite Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 02 ' Operational Status of Facilities and Equipment . . . . . . . . . . . . . . . . . . . . . . . . 2 02.1 Cumulative Assessment of Unit 2 Control Room Deficiencies, Operator Workarounds, and Bases for Continued Operation . . . . . . . . . . . . l. . 2
.08 Miscellaneous Operations issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 06.1 (Closed) Violation 50 334(412)/96-03-01 . . . . . . . . . . . . . . . . . . . . . . . 3
, 08.2 Control of Overtime Hours and Workload . . . . . . . . . . . . . . . . . .. . . . . . 4
'i ll. Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 M1 Conduct of Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
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M1.1 Routine Maintenance Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 M1.2 ' Routine Surveillance Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 M1.3 Post-maintenance Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 M3 Mainternance Procedures and Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . 9
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M3.1 Hot Leg Resistance Temperature Detector Failure Compensation . . . g ' 4 M3.2 . Surveillance Tracking Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 M4 - Maintenance Staff Knowledge and Performance . , . . . . . . . . . . . . . . . . . . . . 11 M4.1 Work Activity Coordination . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 11 li t , Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 E2 Engineering Support of Facilities and Equipment . . . . . . . . . . . . . . . . . . . . . . . 12 E2.1 Resolution of Emergent Safety-related Equipment Problems . 12 IV. Plant Support . e . . . . . . . . . . . . . . . -. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 R1 Radiological Protection and Chemistry (RP&C) Controls . . . . . . . . . . . . . . . . 14 R2 Status of RP&C Facilities and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 R2.1 Containment Walkdown and General Housekeeping . . . . . . . . . . . . . 16 !
R7 Quality Assurance in RP&C Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 V. Management Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . -. . . . . . . . . . . . . . . . . . . . . . . . . 17 X1 Exit Meeting Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 INSPECTION PROCEDURES USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ITEMS OPENED, CLOSED AND DISCUSSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 LIST OF ACRONYMS USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 l
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i Report Details Summary of Plant Status Unit 1 began this inspection period at 98 percent. Power was limited due to problems with the plant secondary steam system. The unit commenced a power reduction on April 11 and began the planned surveillance testing outage on April 13 when the main unit generator output breaker was opened.- The unit entered Mode 5 (cold shutdown) on April 13. Reactor startup to 15 percent reactor power was performed on April 30. The unit was shut down to Mode 3 (hot standby) on May 1 due to particulate fouling within the main unit generator hydrogen seal oil syste Unit 2 began this inspection period in Mode 6 (refueling). On March 24, the unit entered Mode 5 when the reactor vessel head was tensioned. Reactor startup was performed on April 11, a the main unit generator was synchronized to the electrical grid on April 12. The unit achieved full power operation on April 18 and remained there through the inspection perio . Operations 01 Conduct of Operations
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01.1 General Comments (71707)
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Using inspection Procedure 71707, the inspectors conducted frequent reviews of ongoing plant operations. In general, the conduct of operations was professional and safety-conscious; specific events and noteworthy observations are detailed in the sections belo .2 Partial Loss of Unit 2 Offsite Power Insoection Scone (71707. 37551. 93702)
The inspectors observed operator response and system engineers' event investigation following the unexpected opening of an offsite power supply breaker [ Air Circuit -
Breaker (ACB)-42) to the "AE" 4 kilovolt (kV) emergency bus. The inspectors reviewed this event based on the importance of offsite power to shutdown safet Observations and Findinas i
On March 29, the operators received an alarm that indicated the supply breaker to "A" train normal 4 kV bus opened and deenergized the bus. This bus supplied the "AE" l emergency 4 kV bus (one of two emergency buses). The 2-1 emergency diesel l generator started as designed and reenergized the "AE" 4 kV emergency bus. The "B" train normal and emergency buses were unaffected. The unit was shutdown in Mode 5 and the reactor was being cooled by the "B" residual heat removal system. No loss of !
shutdown cooling occurred, System origineers determined that the battery charger output for the 2-5 direct current (de) bus, which supplies the "A" train 4 kV normal bus protection relays with power, had
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been oscillating. The overcurrent relay (one of the bus protection relays), due to its susceptibility to voltage oscillations, opened supply breaker ACB-42. Operators promptly
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initiated corrective action to stabilize the 2-5 de bus by restoring the 2-5 battery, which
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had been out of service for maintenance. This was successful in reducing the voltage oscillation; however, oscillations continued until the battery charger was removed from service approximately 23 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br /> after the 4 kV normal bus tripped. The normal 4 kV bus was reenergized approximately 7 hours8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br /> before the battery charger was removed.
