IR 05000338/1989200

Safety Sys Outage Mod & Maint Team Insp Repts 50-338/89-200 & 50-339/89-201 on 890508-12 & 22-26.No Violations Noted. Major Areas Inspected:Implementation of Matl & Work Control Sys to Ensure Mod Conformed to Installation Requirements

ML20246H245
Person / Time
Site:	North Anna
Issue date:	08/08/1989
From:	Cummins J, Gramm R, Konklin J, Lanning W Office of Nuclear Reactor Regulation
To:
Shared Package
ML20246H241	List: IR 05000338/1989200 ML20246H237
References
50-338-89-200, 50-339-89-201, NUDOCS 8909010193
Download: ML20246H245 (59)

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U. S. NUCLEAR REGULATORY COMMISSION OFFICE OF NUCLEAR REACTOR REGULATION Division' of' Reactor Inspection and Safeguards Report Nos:' 50-338/89-200 and 50-339/89-201 Docket Nos: 50-338 and 50-339 Lic' ensee: . Virginia Electsic and Power Company 5000 Dominion Boulevard Glen Allen, VA 23060-Inspection At: , North Anna Nuclear Power Station Inspection Conducted: May 8 - 12 and May 22 - 26, 1989 Team Leader: A do- h/

J. E. Cumins, Senior Operations Engineer Mz.5/sc DateSigned)

T der Assistant Team Leader: b > 25[8'l R. A. Gram, Seniorlperations Date Signed Engineer - Team Leader Team Members J. A. Isom, Operations Engineer, NRR J. M. Sharkey, Operations Engineer, NRR M. Thomas, Senior Reactor Inspector, Region II '

J. Lenahan, Serior Reactor Inspector, Region 11 D..Beckman, Consultant G.~khoads, Consultant D. C. Ford,' Consultant M. I. Good, Consultant E. T. Childress, Consultant D. 8. Waters, Consultant D. S. Shultz, Cone :hant

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Other tiRC personnel Attending the Exit Meeting:

J. Lieberman, W. Lanning, C. J. Haunhney, F. Jape, J. Caldwell, L. Engle,

.G. Laines

. Reviewed by: 4 7/is/ff mes E. Konklin, Chief Dat'o 5fgned

1. eamInspectionSectionC T

l l Approved by: [//nu hbx $!887 Date/ Signed kaype D. ~Lanning, Chie Special Inspection Bra.ch DRIS, NRR

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Enclosure 1 EXECUTIVE SU*ARY The installation and test phase of the safety systems outage modifications inspection (550MI) and the maintenance team inspection (MTI) took place at the North Anna Nuclear Power Station during the weeks of May 8 and May 22, 198 The purpose of the installation and test phase of the 550MI was to examine the licensee implementation of material and work control systems to ensure that (1)~ the modifications confonned to the installation and design requirements and (2)' components and systems were tested to verify that they were capable of performing their intended safety functions. The MTI was perfonned to ascer-tain whether (1) plant systems and components have been properly maintained so

- that they are available.to perfonn their design function and'(2) the components are repaired in a time frame commensurate with their importance to safet The <tnspection team concluded that the field modifications were generally perfonned in accordance with the installation requirements and that the craftsmanship was of high quality. The team found that craft and supervision personnel were knowledgeable of the technical criteria and administrative requirements. The team found evidence that extensive site planning had taken place prior to the modification implementation; such extensive planning resulted in a high caliber of field activity conduct, particularly in the snubber replace-ment activitie The inspection teani also found weaknesses in the following areas, as described below:

• Review of several design change packages from the 1987 outage identified that some of the changes could have been avoided if-more detailed reinstallation reviews and halkdowns had been performee. This concern was further supported by inconsistent-cies found between the pressurizer oven drawings and the installed insulation, and questions regarding the seismic adequacy of the pressurizer insulation (inspector follow-up item 89-200-01).

• 1est personnel in the ad isory operations group were knowledgeable and the tests were well controlled. However, the available test

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engineers appeared to be overburdened by the demands of the test program, and test results were not being completed in a timely manner. Other personnel staffing problems have developed in the predictive n.aintenance engineer groups and have inhibited the implementation of new initiatives. In addition, the team was concerned with an apparent shortage of I&C technicians and engineer * Ineffective and untimely corrective actions were implemented to address concerns that had been identified regarding the preventive staintenance program for stored conponents. Additionally, correc-tive actions regarding problems identified with the engineering work request process were not implemented in a timely manne _ _ _ _ - _ _ _ _ _ _ - - _ _ - _ _ _ . .

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No method was proceduralized for calculating the. neutron. detector current. This was perfomed as an engineering study and contained-a mathematical erro

Equipment clearances.were not all performed in accordance with'

the approved tagout sequence. This situation creates the potential for. causing equipment damage or personnel injur *

Some~ plant procedures were not detailed enough to define the work steps for the. performance of maintenance and testing activitie An example involves the diesel generator maintenance procedur in which complex activities such as the removal of pistons were consolidated into a single procedural step. Electrical modifica-tion test procedures such as the pressurizer spray valve position indication test (inspector follow-up item 89-200-02) also lacked-sufficient detail. Future personnel turnover and.the resulting reduction in the. levels of experience in conjunction with the procedural lack of detail could increase the. likelihood of inadequate maintenance and testing activitie

The licensee did not always adhere to station administrative procedures. A drawing found in a work package did not reflect the most.recent revision; master copies of some design change packages for testing were not maintained within the document vault; some data and signoffs were wrong; two administrative procedures were inconsistent with respect to proper handling of the modification, documentation; and engineering calcula-tions were performed as an engineering study, thus recef @ g a less rigorous revier:.

The root cause evaluation (RCE) program and its implementation appear to be inadequate. A consistent methodology is not in place, and the quality of RCEs reviewed by the team was poor (inspector follow-up item 89-200-03).

Because of wiring deficiencies identified in the ATWS mitigation system actuation circuit (AMSAC) panels, the team considered that the conduct of vendor quality control, the perfomance of licensee vendor surveillance, and the conduct of site receiving inspections

, were inadequate. Specific deficiencies included rejectable wire terminations, minimum bend radius violations, twisted wire jackets, and cracked resistor '

The inspection team was particularly concerned with the availability of sufficient staff resources. The station staffing appears to be at a critical point at which more staff will be needed to adequately fulfill the organiza-tional responsibilities based on: an overburdened advisory operations test group that has had difficulty completing test records in a timely manner; insufficient instrument technicians to implement the balance of plant quality assurance program for preventive maintenance of heating, ventilating and air conditioning system instruments; predictive maintenance manpower constraints which have delayed the implementation of a thermography monitoring program; and staffing restrictions that have impeded the implementation of the human performance evaluation system. In addition, the timely implementation of improvement programs will require that existing staffing levels be augmented.

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- TABLE OF CONTENTS , l SAFETY SYSTEMS OUTAGE MODIFICATIONS INSPECTION '

AT NORTH ANNA NUCLEAR POWER STATION (Inspection Report 50-338/89-200and50-339/89-201)

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1.0 INTRODUCTION AND OVERVIEW .................................... 1 2.0 SAFETY SYSTEMS OUTAGE MODIFICATIONS INSPECTION INSTALLATION AND TESTING PHASE ............................... I 2.1 Scope ........................................................ 1 2.2 Mechanical Modifications ..................................... 2 2.2.1 Reactor Coolant System level Indication (DCPs 88-11 and12)............................................... 2 2.2.2 Bolting for Platform Structural Beem Clips (EWR 89-239). 2 2.2.3 Charging Pump Air Binding (EWRs88-330 Unit 2 and EWR 88-330AUnit1)......................................... 3 2.2.4 Pressurizer Oven Installation and Rework (DCPs 84-69 and 84-70) ............................................. 4 2.2.5 Pressurizer Safety and Relief Valve Discharge Pipe Support Modifications (DCP 84-71) . . . . . . . . . . . . . . . . . . . . . . . 4 2.2.6 Large Bore Snubber Modifications (DCP 86-09)............ 5 2.2.7 Service Water Reservoir Valve House (DCP 84-36) ........ 6 2.2.8 Service Water Final System Tie-in (DCP 84-43) .......... 6 2.2.9 Modification Process Administrative Concerns ........... 7 2.2.10 Conclusions ............................................ 7 2.3 Electrical and Instrumentation Control Modifications .......... 7 2.3.1 Pressurizer Spray Valve Position Indication (DCP 87-25). 7 2.3.2 Anticipated Transient Without Scram Mitigation System Actuation Circuit (AMSAC) (DCP 87-11) .................. 8 2.3.3 Control Room Design Review Panel Modifications

'DCPs 87-21, 87-22 and 87-24) .......................... 10 2.3.4 Station Battery Replacement (DCP 85-29) ................ 10 2.3.5 Service Water Reservoir Improvements, Final System Tie-In and Startup (DCP 84-43) ......................... 11