l The inspectors determined that system engineer confusion and communication i deficiencies with operators hindered the immediate review of the event. Based on l incorrect labeling in the field, poor human factors in the electrical drawing, and l misreading of the drawing, system engineers incorrectly determined that the 2-5 de bus l supplied the 4 kV bus protection relays with power for both "A" and "B" trains. The 2-5 de bus actually supplied power only for the "A" train relays and 2-6 dc bus supplied power for the "B" train relays. System engineers identified the error during subsequent investigation and documented the issue in the corrective action program (Condition Report 990799). Separately, voltage oscillations continued after the 2-5 battery was returned to service and the potential for the protective relays to isolate the offsite power source again was not immediately communicated to the control room staff. As a result, operators delayed removing the 2-5 battery charger from service. This increased the t likelihood of a repeat even The root cause of the 4 kV supply breaker trip was a loose resistor connection in the 2-5 battery charger System engineers initiated a review to determine whether the degraded i charger was a maintenance rule functional failure. The corrective actions associated with the battery charger were appropriate and the extent of condition reviews were sound. Additional issues identified during the event review were properly documented in the corrective action syste Conclusions On March 29, while shutdown, a 4 kV supply breaker tripped resulting in a loss of offsite power to the Unit 2 "A" train emergency bus. The emergency diesel generator started and reenergized the emergency bus as designed. System engineer confusion and communication deficiencies delayed operators from removing a degraded battery charger, which caused the event, from service. This increased the likelihood of a repeat even Operational Status of Facilities and Equipment O2.1 Cumulative Assessment of Unit 2 Control Room Deficiencies. Operator Workaround and Bases for Continued Operation Insoection Scone (71707)
The inspectors reviewed the Unit 2 control room deficiencies, operator workarounds, and I bases for continued operation (BCOs) for cumulative impact on Unit 2 operators. The t
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. 3 review included interviews with various personnel including reactor operators, senior reactor operators, system engineers, and design engineer Observations and Findinos
- The inspectors noted the following about control room deficiencies, operator )
workarounds, and BCOs based on reviews before and after the Unit 2 refueling outage:
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4 workarounds were eliminated,1 was added,14 remained g
4 BCOs were eliminated,2 were added,13 remained
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8 control room deficiencies were eliminated,6 were added,13 remained I
The major items completed were repair of the residual heat removal retum isolation )
valve, and replacement of the service water pump seal supply valves (see NRC l Integrated Inspection Report 50-334(412)/99-01). Severalimportant operator workarounds remained. These included the inability to maintain control rods in automatic and steam generator (SG) water level control problems with the main feedwater regulating valves in automatic (see Section M1.1). The control rod workaround was scheduled for completion on June 30,1999, and additional corrective actions were being planned for the main feedwater regulating valves. These workarounds affect the ability of operators and the plant to respond to certain plant transients. However, the overall cumulative impact of the remaining operator workarounds, BCOs, and control room deficiencies was minimal. The open items were being effectively tracked and pursued to completion. Several open items were old (greater than 2 years), but the expected completion dates were commensurate with their safety significanc I Conclusions Acceptable progress to eliminate significant operator workarounds was achieved during the Unit 2 refueling outage. The cumulative impact of the Unit 2 operator workarounds, I bases for continued operability, and control room defk:iencies was minima Miscellaneous Operations issues 08.1 (Closed) Violation 50-334412)/98-03-Q1: Failure to Adequately implement and Follow Procedures Caused by Human Performance Error a.- Inspection Scope (92700. 92901. 92902)
The inspectors reviewed the response to the violation concentrating on the root cause and corrective actions. The inspectors reviewed the procedure changes that were -
implemented and the training that was provided. The inspectors interviewed the Human Performance Manager to assess the implementation status of the human performance program, t
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4 Observations and Findinas From April 26 to June 27,1998, the inspectors noted an increase in the number of human performance problems. The inspectors determined that the licensee correctly identified the root causes as human performance deficiencies and procedure weaknesse Corrective actions included procedure changes and training. The procedure changes were reviewed and were appropriate. The comprehensive training provided a review of the events and a discussion of lessons leamed and self-checking techniques. Senior managers provided 24-hour oversite coverage for the September 1998 Unit 2 startup. A human performance program was initiated. Discussions with the Human Performance Program Manager indicated that the human performance program is currently in a conceptual state. Implementation is targeted to begin in June 1999. The human performance program is modeled from current nuclear power industry programs with input from the institute of Nuclear Power Operation. Human performance problems during the Unit i restart in August 1998, and more recently, at the beginning of the March 1999 Un.it 2 refueling outage were well recognized by senior station management. Senior station management coordinated an effective response to the more recent human performance problems, which included improvement of preevolution briefings and a reemphasis on self-checking techniques (see NRC Integrated Inspection Report 50-334(412)/99-01). Human performance improved throughout the outage perio Conclusions Corrective actions in response to the violation for failure to implement procedures were comprehensive and effective. Senior station management recognized and responded well to human performance problems during the Unit 2 refueling outag .2 Control of Overtime Hours and Workload Inspection Scope (71707)
The inspectors reviewed the working hours and use of overtime by operations staff, instrumentation and controls personnel, and contractor personnel during 1998 and 1999, with emphasis on the Unit 2 refueling outage, to verify compliance with TS 6.2.2.f. The inspectors examined condition reports (CRs), overtime records, and overtime control In addition, the inspectors interviewed various onsite personnel to determine adequacy of the control Observations and Findinas Limitations on working hours required by TS 6.2.2.f were implemented by: Nuclear l Power Division Administrative Procedure (NPDAP) 2.15. " Administrative Controls," Re ; 1/2OM-48.1.b, " Conduct of Operations, Operations Shift Complement and Functions,"
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Rev.18; and Maintenance Programs Unit Administrative Manual (MPUAM) Section 3.1,
" Overtime Policies, Rev. The operations shift administrative assistant was knowledgeable of the TS overtime guidelines and maintained tracking of operations staff work hours. The average numbers of overtime hours worked in 1998 for Unit 1 and 2 reactor operators, nuclear operators, and senior reactor operators were 618 (30 percent over 40 hour4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> week), 658 (32 percent), and 422 (20 percent) hours / person, respectively. Similar overtime hours were noted for January and February 1999. During the Unit 2 refueling outage most operators worked a 6-day 12-hour rotation each week. Operations staff overtime hours were carefully tracked to manage the use of overtim The inspectors reviewed overtime records for other departments and determined that appropriate controls were being implemented, in general, Duquesne Light Company employee overtime remained within the TS guidance. Contractors assigned to groups, such as construction and refueling, worked in excess of the TS guidance. The deviations were approved in accordance with procedures as permitted by TS. Additional oversight and use of breaks were used to ensure that personnel remained alert. The QSU conducted a surveillance and had similar findings as documented in CR 99096 The inspectors concluded that while no events were attributed to fatigue or excessive workload, management of overtime, especially for operators, continued to be a challenge. Operation Department management has planned or started additional classes of reactor operators, nuclear operators, and senior reactor operators. However, l
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operator staffing remains a long term problem due to the length of time required to train additional staff. The additional classes have also created a burden on the Unit 2 staff, in that, additional overtime hours are needed to fill shift positions. The shift rotations do not account for any absences for reasons such as sickness, vacation, holidays, or convenience days.- This issue of shift staffing has been a long-standing concem of both the NRC and licensee and was documented in NRC Integrated Inspection Report 50-334(412)/97-11 and Systematic Assessment of Licensee Performance Report 50-334(412)/96-9 c. Conclusions Significant overtime was worked for the Unit 2 refueling outage, but hours were carefully tracked in accordance with procedures. While no events were attributed to fatigue or excessive workload, management of overtime, especially for operators (20 to 32 percent overtime), continued to be a challeng .
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ll Maintenance
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.M1 Conduct of Maintenance M1.1 Routine Maintenance Observations Inspection Scope (62707) ,
i The inspectors observed selected maintenance activities on important systems and components. The maintenance work request (MWR) activities observed and reviewed
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MWR 060482 Unit 2 Auxiliary Feedwater Pump Turbine Inspection
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MWR 078109 - Unit 2 Steam Generator "A" Feedwater Isolation Valve Repair ,
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MWR 063583 Unit 2 Main Feedwater Regulating Valve Positioner Replacement
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MWR 078135 Unit 2 Steam Generator "A" Atmospheric Steam Dump Valve Repair { Observations and Findings The maintenance activities were generally performed well. Problems encountered with
, the auxiliary feedwater (AFW) pump turbine (see Section E2.1) and SG "A" feedwater isolation valve,2FWS-HYV157A, were identified during testing and appropriately corrected. Maintenance work on the main feedwater regulating valves (MFRV) was performed to correct an operator workaround.- The valves had a history of oscillating in the automatic mode of operation between 75 and 81 percent power, requiring a dedicated operator to monitor SG water levels. New valve actuator positioners were installed and tested satisfactorily. However, MFRV performance was poor during the post-refueling outage startup. The MFRV oscillations, while in the automatic mode, were larger and occurred over the full range of their required operation. This conditio documented in CR 990949, required operators to constantly monitor stream generator levels during plant power changes. Discussions with the Unit 2 Operations Manager indicated that the operator workaround has not been resolved and will remain ope Conclug[gan
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Maintenance activities were generally performed well. However, maintenance and a design modification did not resolve Unit 2 main feedwater regulating valve (MFRV)
performance problems. The MFRV oscillations during unit restart and power ascension were more predominant than those experienced prior to the corrective maintenanc Steam generator levels were maintained in their proper bands by constant operator control and monitorin J
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M1.2 Routine Surveillance Observations l Inspection Scope (61726)
The inspectors observed selected surveillance tests. Operating surveillance tests (OSTs), reactor surveillance tests (RSTs), Beaver Valley tests (BVTs), and maintenance surveillance procedures (MSPs) reviewed and observed by the inspectors are listed below:
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10ST-30.12A " Train A Reactor Plant River Water System Full Flow Test,"
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10ST-3 " Diesel Generator No.1 Automatic Test," Rev.11
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10ST-24.8 - " Motor Driven Auxiliary Feed Pumps Check Valves and Flow Test," Rev.10
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10ST-2 " Turbine-Driven AFW Pump [1FW-P-2] Operability Test,"
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1BVT-11. " Rod Position Indication System Voltage Monitoring Test,"
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1MSP-1.15A2-1 " Reactor Trip and EST Logic Time Response Test," Rev. 0
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2OST-2 "Overspeed Trip Test of Turbine Driven AFW Pump,"
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20ST-26.8 - " Main Turbine Overspeed Trip Test," Rev. 5
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2OST-2 " Steam Turbine Driven Auxiliary Feed Pump [2FWE*P22]
Test," Rev. 31
2RST- " Core Design Check Test," Rev. 3
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2BVT-1.1 " Recirculation Spray Pump Test," Rev. 6
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' Surveillance tests were generally performed well. Preevolution briefings were detailed and highlighted the critical aspects of the surveillances. For example, operators demonstrated a questioning attitude during the 10ST-24.9 briefing by reviewing the work scope performed on the pump during the outage and desired operator response if excessive gland leakoff was observed during the test. The briefings included -
discussions _of relevant industry operating experience. Senior reactor operators and test !