- 2.3.6 Reactor Coolant System Drain Down Level Indication (DCP 88-11) ............................................ 12 2.3.7 Modification Package Field Changes and Revisions ....... 12 2.3.8 Conclusions ............................................ 13

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2.4 Test Performance .............................................. 14 2.4.1 Design Change Test Program Review ...................... 14 l 2.4.2 Test Procedure Review .................................. 14 t

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2.4.3- Review of Post-Modification Testing ................... 15 i

.2. Observation of Post-Modification Testing .............. 16 2. Conclusions ........................................... 17 3.0 MAI NTEN AN CE T EAM I NSPE CTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.1 Plant Matcrial Condition and Housekeeping...................... 19 3.2 Technical Support ............................................. 20 3.2.1 Site Engineering Procedures ............................ 20 3.2.2 Root Cause Analysis ................................... 21 3.2.3 Engineering Study / Calculation Control .................. 21 3.3 Control of Equipment Clearances (Tagouts)...................... 23 3.4 Control of Vendor Techni ca l Manual s . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3.5 Preventive Maintenance Program Weaknesses ..................... 25 3. Implementation of the Instrumentation and Control Preventive Maintenance Program ......................... 25 3.5.2 Preventive Maintenance Procedure Adequacy .............. 26 3.5.3 Preventi ve Mai ntena nce fo r Stored i tems . . . . . . . . . . . . . . . . 27 3.6 Follow-up on Self-Assessment Corrective Actions ............... 27 3.6.1 Root Cause Analysis Program ............................ 28 3.6.2 Procedure Problems and Wea knesses . . . . . . . . . . . . . . . . . . . . . . 28 3.6.3 Maintenance Self-Assessment ............................ 31 3.6.4 Service Water Review Team Findings ..................... 32 3.6.5 Valve Maintenance ................... ....... .......... 33 3.7 Maintenance Department Staffing ............................... 34 3.8 Overall Conclusions ........................................... 34 4.0 MANAGEMENT EXIT MEETING ....................................... 35

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APPENDIX A - MAINTENANCE INSPECTION DATA ........................... A-1 B-1 APPENDIX E, - LICENSEE PERSONNEL AT EXIT MEETING.....................

C-1 APPENDIX C - ABBREVIATIONS AND ACR0NYMS.............................

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~ 12 INTRODUCTION AND OVERVIEW The installation and test phase of the safety syr,tems outage modifications inspection (SSOMI) was performea to (1) detemine whether the installation

- of the modifications confomed with the design and installation requirements

and.(2) verify the adequacy of the post-modification t? sting to ensure the components and. systems are capable of performing their intended function.

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The $50MI' team examined selected design change packages and engineering work requests to assess the adequacy of management control of the edification proces A maintenance team inspection (MTI) was simultaneously conducted as a performance-based assessment of the maintenance process. The MTI was perfomed to detemine whether plant components (1) have been properly maintained and available to perfom their intended function and (2) are o .promptly repaired in relationship to their importance to safety. The overall goal of the MTI was to determine the effectiveness of the integrated 3 maintenance proces !

The MTI covered many areas of review that are depicted on the maintenance tre (The maintenance tree is a diagram of the areas covered in a site maintenance program and is included in NRC Temporary Instruction 2515/97. See Section 3 of this report.) The major parts of the tree include overall plant performance, management support of maintenance and maintenance implementation. First the team reviewed documents relative to the availability, operability, and reli-ability' of equipment. The team also assessed how well management supported maintenance by reviewing the extent to which corporate and site management was aware of maintenance problems and the resolution of such problems. The team then assessed the implementation of the maintenance program. This involvedthemajorpartoftheteameffortandincluded(1)inspectionof in-process work controls. (2) review of the plant organization including personnel, (3) examination of maintenance facilities, and (4) personnel control, including training and qualification program This inspection was conducted in two phases. During the first phase, the team verified that the detailed design, engineering support, and procurement activities were adequate to support the safety-related modifications planned for this outage. The first phase was performed during the weeks of February 13 and 27, 1989, and was documented in Inspection Report 50-339/89-20 During the second phase, the inspection team reviewed the installation and i

. testing of modification activities. The team additionally retiewed maintenance program implementation activities. The second phase was performed during the weeks of May 8 and May 22, 1989 and is documented herei SAFETY SYSTEMS OUTAGE MODIFICATIONS INSPECTION, INSTALLATION AND TESTING PHASE 2.1 Scope The inspection team reviewed several modification packages for Units I and 2 that were in various stages of completion. The work activities were reviewed with respect to licensee requirements comitments contained in the Updated-1-

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A Final Safety Anal The inspection team reviewed the associated design change packages (ysis Report.DCPs) and the engineering work requests (EWRs) to ensur the personnel responsible for implementing the modifications had received appro-priate work instructions. The inspection team also interviewed responsible construction, engineering, and quality assurance personnel to discuss their areas of the modification activitie The inspection of post-modification testing focused on the review of design change test procedures, observation of testing in progress, evaluation of completed test results, and a review of the appropriate administrative procedures that establish the requirements for perfoming the design change testin .2 Mechanical-Modifications

- 2.2.1 Reactor Coolant System Level Indication (DCPs 88-11 and 88-12)

In response to Generic Letter 68-17 and NRC Inspection Report 50-338/88-01, the licensee had made commitments to install a permanent reactor vessel standpipe arrangement. DCPs 88-11 and 88-12 were issued for making this modification on Units 1 and 2 respectively. Since the Unit 2 installation was not completed because material was unavailable, the licensee had sent the NRC a letter amending the completion date comitment The inspection team examined the storage of support material. The material was appropriately segregated ano tagged. The inspection team examined supports H4 and H5 and found the location and configuration to be consistent with the associated design drawirgs. The tolerances applicable to construction details of the supports had been changed on several occasions by the engineer-ing organization. The inspection team reviewed the basis of the tolerance changes with the responsible engineer and found that these changes did not affect the field activities. Several socket joints were not properly covered to prevent internal particulate contamination; the general foreman rectified

- the situation. The work activities were otherwise found to be proceeding in accordance with the design requirement .2.2 Bolting for Platform Structural Beam Clips (EWR 89-239)

. The licensee had identified that certain structural steel connections had not been properly installed at the Surry site, and corporate personnel had issued potential problem report 88-21. Only the erection bolts had been installed at l the clip angles and the requisite weld between the clip angle and the beam web was missin Engineering personnel at North Anna Unit 2 performed field examinations and identified a large number of clip angles that were improperly installed; deviation report 89-620 was issued. The licensee developed engi-neering criteria to retrofit the connection with either appropriate fastener material or an additional weld. The licensee determined where the questionable connections were located by performing an engineering review of plant drawings; the licensee performed a 100 percent walkdown to identify the associated field conditions. Construction personnel elected to weld the clip connections where necessar The inspection team examined two completed clip connections (number 13 and'14) at elevation 272' in the steam generator cubicle loop 2 found them satisfactory with respect to weld quality and size. The team verified that the licensee had properly resolved the clip angle installation concern __--___

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2.2.3 Charging Pump Air Binding (EWRs88-330 Unit 2 and 88-330A Unit 1) .

By means of these safety-related modifications, the licensee installed three high point air vents and two remote venting valves on the high head safety injection (HHSI) system pump suction headers in both North Anna units. The high point vents were installed in response to the discovery at the Surry Nuclear Power Station of a gas pocket accumulation in the pump suction pipin The gas pocket could be detrimental to pump operation if gas binding and cavitation resulted. The inspection team reviewed the in-progress Unit 1 modification installation and the completed Unit 2 package, and interviewed responsible station engineering, quality control, and management personne The inspection team found the licensee had incorrectly implemented the modifications by means of issuing an engineering work request (EWR) instead of a design change package-(DCF) as defined in licensee procedures NODS-ENG-007,

" Design Control Process," and ADM-3.7, " Engineering Work Requests." In genera EWRs were intended for implementing such minor changes as equipment substitution, not system configuration changes. One of the licensee's engineering representa-tives stated that the Nuclear Design Control Manual, " Glossary of Terms,"

Revision 5, defines when a design change should have been implemented by a DCP or an EWR and that this definition was reflected in ADM-3.7. However, the definition in the glossary of terms was not consistent with the one given in NODS-ENG-007. This concern regarding EWk processing had been previously addres-sed by the 1987 VEPCO corporate quality assurance engineering audit No. 87-61, finding 87-61-15. The finding toentified deficiencies in the processing of EWRs and was still open at the end of this inspection. The fact that this 1987 finding had not been corrected resulted in the continued use of EWRs to imple-ment plant modifications for which the EWR process was not intended. Further, review of the completed EWR 88-330 package revealed numerous administrative errors in the preparation and implementation of the modification that indicated inadequate independent review of the packag The inspection team found, on May 11, 1989, with Unit 2 operating at approxi-mately 30 percent power, that the licensee had left a tygon tube connected downstream of vent valve 2-CH-432 after venting the HHSI suction heade Radiation work practice (RWP) 229, " Venting and Draining of Contaminated Systems," included step 3.1.14 which required the cleanup of vent / drain pipe tailpiece and replacement of pipe caps. The procedure had been improperly completed on May 4, 1989 without removing the tygon tube or reinstalling the

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vent ca The inspection team also found deformed unistrut tubing clips on lines 1/2-CH-947-ICN8-Q2 and 1/2-SI-689-ICN8-Q2. However, the team confirmed that the specified clip material had been properly installed in accordance with NAS-1011. " Specification for Installation of Instrumentation for North Anna Units 1 and 2."