coordinators demonstrated good command and control. System engineers and maintenance technicians provided good support during the tests. Technical specification Limiting Conditions for Operation were appropriately entered. Operators demonstrated a questioning attitude during conduct of the surveillances. Use of the Stop-Think-Act- :
' Review (STAR) principle was effective especially during the recirculation spray pump l test. ' Operators questioned the performance engineer concoming expected pump motor ;
current and closely monitored pump performance during the test. Notwithstanding the overall good performance, the inspectors noted several deficiencies in the surveillance procedures. The deficiencies included the potential for an unplanned TS 3.0.3 entry, unclear acceptance criteria, and incomplete precautions / limitations and initial condition The good proevolution briefings compensated for the weaknesses identified in the procedure n
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' An example of the procedural deficiencies was incomplete initial conditions in 1MSP-1.15A2-1, " Reactor Trip and ESF Logic Time Response," Rev. O. Performance of this procedure caused an unanti'cipated reactor coolant system letdown isolation and allowed the SG levels to fall below scale on the narrow range level instrument. The safety significance of this event was minimal since Unit 1 was shutdown and the normal cooling path was unaffected. These problems were documented in CR's 990941 and 99096 The procedure was normally performed later in a refueling outage when letdown was isolated and the SG's were not being used for decay heat removal. However, the information detailing the conditions needed for performance of the test was not in the procedure. Operators and maintenance technicians conducted a thorough critique of the event. The necessary procedure changes were implemented and the surveillance was successfully completed. The General Manager of Nuclear Operations stated that procedure enhancements identified during the refueling outage were being evaluated and prioritized through the lessons learned progra Conclusions Eleven surveillance tests were performed well with strong preevolution briefing Surveillance procedure deficiencies continued to challenge the operating staff. In most cases, operators successfully identified and compensated for the procedure deficiencies prior to performing the surveillance tes M1.3 Post-maintenance Testina
. Inspection Scope (62707)
Early in 1998, the licensee had difficulty identifying and promptly performing post-maintenance tests (PMT) to support restoring equipment operability following maintenance activities. In January 1999, the "B" control room emergency ventilation system was inoperable for two days due to inadequate PMT requirements (see NRC Inspection Report 50-334,412/98-11). The inspectors reviewed various records and conducted field observations to determine whether PMTs were properly prescribed and implemented during the recent Unit 2 refueling outage and Unit 1 surveillance testing outag Observations and Findinas The inspectors reviewed 60 MWRs for Unit 1 and Unit 2 work activities. In each case, the specified preoperational and operational PMTs were appropriate. The inspectors observed several PMTs including an operational test of the Unit 2 auxiliary intake structure traveling screen, following replacement of the lower sprocket assembly, the drive chain, and over 55 of the screen baskets. The operational PMTs were properly ;
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i Senior Reactor Operators (SROs) from the one-stop-shop (OSS) were assigned to track I MWRs which were complete and awaiting PMT The number of MWRs awaiting testing was small (about 50 for both units combined). The inspectors determined that operators l
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were proper 1y managing the PMT schedule to ensure equipment was properly restored to service without unnecessary delays. The SROs demonstrated comprehensive knowledge of equipment status and planned testin Conclusions Post-maintenance test requirements were properly specified and performed following equipment maintenance during the Unit 2 refueling outage and the Unit 1 surveillance testing outage. Senior reactor operators assigned to the OSS effectively managed PMT schedule implementation and ensured equipment was promptly restored to service following planned maintenanc M3 Maintenance Procedures and Documentation
M3.1 Hot Leg Resistance Temperature Detector Failure Compensation Insoection Scope (42700)
On April 7, a "B" reactor coolant loop hot leg resistance temperature detector (RTO)
failed its time response test. Operators promptly placed the associated instrument j bistables in the tripped position as required by TS 3.3.1.1. This action made up one half f of the logic for several reactor trip and engineered safety feature (ESF) a'ctuation circuit The inspectors observed maintenance technicians perform 1MSP-6.86-1, " Hot Leg RTD i'
Failure Compensation [T-RC422]," Rev.1, which compensated for the failed RT Observations and Findinos The infrequently performed maintenance surveillance procedure (1MSP-6.86-l) removed the failed hot leg RTD from the input summing amplifier that generates the T., signal to various protective and control functions. Completing this procedure permits the associated bistables for several reactor trip and ESF actuation circuits to be retumed to their normal positio ,
Technicians obtained appropriate approval from the nuclear shift supervisor prior to performing the work. They also informed the reactor operator of expected indications and alarms prior to commencing work. Procedure steps were accomplished in order, and verifications were performed where require The inspectors noted two problems that were encountered in the performance of this )