The team witnessed the attempted performance of a leak check on a Unit 1 HHSI vent line installation. The team observed that operations personnel were performing the valve lineup without any written instructions; the quality control inspector was not familiar with the test details; a pre-test briefing had not been held to coordinate the involved test pcrsonnel; the test engineer did not have a copy of the test procedure, which was subsequently obtained;

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' and a work request tag was hung from a test boundary valve. After considering the problems encountered with initiating the test evolution, the responsible supervisor determined that proper control had not been established to run the test and the test was aborted. The test supervisor demonstrated good judgment

.by terminating the test. It appeared that the problems were aggravated by the lack of a pre-test meeting and because the advisory operations group was overburdened on the day the test was conducte .2.4 Pressurizer Oven Installation and Rework (DCPs 84-69 and 89-70)

.The licensee performed these non-safety-related modifications in Units 1 and 2 in response to NUREG-0737, * Clarification of TMI Action Plan Requirements,"

Item II.D.I. These modifications involved installation of seismically qualified metal reflective thermal insulation boxes (ovens) to enclose the pressurizer safety valve loop seal piping, while exposing the loops to an uninsulated section of the pressurizer. The three ovens per unit were designed to maintain the loop seals above 400*F to prevent water slug formation and flow through the safety and relief valves. The inspection team reviewed the in-progress Unit 1 modification package, observed the work in the field, reviewed the completed Unit 2 package, and interviewed esponsible personne The inspection team found that craft personnel were modifying the existing pressurizer insulation without referring to the drawings in the DCP. This resulted in numerous deviations from the specified installation requirements for the split-line brackets and reinforcements. Additionally, the approved DCP orawings were found to erroneously depict the pressurizer insulation ecnfiguration. It also appeared thet the manufacturer of the pressurizer shell insulation had not been advised of the modifications to the original insulation for considering possible seismic design impact. This appeared tc be inconsistent with ADM-3.1, " Administrative Procedure for Control of Design Change Implementation 1," Section 4.2. The licensee issued field change request (FCR) 49089 for design engineering evaluation of the as-built insulation configuration, including the oeviations from the DCP drawings. The engineering group found that a review had not been performed to address the seismic loading qualifications of the pressuri-zer shell insulation to which the seismic ovens were attached. The licensee issued a deviation report to evaluate the as-built insulation configuration and separately began a seismic f ailure mode evaluation to determine the impact

- on the operation of Unit 2. Effective oversight had not been established for the subcontractor involved with this work activity and erroneous engineering documentation was utilized to support the modification implementation. This item is an inspector follow up item pending completion of the seismic analysis (89-200-01).

2.2.5 Pressurizer Safety and Relief Valve Discharge Pipe Support Modifications (DCP 64-71)

l This modification replaced the pressurizer belly bands and support members for f the pressurizer safety and relief valves and upgraded or replaced supports for the discharge piping between the valves and the pressurizer relief tank. The licensee initiated the inst 611ation of the niodification in 1985 in response to the requirements of NUREG-0737. Item II. The work was continuing during the-4-

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1989 outage because during previous outages, the licensee had encountered exten-sive concrete reinforcing bar problems that had interfered with this work while drilling anchor bolt holes for support mounting plates on the discharge relief line. The inspection team reviewed installation documents, conducted walkdowns of the areas affected by the modification, and observed work activities for conformance to procedures and design drawings. No deficiencies were identified as a result of the revie The inspection team observed that the DCP had been revised 59 times since it was first approved for implementation. About 60 percent of the revisions involved drawing changes and changes to the installation procedures resulting from field problems in drilling support plate anchor bolt holes. The manner in which revisions were made to t.he installation procedures increastd the amount of documentation that m ro uired to be processed by the craft perscnnel in perfonning the field etstallatio The inspection team questioned the licensee concerning commitments made to the NRC for completing the modification. The licensee responded that it was pos-sible that the modification would not be completed during this outage. The team reviewed the licensee and NRC correspondence that was available and did not note any licensee conrnitment. dates for completing the installation. However, review of a 1987 inspection report by a NRC regional inspector showed an antici-pated installation during the current refueling outage. The team referred the results of the schedule completion review to the NRC project manage .2.6 Large Bore Snubber Modifications (DCP 86-09)

This modification removed large bore snubbers on the steam generator and reactor coolant pump supports, and either replaced them with new snubbers or rigid restraints or elininated the snubbers. The team reviewed installation documents, conducted walkdowns of the areas in which the snubbers and restraints were being removed or replaced and observed completed installations for conformance to installation procedure requirements. The installed hardware was found to conform to the design requirement To control DCP work, the licensee keeps an engineering copy in the document centrol area and uses that copy as the master record of work perfonned in the field. Field copies are issued to craft crews for completing and signing off wcrk activities. The field copies arc returned to document control and signa-tures and data are transferred to the engineering copy on a daily basis. Con-

- tainment copies are not returned, but signatures are placed in the engineering copy by individuals responsible for the wor The installation procedures for DCP 86-09 required sequencing of certain snubber removals and installations to maintain operability of the support structures and the rc6ctor coolant loops in the event of a seismic disturbance during the modification. During its review of the engineering copy of the procedures, the team documented apparent out-of-sequence work activities: Work was recorded as being started on procedure P28U1 on May 3,1989 (pulling snubber, pins, etc.)

before the engineering hold of step 4.8.6.2 was completed on procedure P27U Review of the containment working copy of the DCP revealed that the responsible engineer had signed off on step 4.8.6.2 as completed on May 3, 1989. Another engineer signed off on the step in the engineering copy the next day, without-5-

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indicating that he was signing for the first engineer, contrary to the require- !

ments of ADM-3.1, step 4. The licensee corrected the discrepancy by annota- !

ting and correcting the date and signature, and issued a deviation report to document the incorrect signatures and dates. The team remained concerned, however, that the transferring of signatures and information into a single

. official record could lead to other error Review of field installation drawings associated with the containment working copy revealed that one of the 10 drawings in the package (drawing N8609-1-1-FV-17L)

was not the current revision. The licensee replaced the out-of-date copy of the drawing with the correct copy, verified that all other drawings in the package were the correct revision, and initiated an investigation of the possible source of the discrepancy. This was determined to be an isolated inciden The team toured the facility assembled by the nuclear site services (NSS)

organization for training craft crews involved in snubber replacements on Units 1 and 2. Training included rigging with actual weight mockups and simulated interferences and holding critiques on individual and crew perfor-mances. Following the completion of the project for Unit 2, the project team met to discuss Unit 2 lessons applicable to Unit 1. This appeared to be a good way to improve communications, resolve problem areas experienced, and avoid potential problems. The licensee reported that the project was proceeding more smoothly and with less personnel radiation exposure than was experienced at Unit 2. The team considered these activities to be a strengt .2.7 Service Water Reservoir Valve House (DCP 84-36)

This modification upgraded and replaced the spray array system for the service water system discharge pond and installed a new valve house and a new spray array bypass system. The modification was essentially completed in 1987 before the tie-in to the existing system and initiation of control room changes that took place by means of another DCP. The DCP for this complex and involved modification had to be revised 211 times because of field interferences, instal-lation procedure chan5es, and administrative requirements. The team conducted a walkdown of the service water valve house and found that, in general, the modification had been performed well and that workmanship was goo However, several minor deficiencies were identified during the walkdown of the valve house: loose concrete expansion anchors were found on emergency light suppcrts 1-ELT-SW-007 and 1-ELT-SW-014; an electrical conduit support was i

- improperly shimed from the wall; loose bolts were found on fan unit 2-HV-UH-70B and transformer TRANS-117; some U-bolt support fasteners on a 1-inch radiation acnitor line were only provided with single nuts; the cover of junction box JB 5078 was missing a screw and junction box JB 5088 was missing a portion of the sealing gasket; some concrete anchor bolt washers on a radiation monitor line support were deformed, indicating misinstallation; test buttons on emergency lights 1-ELT-SW-007 and 1-ELT-SW-018 were broken; and a valve packing leak was noted on valve 123B. The licensee initiated corrective actions for these items as documented on work requests, deficiency reports, and deficiency card .2.8 Service Water Reservoir System Tie-in (DCP 84 43)