procedure. Step Vll.C.3 directed the technicians to jumper each of the four input test
- Jacks on the summator to common, but the procedure did not direct the removal of the jumper for subsequent bias adjustment of the summator. The technicians notified their supervisor and obtained permission to remove the jumper. The technicians properly documented the procedural discrepancy on the procedure critique sheet. The inspectors discussed these actions with the supervisor involved. The supervisor's direction of the removal of the jumpers was in accordance with the plant maintenance manual in order to restore the system to norma l l
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.. 10 A second problem with the performance of the activity occurred when the technicians were unable to obtain the desired voltage output as directed by the procedure. They
. stopped the procedure and consulted their supervisor. The supervisor noted that the technicians had failed to accurately transcribe the values for the summator output, calculated earlier, to the data sheet. The proper values were recorded and the procedure continue Conclusions Technicians proper 1y completed an infrequently performed procedure which modified protective logic circuitry to compensate for a failed reactor coolant loop temperature i
- detecto I M3.2 Surveillance Trackina Prooram , Inspection Scoos (61700) i Last year, extended outages occurred for both units due to incomplete or inadequate -
technical specification (TS) surveillance testing and tracking. Past licensee review indicated that a cause was the lack of centralized control of surveillance testing. The inspectors reviewed the program for tracking and scheduling surveillance activities and interviewed the surveillance coordinators, outage management personnel, operations personnel and Quality Services Unit (QSU) auditors. The inspectors also examined a sample of the Maintenance Planning and Scheduling database used to track surveillances, as well as completed operations surveillance test Observations and Rndings Technical specification surveillance requirements are scheduled on a document known ,
as "the matrix." The matrix provides a cross reference between TS surveillance j requirements and the surveillance procedures performed to satisfy those requirement Although it is not classified as a controlled document, administrative controls were j implemented for the matrix as part of the licensee's restart action plan. The General Manager of Nuclear Operations was assigned responsibility for the matrix. Several ,
surveillance coordinators were appointed in the planning and scheduling departmen l Their duties included tracking and coordinating the performance of surveillance )
requirements performed less often than once every 7 days. These surveillance i coordinators also were responsible for processing changes to the matrix that were i identified by the various departments sharing TS surveillance responsibilit '
The surveillance coordinators were knowledgeable of the regularly scheduled ;
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surveillance requirements performed on line. They communicated well with outage planning personnel for coordinating' outage surveillance requirements. The outage director for the upcoming Unit 1 surveillance outage coordinated the scheduling of the j major outage activities through the surveillance coordinator l l
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The surveillance tracking database provided a report of surveillances which had either approached or exceeded their deadlines. This report, called a " limit date" report, was reviewed by the surveillance coordinators on a daily basis and prompted them to investigate upcoming surveillance deadlines before they occurre Quality Services Unit (QSU) department auditors maintained oversight of surveillance activities of both units by performing periodic QSU surveillances of this area. A detailed QSU audit of TS surveillance testing activities for Unit 2 was near completion at the close of the inspection period. The report for this audit was not yet available for the inspectors to view, but interviews with the lead auditor indicated that this audit was performed adequately, using a pre-approved audit plan and with participation of technical experts from outside the licensee's organizatio The inspectors' examination of a sample of the completed operations surveillance tests, as well as their review of the surveillance tracking database, showed no examples of missed surveillance requirements. The review of the active file of TS surveillance matrix changes did not show any instances of surveillance requirements which were being i inappropriately relaxed or deleted, Conclusions Corrective actions to eliminate scheduling problems associated with missed technical specification surveillances were properly implemented. The establishment of the surveillance coordinator positions and the surveillance tracking database created additional barriers for preventing missed surveillance M4 Maintenance Staff Knowledge and Performance M4.1 Work Activity Coordination Insoection Scope (62707. 71707)
The licensee experienced numerous work coordination and communication problems during plant outages in 1997 and 1998. At times, these problems had increased operator workload in the control roorn to the point of distraction and human performance errors. A new concept, called the one-stop-shop (OSS), was implemented for scheduling and coordination of work activities during the Unit 2 refueling outage (March 1999) and the Unit 1 surveillance testing outage (April 1999). The inspectors observed OSS activities and field work activities, conducted interviews, and reviewed records to !