This modification tied in the new service water spray arrays and spray bypass system to the ren.ainder of the service water system. The team reviewed the-6-

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76 DCP revisions to detennine whether any revisions could have possibly been avoided by increased engineering involvement before release of the modifica-tion to the field for installation or by better walkdowns and coordination with site construction and other personnel to resolve installation details and interferences. The team noted that the engineering organization was responsible for preparing the installation procedure in this and other DCPs, rather than the installing organization at the site. The team believed that approximately 40 percent of the revisions could have been avoided. The licen-see stated that it was also concerned about the large number of revisions and was ettempting to reduce the number of field changes in more recent DCP There were not enough recently completed DCPs being worked to determine if this goal was being accomplished. One drawback to the high number of docunent revisions was the complexity of integrating these changes into the original document. This situation could confuse the installation. personne .2.9 Modification Process Administrative Concerns The team identified several concerns related to the implementation of the administrative progran, controls. These concerns included: inconsistent administrative procedure guidance regarding the use of colored paper for controlled copies of EWRs and DCPs and how to handle previously issued documents; instead of returning the copies to t.o document control log room as required by site procedures, test personnel maintained controlled color copies of DCPs 87-11, 87-12, 87-13, 87-15, and 87-21. Two FCRs were not incorporated into DCP 87-11 that was stored at the advisory operations office; signatures from DCPs 86-03 and 87-11 were not transferred to the master copy each shif t as is reovired by site procedures; the updating of a master control-led copy and several fie1<' copies is cunibersome and appears prone to personnel error. Although these concerns did not lead to any hardware problems, they indicate a tolerance to working contrary to the guiding procedures rather than amending the procedures to make them consistent with the actual mode of opera-tio .2.10 Conclusions The team noted that the NSS personnel involved in the management and direction of the modification installations were very knowledgeable of the work and work standards. Extensive preplanning was notea to facilitati ' accomplishment of the modifications. The installed plant hardware was generally found properly installed with some exceptions in the service water valve house and the pres-

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surizer oven insulation work activities. Numerous administrative concerns were I

identified with the modification documentation. Sone corrective actions had not been implemented in a timely manner to rectify concerns with the engineering work request program. The need for increased engineering review prior to release of t1e modifications to the field was apparent as evidenced by the large number of DCP revisions and inconsistencies between the engineering drawings and the pressurizer insulation.

l 2.3 Electrical and Instrumentation Modifications 2.3.1 Pressurizer Spray Valve Position Indication (DCP 87-25)

This modification installed pressurizer spray valve position-indicating lights in the control room. This was in response to a control roora design review

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(CRDR), which stipulated that visual displays in the control room should give operators all of the information about the status of systems and parameter

values needed to accomplish operational tasks in normal, abnormal, and emergency situation During its review of this design change package, the team found that this particular CRDR improvement was not entirely effective because confusion existed with regard to the actual position of pressurizer spray valves PCV-2455A and PCV-2455B. Although conversations with operational personnel indicated that both valves were in the closed position at the time of the inspection, the team ,

noted that the indicating lights were inconsistent: one of the valves indicated

"mid-position " the other indicated " closed." After the team made this observa-tion, the unit operator performed a bench board lamp test to ensure that the noted condition was not the result of a burned-out bulb. The lamp test confir- '

med that the indicating bulbs were in working orde The team also reviewed the functional test for the modification to detemine its adequacy.and completeness. The team found that the post-modification test lacked sufficient detail because it did not quantify the acceptance values for the limit switches that actuate the open and shut valve position-indicating lights. Because the test procedure was inacequate, the original intent of the modification was not fulfilled as the position-indicating lights did not accu-rately depict the valve position. Pending further licensee investigation this concernisaninspectorfollowupitem(89-200-02).

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2.3.2 Anticipated Transient Without Scram Mitigation System Actuation Circuit (AMSAC) (DCP 87-11)

The licensee installed this modification to meet the regulatory requirements of 10 CFR 50.62. Each pressurized water reactor must have equipment from sensor output to final actuation device, that is diverse from the reactor trip system, to automatically initiate the auxiliary (or emergency) feedwater system and cause a turbine trip under conditions indicative of an anticipated transientwithoutscram(ATWS). The AMSAC system, if actuated, trips the main turbine, starts all auxiliary feedwater pumps, shuts the steam generator blowdown and sample valves, and provides a redundant reactor trip by tripping the rod drive motor generator sets. When it performed field inspections of

. the AMSAC panel mounting, construction, internal wiring, and selected cable and conduit runs tn ensure compliance with the modification package, referenced specifications, and procedures, the team noted numerous deficiencie The inspection team found numerous wiring deficiencies in the Unit 1 AMSAC cabinet that appeared to have occurred at the vendor facility and that had not been identified by eit?.er the vendor's or licensee's quality assurance (QA) inspections of the cabinet. For example, the team noted numerous wires with severe bend radii (sharp 90-degree bends at the terminal barrel) and ,

termination deficiencies such as wires with broken strands on AQ, BQ and C0 test' function switches. The wiring and terminations did not meet the requirements of North Anna specification (NAS) 3012. " Criteria Specification for Design and Identification of Electrical Cable Systems for North Anna Power-8-

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Station Units 1.and 2 " Revision 1. The wire was Rockbestos, two-conducto AWG, 600-V, seven-strand wire. . Deficiency details follo _

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L Switch AQ-Point 34,' wire ASIV - 3 broken strands Point 33, wire 8033 - 2 broken strands Severe bend radius - wires CR1, CA1A. CA1B, CSIII, C115 C72,

.TC61, TC64, TC67, BQ27, B031 DD11 TC65, TC68, CRI, CA2A, CRII, CA2B, C11 *

iSwitch BQ Severe bend radius - wires AQ31, BQ13 -TC50, TC56, AQ33

Switch CQ-Point 33, wire BQ33 - 1 broken strand Point 31, wire B031 - 4 broken strands Point 27, wire BQ27 - 4 broken strands Point 21, wire TC65 - 3 broken strands Point 2B, wire C115 - 2 broken strands Severe Bend Radius - Wires A73, AA1B, ARII, 8031. TC46 Because of these deficiencies, the team concluded that both the vendor riuality control as well as the licensee's~ receipt inspection were inadequate. After discussing the deficiencies with'the licensee, the licensee issued a deviation, report and initiated a reinspection of the entire panel. The team also found

that a-diode lead was not secured by its screw and was'just touching the lug barrel on terminal 36 of terminal board TC. Also, three ceramic resistors,

-AC-LTA5, AB-LTA3, and CC-LTC2, had cracks in the ceramic material at the point were the terminal lug entered.the ceramic coating. The licensee agreed with these deficiencies and issued deviation report As a result of large number of electrical wiring deficiencies found in the

-. Unit 1 AMSAC cabinet, the team performed a field inspection of the Unit 2 AMSAC panel, which had recently been completed and was in operatio .

Deficiencies similar to those in the Unit 1 AMSAC cabinet were found, although they were not as numerou Several wires on test function switches AQ, BQ, and CQ had severe bend radii-(sharp 90-degree bends) that were similar to the Unit 1 deficiencies. The team noted no broken strands and the terminations were not twisted, as on the Unit 1 panel. The deficiencies noted were:

• Switch AQ - severe bend radius at termination points 17, 18, 21, 22, 23, 25, 26, 29, 30, and 3 * Switch BQ - severe bend radius at termination points 17, 1B, 21, 22, 25, 26, 30, 33, and 3 _ - -____-_ - __ _ _ _ _ _ _- _ - - _ ____ _ ____ _ _ _ _ - -_____ _ - _ - ____ _ _ - _ - __

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Switch CO - severe bend radius at termination points 18, 21, 26, 29, 30, 32, and 3 Even though sone of these bend radius violations were extremely severe, the wires were satisfactory for operatio The team also identified several-seismic Class I conduit supports which did not conform to specifications. Seismic Class I conduit support 1-87-11-10011, which was complete and had been inspected and accepted by quality control personnel, had an unacceptable clearance between the support baseplate and the concrete wall. NAS-2016. " General Notes for Safety Related Conduit Supports," required that, for support baseplates less than 15 inches, no gap greater than 1/16 inch was allowed to a width of more than 1 inch for greater than 60 percent of the support length or width. It was found that the left side of the baseplate had a 1/8-inch gap to a width of about 2 inches for 100 percent of the baseplate length. Site engineering personnel recognized the deficiency and prepared a deviation report to correct the problem. Additionally, two other supports were identified, 1-87-11-7560 and 2-85-19-2021, that had similar excessive wall to baseplate clearances. In general, however, the workmanship and con-formance to specification requirements for most of the supports were excellen .3.3 Control Room Design Review Panel Modifications (DCPs 87-21, 87-22, and 87-24)

In general, the team noted that work activities associated with Modification Packages 87-21, 87-22, and 87-24 were performed in accordance with design and procedural requirements. The inspectors noted material workmanship that was of good quality and personnel appeareo knowledgeable about design and installation requirements. However, during the examination of modified field wiring, the following wiring deficiencies that did not comply with applicable design documents were identified:

• Cables i 2SC18NX015, 2SC18NX016, and 2SCIChX017, routed to the auxiliary shutdown panel, were labeled with a suffix of A-1F and A-2F on conductors landed at terminal block TA although the wiring diagram (N8721-3-2FE3CO)

identified these cables with a different suffix of C+ and C .

• The conductor at terminal point 3 of lamp test relay A6 was identified as 2RSI-BO-IPTO although the wiring diagram (N8723-2-2FE3LF) required

, a conductor with an identification of 2RSI-BO-1P0 * The conductor at terminal point 3 of lamp test relay A7 was identified as conductor 2RSI-AO-1PTO although the wiring diagram (N8723-2-2FE3LA)

required a conductor with an identification of 2RSI-AO-1P0 In each instance it was cetermined that the dcficiency did not affect the functional integrity of the associated circui .3.4 Station Battery Replacement (DCP 85-29)

This modification replaced C&D manufactured batteries, that were installed originally, with Exide-type 2GN23 cells. The intercell connectors, miscel-laneous hardware, and associated two-tier seismic battery racks were also-10-

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replaced. The licensee had replaced six of the eight vital station batteries during the previous outages and only batteries 1-BY-B-IV and 2-BY-B-IV remained i to be replaced. The Unit I vital station battery 1-BY-B-04 was replaced during ]

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During its review of Modification Package 85-29, the team reviewed engineering calculation EE-0009, *125Vdc System Analysis." The calculation was written in response to NRC identified concerns at the Surry Power Station regarding the loads on the 125V-dc. system, adequate battery sizing, and required voltage i levels at various distributions panels at North Anna Units 1 and 2. The review of this engineering calculation raised some concern because it stated that Unit 2 Battery 2-BY-B-IV was acceptable for operation although the calculation EE-0009 had shown the battery was too small and must be replace The calculation stated that by allowing the design margin to be eliminated and by preventing auditional loads from being placed on the dc bus associated with Battery 2-BY-B-IV, the battery would be acceptable for operation. The team disagreed with this justification as it did not consider the less-than-optimal operational factors detailed in the governing Institute of Electrical and Elec-tronic Engineers (IEEE) Standard 4B5-1983, "Recomended Practice for Sizing Large Lead Storage Batteries for Generating Stations and Substations." Unit 1 Battery I-BY-B-IV was not a concern since it was repleced during this current outag After discussing this concern with the licensee's project and corporate engineering personnel, the team found that the justification statement for calcu-lation was misleading and that the battery was of adequate size for the existing load profile. To confirm this information, the team reviewed the actual loao profile for Battery 2-BY-B-IV; engineering standard STD-EEN-0026. " Guidelines for Electrical System Analysis" and capacity and service surveillance test data for the battery in question and found that the battery was in good condition and exhibited no signs of degradation. Additionally, the tests demonstrated that the battery was fully capable of meeting plant Technical Specification Consequently, while it is clear that the addition of new system loads has impacted the original design margin of Battery 2-BY-B-IV, the review of current load profiles and applicabla test data indicated that the battery has sufficient capacity to treet existing Service requirements. However, in order to resolve the hRC concerns regarding the inadequate justification, the licensee has comitted to revise engineering calculation EE-0009 to provide sufficient analysis to

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demonstrate the continued safe and reliable operation of vital station Battery 2-BY-B-I .3.5 Service Water Reservoir Improvements, final System Tie-In and Startup (DCP 84-43)

This modification added a r.ew spray system to the existing service water reservoir. The Unit 3 and 4 pump house served as a valve house for the spray and winter bypass header for Units 1 and 2. The team inspected field change 56 to this modification which was an electrical field change that changed relays in several panel:: so the service water ventilation fans and heaters are removed from the diesel loading during an undervoltage condition. The team performed a field inspection of relays in panels 1-EP-MC-50 (MCC-1H1-3A)

cubicle B2, 1-EE-SW-01 compartment 15H2A, 1-EP-MC-51 (MCC-1J1-3A) cubicle B2,

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. 1-EE-SW-02' compartment 15J2A,2-EP-MC-50(MCC-2H1-3A)cubicleB2,and2-EP-MC-51 (HCC-2J1-3A) cubicle B2 and noted that the relay installations, wiring, termina-tions, and cleanliness in most panels was excellent. The craft group installed

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the relays in accordance with drawings, the wiring runs were neat, and termina-tions. exhibited quality workmanship. The team noted a minor wiring crimping deficiency at terminal point RC10 on relay 27Y-1ENSH03 in 4160V panel 1-EE-SW-0 .The team also found that, unlike tne other electrical panels, the bottom section

of 4160-V panel 1-EE-SW-01, compartment 15H2A was very dirty. The panel bottom had an accumulation of 1/4 inch of dust along with small copper washers and cutoff tie wraps. This panel was in sharp contrast to several similar panels inspected during the inspection. Most of the other electrical panels inspected f were very clea I 2.3.6 Reactor Coolant System Drain Down Level Indication (DCP 88-11)

This modification package provided for the installation of a permanent reactor vessel level system to be used only during outage activities when the vessel is drained below the nozzles. The-indication would consist of a standpipe from the spray line on top of the pressurizer to the drain line on "C" cold le ' Local level indication would be by a magnetic flag in'icator d on the standpip Remote indication in the control room would utilize a Rosemount differential pressure transmitter. The inspector reviewed the electrical portion of the modification package and discussed the modification with electrical nuclear site services personnel. Installation of the modification had not starte The inspector noted no deficiencies in the modification package revie .3.7 Modification Package Field Changes ano Revisions The team reviewed field changes anc :evisions for modifications DCP 85-08 DCP 87-21 DCP 87-23, DCP 87-25, and DCP 87-29. The team found that 32 of the 123 field changes or 25 percent could have been avoided by a more comprehensive technical review and engineering walkdowns before modification approval. Also, 15 additional field changes were found to involve drawing deficiencies. The review indicated that the NSS construction personnel caught many errors that are typically identified during field walkdowns and drawing revievs performed by the engineering group before the modification is approved. The following examples are illustrative of field changes and revisions that appeared to be avoidable:

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Miscellaneous Panel Modifications (DCP 87-21)

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The DCP directed that 6 plate be fabricated to mount an indicator on the emergency diesel generator 2h isolation panel. The dimensions specified for the plate were incorrec A physical separation barrier obstructed the mounting area for a .

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The drawing showed one plate, the physical work required two plate Drawings depicted three undervoltage lamps in reverse numerical order contrary to good human engineering principles. (This modification was

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Two radiation monitor recorders did not fit in the required location because they interfered with existing terminal board Several wires for the internal wiring in one radiation monitoring parel were too short to reach required termination point A pressurizer level indicator was eliminated but.the associated indicator was not eliminated from the test procedur *

Inadequate Core Cooling Monitor (DCP 85-08)

The mounting hardware for blank plates was not specifie There was a interference between a vent line and a pressure inoicato Several cables were too short to reach the new termination locatio *

Instrumentation and Control Relocations (DCP 87-23)

Cover plates had incorrect dimensions and cover plate holes interfered with a stiffener weld bea A reviewer inadvertently marked the DCP as out of compliance with Appendix R requirement *

Control Room Design Review Instrumentation Ranges Changes (DCP 87-29)

The design sketch of the flow indicator scales did not match the actual scale It appeared the number and the nature of the field changes associated with the five modifications were excessive and that cesign change packages required the performance of more in-depth engineering walkdowns and technical reviews during the DCP review and approval proces .3.8 Conclusions

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The team found the electrical plant modifications completed at North Anna were comprehensive and effectively implemented. Plant and contractor construction personnel were exceptionally knowledgeable with regard to the modifications and the modification program. It appeared that engineering preparation of the modification packages could be improved, to reduce the number of field changes associated with the modifications. Specifically, the team was concerneo that the excessive field changes could increase the probability of error as well as placing unnecessary reliance on craft and quality control inspections to detect

! potential design errors. The deficiencies in as-built electrical drawings further compounded the problem and served to emphesize the importance of careful preparatory engineering walkdowns and revie _ _ _ . - _ - - - - - - - - . - - _ _ _ a