assess the effectiveness of scheduling and coordinatio i
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i Observations and Findinos J l
Outage management personnel conducted visits to other nuclear plants to identify I methods to improve overall outage work activity coordination. Based on these visits, the l OSS was established as a centralized team of outage management, Operations ;
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Department, and support group personnel to maintain communications and coordination necessary to execute the outage work plan. The outage shift manager supervised an
~ OSS staff of 20 people who coordinated work activities within functional windows including primary system, secondary systems, instrumentation and control, electrical, clearances, post-maintenance testing, health physics, ed scheduling. ' One-Stop-Shop staffing included nine SROs on each shif '. The inspectors observed that work activity volume in the control room was well controlled. Maintenance work requests and CRs not associated with operational issues or TS limiting conditions for operation were reviewed and authorized by the OSS operations clearance coordinator (an SRO). The majority of outage work activities were
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approved and coordinated by the OSS. This permitted the nuclear shift supervisor to
' focus attention more directly on infrequently performed evolutions and maintaining safe shutdown plant condition ,
The inspectors noted that SROs from the OSS were s, Iso assigned as coordinators for infrequently performed evolutions such as the recirculation spray system, high head safety injection system, service water system, and low head safety injection system full ,
flow tests. Planning, proevolution briefings, and conduct of these evolutions were J excellent. Although the work activity volume remained high, the number of human performance errors declined throughout the inspection period. The inspectors concluded that the improved human performance was in part, a result of OSS work activity coordination and reduced burden on the control room staff. In addition, the inspectors observed that post-maintenance testing and system restoration following planned
' maintenance activities were completed in a more timely manner than that observed during plant outages in 1997 and 199 Conclusions Work activities were safely coordinated through the one-stop-shop during the Unit 2 refueling and Unit 1 surveillance testing outages. The improved work activity coordination effectively reduced burden on the control room staff. The reduced burden enabled the nuclear shift supervisors to focus more directly on maintaining safe shutdown plant conditions and contributed to improved human performance, lit. Enaineerina E2' Engineering Support of Facilities and Equipment i
E Besolution of Emeroent Safetv-related Eauioment Problems Insoection Scope (37551. 62707)
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I The inspectors observed system engineering and maintenance personnel's resolution of safety-related equipment issues, focusing on root-cause assessment, corrective actions, and timeliness of resolutio I I
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The following safety-related equipment problems were reviewed:
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480 Volt Motor Control Center Type 42 Interlock Contactor Failures
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2OST 24.9, "Overspeed Trip Test of Turbine Driven AFW Pump
[2FWE*P22),"Rev. 6 Turbine Binding Problem
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2OST 46.2, " Post-DBA Hydrogen Control System Train "B" Test," Rev. 4, Test Problems
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Hot Leg Check Valve Backleakage
Supplementary Leak Collection and Removal System Fan 48 Failure to Start b. Observations and Findinas Failures of the 'A.' train auxiliary service water discharge valve (2SWE-MOV116A) and circulating water valve (2CWS-MOV21) to open from the control room in August 1998, were investigated by the system engineer. The actual safety significance of these failures was minimal. Voltage readings obtained at the motor control center (MCC)
indicated that the linestarter Type 42 interlock contactor failed to cycle. This was reported as CR 981670. The system engineer correctly identified the root cause of the contactor failure as frictional binding due to the presence of metallic dust within the contactor mechanism. The system engineer, through analysis, determined the dust was caused by grinding during original plant construction. The system engineer developed and maintenance personnel implemented a comprehensive refurbishment plan for the Unit 2 refueling outage. The plan involved removal and cleaning all"A" safety train MCC contactors as well as any safety significant "B" train contactors which could not be worked during power operation. Additionally, the system engineer revised preventive maintenance procedures to include the contactor refurbishments during routine MCC maintenance. Corrective actions were comprehensive and effectiv On March 31, during 20ST-24.9, "Overspeed Trip Testing Of Turbine Driven AFW Pump
[2FWE*P22)," Rev. 6, the AFW turbine was unable to reach the overspeed trip rotational speed. The turbine began to slow down and eventually seized. Condition Report 990971 was initiated. System engineering and maintenance personnel thoroughly investigated the problem by carefully disassembling and inspecting the turbine. Although q preliminary information indicated that the problem may have been caused by foreign materialin the oil system, good persistence and a questioning attitude by both system engineering and msintenance personnel identified the root cause. A lock nut, which had )
not been properly secured, had backed away resulting in axial movement of the turbine !
shaft and subsequent reduction of govemor shaft clearances. The AFW turbine was !'