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2.4 Test Perfonnance 2.4.1 Design Change Test Program Review The team reviewed the administrative procedures that establish the requirements for preparation, review, approval, and implementation of the design change test program. The test program is not limited to design changes but may be used to test work perforned under engineering work requests (EWRs) and the maintenance program when necessar The team reviewed the associated administrative procedures and held discussions with responsible personnel to verify that:

• Written requirements have been established for the preparation, review, and approval of design change test procedure * Lines of authority and responsibilities have been established to implement the design change test progra * Written measures have been established to assure that operating documents such as procedures, drawings, and Technical Specifications are revised to reflect the design chang The advisory operations group reports to the Superintendent of Engineering and is responsible to review design changes and EWRs to develop the associated test procedure required to verify the functional performance of the completed design change. The group is also responsible for the implementation and documentation of the operational and preoperational testing required to verify the acceptance crittria of the design change. Field changes to design documents also must be issued to the group supervisor for review of testin by the Station i;uclear Operating Safety Comittee (gThe SNSOC). requirements team concluded before review that the administrative framework was satisfactor .4.2 Test Procedures Review The team reviewed the testing for the design changes and EWRs listed belo * Service Water Reservoir Improvements Final System Tie-In (DCP 84-43)

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• ATWS Mitigation System Modification (AMSAC) (DCP 87-11)

• ChargingPumpAirBinding(EWR88-330)

The team considered the attributes listed below, where applicabl * Test objectives, prerequisites, precautions, and initial system conditions were state * Testing of the modified systems and components was in accordance with the design requirements and testing requirements stated in the design change packag * Acceptance criteria were appropriately specifie _ - _ - _ - - - _ _ _ _ _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ - _ _ _ _ - _ _ _ _

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Test procedures were reviewed and approved in accordance with administrative control I The team found the test procedures were in accordance with the administrative {

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2.4.3 Review of Post-Modification Test Results The team examined the DCPs and EWRs listed below and verified that the ,

modification testing was completed in accordance with the requirements stated in the associated EWRs and DCfs, that field changes were reviewed and approved in accordance with administrative controls, that test acceptance criteria were met, and that the test results were reviewed and approved by the appropriate personnel. The following design changes were reviewed by the team:

Control Room Design Review (CRDR) Instrument Range Changes, Unit 2 (DCP 87-29)

• CRDR Miscellaneous Panel Modifications, Units 1 and 2 (DCP 87-31)

• Installation of Instruments in Response to NRC Bulletin 88-08, Unit 2 (EWR88-329)

• Install Vent Yalves on the Suction Lines for Charging Pump, Unit 2 (EWR88-330)

• Containment Electrical Penetration Secondary Protection, Unit 2 (DCP 89-02)

• ATWSMitigationSystemModification(AMSAC)(DCP87-12)

• Service Water Reservoir Improvements Final System Tie-in (DCP 84-43)

The associated test documentation was found properly controlled and complet The inspection team's review of the post-modification testing was limited by the number of tests in progress at the time of the inspection. However, the team reviewed the following completed modification tests as well as surveillance:

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1-PT-67A "Intercell Connection Resistance Test *

2-PT-87 "DC Distribution System Service Test"

• 2-PT-88B "DC Distribution System Capacity Test for Train B"

• 1-PT-83.3 " Load Sequencing Timers Verification Test" The review of historical tests and test data sheets indicated that test activities had been performed in accordance with requirements. The team noted that scheduled test frequencies had been met and that test results had been

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i appropriately recorded and reviewed. Additionally, acceptance cHteria, where specified, were clearly defined. However, the team identified se u ral weaknesses with regard to the content and clarity of some test procedures. The weaknesses observed did not appear to have affected the performance or results of actual tests but did indicate the need for procedural enhancement in several area _ _ _ _ _ _

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The team identified weaknesses in vital station battery test procedures. The team review of 2-PT-87 indicated that, in oroer to ensure that the tested battery would maintain an acceptance criteria load of 200 to 220 amps for at least 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, the test engineer would need to add the total bus load to the value obtained on the load bank recorder. However, steps defining this pro '

cess were missing from the procedure. Additionally, step 3.6 of the procedure requires that the test engineer label the lead bank recorder printout with the

, following information: test number, time and date, battery number, charger number, test step number, and recorder number. The inspectors noted that load bank recorder prictouts contained in the 2-PT-87 service test performed on March 3,1989, did not contain sufficient labeling to detemine which battery bank had been teste The inspectors discussed these concerns with the licensee's performance test personnel. The discussions indicated that the licensee is aware of the identified test weaknesses and intends to revise station battery test procedures before the next outag .4.4 Observation of Post-Modification Testing During the observation of test conduct, the team verified that the test prerequisites and initial conditions were satisfied, testing was completed in accordance with procedural requirements, personnel perfoming the tests were qualified, test data were recorded and evaluated, and testing results trat acceptance criteria. The tean witnessed the following test:

Motor-operated valve (MOV) testing on MOV 1-CH-MOV-1267A on the Unit I charging system, lhe testing was performed after a new torque switch was installed in the MOV as directed by a Limitorque service bulletin. The licensee perforned the test according to test procedure EMP-SP-MOV-3.1, * Post-Maintenance Testing and Adjustment of Motor Operated Valves Using MOVATS 2150." During the test, the licensee made some minor adjustments to the MOV. The team discussed the evaluation of the MOVATS data with cognizant personnel and reviewed the signature report and verified that the test data indicated the valve was cperating properl *

The team walked down portions of the Unit I charging system piping and verifiec the valves were lined up in accordance with the test instruc-

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tions. After the walkdown, the licensee successfully performed the hydrostatic test on the vent valv *

The electrical maintenance personnel performed the periodic test for heat tracing alarm setpoints, 1-PT-59.6. The periodic test specified that the setpoint verifications be performed in accordance with Electrical T.aintenance Procedure EMP-C-HT-2. The test demonstrated the alam setpoints for circuits addressed by Technical Specification The team also observed sections of diesel generator test 1-PT-83.3, " Load Sequencing Timers Verification Test." The test verified that the emergency diesel load sequencing timers were within the tolerances as shown in the Technical Specifications. Two electricians conducted the electrical surveil-lance test, which involved the use of a clock-timer to sneesure the pickup

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and dropout times of various contacts associated with the diesel generator load sequencing timer circuit. The timer data sheets and the acceptance criteria were in Procedure 1-PT-83.3 and the actual details of the test were in Procedure EMP-P-RT-193, * Electrical Maintenance Procedure for Timer Set Point Checks." The team noted that the electricians were meticulous, cau-tious, and familiar with the procedure. Although Procedure EMP-P-RT-193, like many of the other procedures at the plant, lacked the level of detail normally found in procedures of this nature, there were no significant problems observed with completing the test because of the experitnce level of the personnel involve The team found the technical conduct of the tests to be satisfactory. However, because of the lag in completing test documentation and over-reliance on the group supervisor to perform the field test activities, it becane apparent to the team that the advisory operations group (see Section 2.4.1) was understaffe .4.5 Conclusions The team found that electrical and instrumentation test activities were accomplished in accordance with requirements, although weaknesses were noted with the clarity and detail of some test procedures. However, the team found that the knowleoge level of plant personnel compensated for these weaknesse On the basis of the inspection results, the team concluded that licensee personnel were very knowledgeable in the area of testing requirements, were well qualified to perform the tests, and performed the testing in accordance with procedure requirements. The team further concluded that the advisory operations group was understaffed because the group was overburdened with implementing the testing program and had difficulty completing the test records in a timely manner.

l 3 MAINTENANCE TEAM INSPECTION l

The maintenance team inspection (MTI) is an NRC inspection effort performed at virtually all commercial U.S. nuclear power plants. Its primary objective is to determine whether all components, systems, and structures of the nuclear power plant, in this case Hurth Anr.a Nuclear Power Plant Units 1 and 2, are adequately maintained so that they can perform their intended functions. The

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inspection team followed the guidance in NRC Inspection Manual Temporary Instruction (TI) 2515/97, Maintenance Inspection, dated November 3,1900 to conduct the inspection. To focus the inspection and to ensure uniformity with MTIs at other nuclear power plants, the team used the maintenance tree diegram essociated with T1 2515/97. Additionally, the North Anna maintenance process was reviewed to determine if it provided for the prompt repair of plant compo-nents, systems, and structures, es appropriate to their prescribed function !