repaired and tested satisfactorily. Procedure improvements were planned to prevent reoccurrenc On April 2, during the performance of Unit 2 OST 46.2, " Post-DBA Hydrogen Control .,
System Train "B" Test," Rev. 4, the TS required flow of 42 standard cubic feet per minuto (SCFM) through the system was not obtained. This condition was identified in CR 990823. The system engineer performed good troubleshooting and diagnosis of the problem. The system engineer determined that procedure inadequacies resulted in i
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inaccurate data obtained from the field. The procedure was revised, and the test was successfully re-performed using a more accurate flow measurement method on April On April 2, based on data from the performance of procedure 2OM-50.4.A, " Plant Heatup from Mode 5 to Mode 4," Rev. 37, design engineers determined that there was i backleakage through the hot leg safety injection check valves. This was documented in 3 CR 990816 and described in BCO 2-99-002. The testing was conducted in response to a concern described in NRC Information Notice 89-36, " Excessive Temperatures in Emergency Core Cooling System Piping Located Outside Containment." The design i engineers evaluated the leakage using American Society of Mechanical Engineers (ASME) Section ill, Appendix F, and determined that the system was operable. At the q end of the inspection period, long-term corrective actions were being evaluate On April 10, the Unit 1 Supplementary Leak Collection and Release System (SLCRS)
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"4B" fan failed to start. Maintenance personnel performing troubleshooting cycled the breaker which eliminated the "as-found" condition before the system engineer could become involved in the causal analysis. The system engineer identified this and initiated <
CR 990904. The corrective action board (CAB) inappropriately prioritized this CR too l low, since NPDAP 5.6, " Processing of Condition Reports," Rev. 3, specifies that inservice failures of safety-related 4180 volt or 480 volt equipment should be Category 3 and CR 990904 was assigned a Category 5 (trending only). The system engineer initiated CR 990923 to raise this to the attention of the CAB. On April 14, the "4B" SLCRS fan failed to start again. Maintenance personnel appropriately preserved the breaker status to allow for diagnosis and data collection. The system engineer, working with maintenance personnel, performed extensive troubleshooting on the circuitry, but could not identify a cause for the breaker failing to close. The breaker was replaced which corrected the situation. The system engineer was aggressive in his resolve to identify and correct a repetitive breaker proble c. Conclusions Good root-cause assessment by system engineers and maintenance personnel provided timely corrective actions for several safety-related Unit 2 refueling outage equipment problems. A system engineer was aggressive in his resolve to identify and correct a Unit i repetitive breaker proble IV, Plant Support R1 Radiological Protection and Chemistry (RP&C) Controls Insoection Scooe (83750)
The specific focus for this inspection was to review and observe activities associated with the Unit 2 seventh refueling outage (2RO7). Conduct of work in radiological areas, especially in the containment, auxiliary, and safeguards buildings associated with the outage, was observe .
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Areas of inspection focus were based on the following regulatory requirements from 10 j CFR Part 20:
20.1101 Radiation protection program 20.1601 Control of access to high radiation areas 20.1602 Control of access to very high radiation areas 20.1902 Posting requirements 20.1904 Labeling containers 20.2103 Records of surveys The inspection was conducted via direct observation of in-process work in the J radiologically controlled areas (RCA), review of pertinent documents including surveys, radiation work permits (RWPs) and as low as is reasonably achievable (ALARA)
reviews, and discussions with cognizant personne !
b.- Observations and Findinos The 2RO7 commenced on February 26,1999. The radiological dose goal established for this outage was to not exceed 105 person-rem. This goal included reactor .
disassembly, fuel exchange, reactor reassembly, inservice inspection, and local leak rate testing. Tha outage did not include eddy current testing in the steam generators, which was performed as part of the unit extended shutdown in August 1998. That work was .
reviewed during a previous inspection (NRC Integrated inspection Report 50-412/98-05).
Other significant outage work, specifically the inspection of snubbers near the steam generators, is not included in the outage goal, as the work was not identified until after the close of the outage scop Generally, outage activities were performed at well below their established exposure i goals, with the exception of the refueling path activities, which tracked closely with the dose goal established. Discussions with Health Physics personnel revealed that the causes for the significant exposure reduction were: (1) a reduction in the number of contractors hired to work this outage; (2) reduced work interferences, especially in the three reactor coolant pump cubicles, since the steam generator work was already j completed in August; (3) lower effective dose rates in many areas, due to the extended !
plant shutdown throughout most of 1998; and, (4) lower dose rates on work near the i steam generators, since each remained water filled on the secondary side throughout the outag Outage activities observed in the containment included reactor reassembly, specifically reinstalling the reactor vessel head, stud tensioning and cavity decontamination. Due to the potential for hot particles in the work area, additional contamination controls were I utilized, including enhanced survey techniques for personnel and equipment ;
contamination detection. Other work in the containment included removal of outage i equipment and the continuation of valve testing. All areas examined were appropriately i posted and controlled. Program enhancements included the extensive use of j informational postings to aid in maintaining occupational exposures Al. AR !