This section addresses the observations and concerns that appeared to be strengths or weaknesses in the maintenance program or its implementation. The evaluction '

of the maintenance process included a discussion of these items during the rating process documented in Appendix A to this repor ,

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' Appendix A contains the summary of the team's findings, as discussed with licensee management representatives at the conclusion of the inspection. Near the end of the onsite inspection, the team reached a consensus for rating each assessment element. . The rating procedure considered primarily the maintenance activities, personnel interviews, and docunent reviews conducted during this inspection. A summary presentation of the team ratings of all emintenance program elements is also provided on the attached diagram. The ratings are presented using shading and scales, as described in the legend to the maintenance inspectica tree. The ratings have been broken down into three parts:

• Element-Adequacy: a measure of how well the licensee maintenance program has described and documented the requirements of the elemen Green - The element was determined to be fully included in the licensee maintenance progra Yellow - The element was determined to be adequately addressed in the licensee maintenance progran Fed: - The elenent was determined to be missing or inadequately aodressed in the licensee enintenance progra Blue: - The element did not apply, was not evaluated, or the team had insufficient data available to make a determinatio ' ' Element Implementation: a measure of how well the licensee maintenance process has implemented the requirements of the elenen Green - The element was determined to be in place and functioning wel Yellow - The element was determined to be in place, but could be strengthene Red - The element was determined to be missing or inadequat Blue: - The element did not apply, was not evaluated, or the team had insufficient data available to make a determinatio .

• Composite Elenent Rating: a composite rating for the level 2 end 3 blocks (blocks 1. II, III, and 1.0 through 8.0) and for the overall maintenance program was determined by combining the Elenant Adequacy end Element Implementation ratings of individual level 4 blocks of the tre Good - More than minimal efforts have been made in this area, and this area has oesirable qualities with only a few minor areas requiring improvemen _ _ - _ --- _ -

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Satisfactory - Applicable requirements of this element have been developed, documented, and effectively implemented. Areas requiring improvement are approximately offset by better perforunce in other area Poor - Inadequate or no effort has been made in this specific are The shading of Section 1 of the maintenance tree was an exception to the procedure described above.Section I deals with historical data and material condition, fn' tMich a two-part (program and irrpleinentation) plant breekdown was not appropriate. 'Ifrefore, only a single color code was used for Section I block The paragraphs of AppeMix A are numbered to correspond to individual blocks of the maintenance inspection tree, and the individual ratings discussed above and their bases are surrarized in the appendi .1 Plant Faterial Condition and Housekeeping The team conducted system walkdowns, general inspections of plant buildings, and observed plant mater'al condition and housekeeping conditions while witnessing rnaintenance activities. Although there were notable exceptions, the team considered material condition and housekeeping to be exemplary. The licensee had implemented an extensive area-by-area plant cleanup and painting program approximately two years ago. To ensure the improved material condition was maintained, the plant instituted a fomal walkdown inspection program to self-police the areas. Within the framework of this program, specific indivi-duals were assigned a plant area anc were accountable for ensuring that the material condition and housekeeping of their area was maintaine The first notable exception involved the two auxiliary building penetration areas that were maintained as high-radiation and loose-surface-contamination areas and required catensive protective clothing and, in some sectors, respira-tory protection for access. Excessive system leakese in both areas had caused standing or running water on the floor, which further complicated access and radiological control. The licensee advised that these areas had been evaluated and mejor decontamination and cleanup were planned, but they had been deferred in favor of tending to other plant areas in which a faster and greater benefit

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could be obtainto. The second exception to good conditions was the service water pump nouse which appeared to be in need of besic tieaning and paintin This builoing also had not yet been addressed by the plant-wide program. Addi-tional maintenance discrepancies identified by the team are discussed belo In addition to the general observations, the team conducted a more detailed inspection of the service water (SW) system and the instrument air (IA) system from the aspect of their importance to safety. Althcugh the systems appeared properly inaintained and operatec, the team noted numerous minor discrepancie For example, the IA system discrepancies included Irissing handles on instrument root vahes, crac6ed instrument face glasses, and severely bent instrument air lines to air-operated valves. For the SW system and pump house, the team found local valve position indicators without proper labeling, a broken ventilation-19-

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damper actuator am, unauthorized (handwritten) changes to painted pump mark numbers, and an empty portable eyewash container adjacent to a chemical storage area. In response to the team's observations, the licensee initiated corrective action for all of the discrepancies identified during the inspectio The team noted two items that may require increased management attentio In the first instance, the team noted approximately 7 pounds per square inch dif-ferential (psid) pressure across instrument air dryer 01-IA-D1. The auxiliary building log specified a maximum of 5 psid for the air Jryer. If the observed pressure exceeded 5 psid, the log required a work request to be submitted to replace the cartridge filter. This log required checking the filter differen-tial pressure reading once every four hours. The team reviewed the log data for the previous day and noted that the high filter differential pressure had not been identified. In response to the team's observation, and as required by procedure, a work request was initiated to replace the filter cartridg Operations personnel informed the team that although this cartridge had been replaced within the previous week, they could not explain why the logs did not reflect the observed high differential pressure readin The second item that might require increaser' :nanagement attention concerned the use of instrument calibration stickers. Nunerous calibration stickers applied to IA system instruments (for example, pressure gauges 01-IA-p!-121, 02-IA-PI-220, and 02-IA-PI-221) indicated that the instruments were overdue for calibratio According to the calibration stickers on the instruments, the instruments had a 2-year calibration frequency. However, a master calibration schedule indicated that the calibration frequencies had been increased from a 2-year cycle to a 4-year cycle and that all of the instruments were in current calibration. The assistant instrument supervisor responsible for instrument calibration indicated that he was aware of incorrect information being on calibration stickers in ti.ir plant, but there was no plan to correct these calibration stickers. The team was cone.arned that an incorrect calibration sticker, indicating an out-of-calibration instrument, could be confusing to operations personnel, particu-larly if they relied on these instrument readings for system operation. In response to the team's observation, the licensee stated that this problem would be reviewe ,2 Technical Support

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The inspection team noted seaknesses in the administration and day-to-day operation of some elements of the technical support function. Although the safety significance of the observations appears minimal, there is a potential for compromising safety as a result of the current implementation practice .2.1 Site Engineering Procedures Over the past year, the station and corporate engineering organizations were restructured to create and staff a station engineering services group with onsite design engineering, systems engineering, testing, and other functions reporting to the station manager. However, following the reorganization, the former corporate-based organization used a mix of site end corporate procedures thtt no longer reilected the correct organizational authorities and responsi-bilitie Further, new functions, such as systems engineering, had besn created without a formal mission, charter, or procedures. At the time of the inspection, I

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the affected managers had reached preliminary agreement on an engineering jurisdictional statement. Development of the controlling procedures was part of the corporate procedures upgrade program, a program best characterized as in its early developmental stages. This effort will affect more than 15,000 procedures, and current plans target a completion date of 199 The absence of procedures that accurately reflect the current organization potentially reduces the effectiveness of the staff. For example, although the systems engineering group had been established and was 50 percent staffed, no procedures existed to describe responsibilities and authorities. Similarly, the functional (how to) proceoures for their activities had not been identifie .2.2 Root-Cause Analysis Administrative procedure ADM 16.12, * Root Cause Evaluations for Equipment Failures," ENG-16. " Root Cause Evaluation," and ADM-16.17, * Human Perfomance Evaluation Program," described the licensee's root-cause determination and fail-ure analysis progrcm. ADM-16.17 provided administrative controls for specific use of the human perfomance evaluation system (HPES) based on guid6nce promul-gated by the Institute of Nuclear Power Operations (INPO). HPES constitutes a highly detailed evaluation of problems involving human perfomance. At the time of this inspection, the HPES program was in the early implementation phase and appeared to be effective. However, because of staffing restrictions, a limited number of personnel were available to perfom HPES evaluations.

l ADM-16.12 sets forth the administrative requirements for the initiation, review, I and approval of root-cause evaluations (RCEs) but provides essentially no tech-nical guidance. ENG-16, issued in March 1989, contains only general guidelines for RCEs, such as a description of the typical steps required for an RCE, that is, problem definition, data collection, analysis, corrective action, and recom-i mendation The team reviewed seven RCEs conducted during 1989 (Nos. 89-09, -22. -23.-29-40. -50, and the RCE performed for Deviation Report 89-485). Twn of the RCEs that appeared to be adequate' involved a detailed hPES evaluation done for a testing procedure problem in RCE 69-09 and an extensive engineering evaluation

-- although not a structured RCE -- performed for auxiliary feedwater pump conditions in RCE 69-23. The team noted that none of the RCEs appeared to use industry-accepttd techniques for identifying the ultimate root cause(s) for

- failures. The evaluations ranged in length from one to two paragraphs of deductive logic discussion to more extensive evaluations that approached the guidelines of ENG-16.-

The RCE program and its implementation were considered by the team to be inadequate. The licensee did not yet have a consistent methodology in place, and the quality of the RCEs revitwed by the team was poor. This concern is an inspector follow-up item (89-200-03).