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s 16 Tours of other portions of the RCA, especially in the auxiliary building, revealed a number of instances where the establishment and control of contaminated areas was deficient. Upon notification, the license undertook immediate corrective actions to resolve this minor defec Conclusions The radiation protection program was effective during the Unit 2 refueling outag Appropriate controls for personnel radiation protection were established in the radiologically controlled areas. Enhanced informational postings, especially in the containment, aided in maintaining occupational exposures At. ARA. Minor contamination control issues were promptly correcte R2 Status of RP&C Facilities and Equipment R2.1 Containment Walkdown and General Housekeepina Inspection Scope (71707. 71750)
The inspectors performed a walkdown of the Unit 1 containment on April 26, after the majority of the surveillance outage work had been completed. The containment area )
was examined for boric acid leaks, proper storage of equipment, and general
! housekeepin Observations and Findinas The Unit 1 containment was clean and free of debris. In general, equipment was generally properly secured in position. Minimal boric acid leakage was identifie Supports, snubbers, and spring cans were sampled and had sufficient fluid levels (snubbers), and were within the free movement range (spring cans). Deficiencies identified were either promptly corrected or entered into the proper tracking syste Conclusions l Housekeeping, including storage of equipment, boric acid leaks, and structural support j condition, was good for the Unit 1 containment at the conclusion of Unit 1 surveillance j outage activities.
I R7 Quality Assurance in RP&C Activities Inspection Scope (83750)
Audits, surveillances, and self-assessments performed were reviewed for scope and depth. Adequacy of the corrective action program for findings and deficiencies, including timeliness and breadth of corrective actions, was also reviewe .
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r 17 The inspection was accomplished via reviews of licensee documents and discussions with cognizant plant personne Observations and Findinos The program for assuring quality performance in the radiological controls program included surveillances and audits performed by members of the QSU staff. During the 2RO7, a number of work observations, taken on a daily basis, had been incorporated into several surveillance reports that had already been issued. Additional observations were presented to the inspector during discussions with the lead QSU auditor for this area. These observations will be incorporated into additional surveillance reports. In general, the scope and depth of the surveillances were adequate to identify appropriate work practices and controls, and to document deficiencies. Deficiencies were documented in the CR process and tracked until resolutio In addition to the outage related surveillances, OSU also conducts an annual audit of the Health Physics program. The most recently completed audit, BV-C-98-15, was issued J on December 11,1998, and contained the results of the 1998 annual audit. The report documented the findings of two auditors, including a technical specialist brought in to evaluate the radiation monitoring system. The scope and technical depth of this audit were sufficient to appropriately identify weaknesses in the health physics program, and all identified deficiencies were documented in the CR program. None of the identified deficiencies were significant with respect to actual effect on worker or public health and safety. Previously identified CRs were also summarized in this report, together with their resolution, Conclusions The scope and depth of Quality Services Unit surveillances conducted for the Unit 2 refueling outage, and as part of the annual health physics program audit, were adequate to identify and document program deficiencies. All identified deficiencies were entered into the condition report program and tracked through resolutio !
l V. Manaaement Meetinos
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X1 Exit Meeting Summary
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The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on May 7,1999. The licensee acknowledged the findings presented.
l The licensee did not indicate that any of the information presented at the exit meeting was l proprietar !
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t 18 INSPECTION PROCEDURES USED
- IP 37551: Onsite Engineering IP 42700 Plant Procedures IP 61700 Surveillance Procedures and Records IP 61726: Surveillance Observation
- lP 62707: Maintenance Observation IP 71707: Plant Operations IP 71750 Plant Support IP 83750 Occupational Radiation Exposure IP 92700: Onsite Follow-up of Written Reports of Nonroutine Events at Power Reactor Facilities IP 92901: Follow-up - Operations IP 92902: Follow-up - Maintenance IP 92903: Follow-up - Engineedng IP 93702: Prompt Onsite Response to Events at Operating Power Reactors ITEMS OPENED, CLOSED AND DISCUSSED i
Closed 50-334(412)/98-03-01 VIO Failure to Adequately implement and Follow "
Procedures Caused by Human Performance Errors. (Section 08.1)
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LIST OF ACRONYMS USED 2RO7 Unit 2 Seventh Refueling Outage ACB Air Circuit Breaker AFW Auxiliary Feedwater ALARA As Low as is Reasonably Achievable ASM American Society of Mechanical Engineers BCO Bases for Continued Operation
'BVT> Beaver Valley Test
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CFR- Code of Federal Regulations CR ' Condition Report
.dc- Direct Current ESF _ Engineered Safety Feature kV Kilovolt MCC Motor Control Center MFR Main Feedwater Regulating Valve MPUAM Maintenance Programs Unit Administrative Manual 4
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MSP Maintenance Surveillance Procedure MWR Maintenance Work Request i NPDAP Nuclear Power Division Administrative Procedures '
NRC Nuclear Regulatory Commission
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'OSS One-Stop-Shop OST Operating Surveillance Test PMT Post-Maintenance Test - ;
QSU- Quality Services Unit RCA- Radiologically Controlled Area RP&C' Radiological Protection and Chemistry RST: Reactor Surveillance Test -
RTD Resistance Temperature Detector :
~RWP ,
Radiation Work Permit SCFM Standard Cubic Feet per Minute SG' Steam Generator
'SLCRS: Supplementary Leak Collection and Release System j SRO Senior Reactor Operator l STAR Stop-Think-Act-Review TS Technical Specification
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