3.2.3 Engineering Study / Calculation Control The team noted a problem with the controls applied to engineering study calculations while observing the calibratico of the power range nuclear instru-ments. The problem occurred as a result of erroneous calibration data supplied by the technical services reactor engineering group .-- - ____ _-__ - . - _ _ - _ - _ - - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _

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Section 4 of procedure ICP-NI-2-N-41, " Instrument Calibration Procedure Power Range Channel N-41 - Protection Channel 1,* dated March 24, 1988, requires the insertion of data on neutron detector current for establishing the detector calibration. A technical services reactor engineer provided this data via a memorandum (dated May 9, 1989) to the supervisor of the instrument department. After adjusting the power range channel using the supplied data, the technicians attempted to perfom step 4.12.7, which required a gain adjustment of the N-41 channel reading to norte with the other power range channels. The technicians could not complete this step of the procedur After reviewing the steps that had been performed to that point, the techni-cians determined that the data supplied by the reactor engineer had betn incorrect. The power range channel was declared inoperable until an infomal root-cause determination of the calculational error cculd be mad During a review of the neutron detector corrent calculation perfomed as part of engineering study ES-89-11, the licensee's staff discovered that the engineer performing the study calculations had invert 7d a fraction, causing a proportional error in the calibration values. The lic.ensee's review and approval of the engineering study failed to identify the error. The corrective action consisted of per"oming the calculation again as a controlled calcula-tion in accordance with ADM-17.15, " Preparation, Retention, and Review of Calculational Bases Associatec With' Controlled Station Documents," dated June 16, 1988, which corrected the original error. The team detemined that the methodology and instructions for the calculation were not fomally des-cribed by an approved procedure. This appeared to contribute to the personnel error that resulted in the incorrect data. Further, use of the engineering study administrative controls described in procedure ADM-34, * Engineering Studies," dated March 15, 1988, did not appear to provide adequate controls for input data, calculational methodology, verification of output data, and technical review. In response to the team's observation about the lack of a procedure for perfoming the neutron detector current calculation, the licensee stated that a specific procedure would be written to control this calculatio The inspection team noted that the licensee routinely used engineering studies to perfom what appearea to be formal calculations. Formal calculations require the application of stricter control measures than engineering studies. As dis-Lussed above, the recent reorganization of corporate and station engineering resulted in numerous procedures that did not reflect the actual organizatio .

The team reviewed engineering studies 89-01 through 89-11 with respect to their eventual use, the guidance of ADM-34.0, and the requirements of station admin-istrative procedure ADM-17.15. In several instances, the study calculations appeared to verge on being calculations that require control in accordance with ALM-17.15. For example, studies 89-01 and 89-02 provided calculations for the

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calibration of steam generator leakage dctection system N-16 monitors on the L main steam headers and study 09-04 calculated new boric acid heat trace circuit setpoint' change Other studies, however, appeared to clearly require control under ADM-17.1 For example studies 89-05, -06, and -11 calculated calibration current values for the power range nuclear ir.struments that were subsequently used for actual protection instrument calibration as discussed abov __ _ _ _ - _ - _ _ _ _ _ - - _ - _ _ _ _ - _ _ - - _

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.The supervisor of the site engineering program acknowledged the team's concern-and stated that, until the overall program is reviewed as part of the proce-dures upgrade and reorganization processes, the use of engineering studies in lieu of formal calculations would be carefully controlled and calculations

. performed by station engineering services would be controlled in accordance with ADM-17.15 or by the EWR proces .3 Control of Ecuipment clearances (Tagouts)

i The team reviewed the control room tagout log and identified several equipment clearances that were not in compliance with procedure ADM-14.0, * Tagging of Syster.s and/or Components." As a result, activities that needed to be directed by the shift supervisor, such as independent verification and hanging tags in a specific sequence, were not accomplished. The deficient tagouts applied only l

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to modification activities; other plant activities did not appear to be affecte The team discussed with the licensee the following examples of practices contrary to the requirements of ADM-14.0:

Tagging record N1'212966, dated April 5,1989, was issued and tags set.to support work on engineering work request (EWR) No. 89-03 Fourteen tags were prepared and ordered to be hung in a specific sequence in accordance with the tagout. For reasons not indicated on the tagging record, two tags (tag numbers 1152856 r 1 1152863, sequence #6 and #13 tags) were not hung. When the shih supervisor approved the tagging record, the tagout did not indicate that tags 6 and 13 were not to be hung. By the signature in block fl9, it appeared to the team that the tags had been hung by the operator preparing the tags. The tagout sheet also ir.dicated that the shift supervisor required an independent verification for placing and removing the tags (block #15), however, no auditable evidence was available to inoicate that an independent verification was accom-plished as directe *

Similar problems were noted on tagging records N1 212684 and N1 212685, dated February 11, 1989. These records were prepared to support work order DCP B7-18, a design modification package for the service water system. Six tags were specified to be hung in a particular order for two different motor-operated valves (MOVs).

Three tags were required for each valve, including the electrical power, the handwheel, and the control switch. Although the shift

. supervisor approved the tagging record, only two out of the six tags were hung (one tag for each of the handwheels of the two MOVs for N1 212684) and only one out of six tags were hung for tagging record El 212685. No annotation was made on the tagging record to indicate why only the third and fourth sequence tags were hun *

Other examples of tagging records where errors were made included N1 213092 and N1 213043. In these two cases, a record sheet was prepared of numerous tegged components, but only selected items were tagged, and included in the sequential creer to be hung. The corponents left untagged were not deleted from the record sheet and there was no annotation to indicate the reason for not tagging the components. Tagging record N1 213092 was signed by the person placing-23-

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the tags, but record N1 213043 was not signed by the person placing M, the tag The team was concerned that failure to hang all tags required by the tagout created the potential for personnet injury and equipment damage. The-licensee's corrective action, in response to the team's concern, consisted of

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perfoming independent. verifications and issuing individual tagouts rather than setting selected portions of a large tagout. None of the instances

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The team reviewed the tageut program as defined in ADM-14.0, " Tagging of Systems and/or Components," and made the following observations:

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No precautions were listed in the procedure such as preventing the removal of a component with an installed danger ta *

Although several paragraphs (such as 5.4.4, 5.9.2, and 5.9.4) -

addressed the subject of independent verification, ADM-19.17

" Independent Verification," was not identified in the reference section of ADM-14.0 nor in the body of the procedur "

The licensee upgraded the type of tags used in the plant to include the use of machine prepared stickers containing bar code and other information. However, ADM-14.0 had not been revised to incorporate the use of the new tag .4 Control of Vendor Technical Manuals On two occasions the inspection team noted vendor technical manual problems that could affect safety-related maintenance activities. On March 20, 1989, the con-

- trolled leakage seal reactor coolant purnp technical manual, file number WR12, was replaced by the vendor with a revised issue containing only pump informa-tion, whereas file number WR12 had contained both the motor and punip infomatio The vendor manual / file revision sheet, Attachn.ent 8.2 to ADM-6.18. " Control of Vendor Manuals, Vendor Files and Interface," was prepared by document control staff and forwarded to the mechanical department supervisor for action. The electrical department supervisor was not notified in accordance with the requirements of paragraph 6.3.3, ADM-6.18. Thus the electrical department supervisor was totally unaware of a significant manual revision to equipment

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under his cognizance. Document control staff had to be called at home to deter-mine the location of the motor portion of the technical manual (File number WR70) because the manual revision sheet did not reference the new file location and the maintenance satellite document control library index had not been updated with this chang The team determined that material received from Westinghouse Electric Co. was sent directly to the station manager, rather than to the licensing group that was nortrally responsible for assigning action to the responsible site depart-ment (s). In this case, licensing was not notified of the manual revision. The I

document control staff acted in accordance with their judgment as to who had responsit,ility and forwarded action correspondence only to the mechanical grou The team determined that ADM-6.18 provided inadequate guidance to the dccument control staff to ensure that the proper addressees for action were identified and routed manual revisions affecting their activitie _ - _ - _ _ _ - - - _ _ _ _

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I The team also noted that Westinghouse was the only vendor that consistently forwarded technical manual revisions, bulletins, and other pertinent plant infonnation to the station manager, so that the licensing group could assign proper action to the responsible staff. The team determined that most vendor-related material does not necessarily pass through licensing; thus a high probability existed that vendor information requiring licensee action would not be received by the responsible department and acted on. It was the team's opinion that the provisions of ADM-6.18 should be strengthened to ensure that all written and verbal correspondence from the vendors to station personnel be reviewed by the licensing staff and placed in the commitment tracking system (CTS) to ensure proper station action. 1he licensee had previously identified the problem of vendor technical infonnation transfer to cognizant personnel as part of the recommendations made by the service water review team, as discussed in Section 3.6.4 of this repor The second example of vendor technical manual problems discovered during the inspection concerneo an im cr.rd (PM Code M-10-P/r-15) proper for the reference auxiliary on a(AFk)

feedwater preventive maintenance pump. The PM (PH)

card referenced Ingosol Rand technical manual file I-129. This technical manual was noted to address AFW pumps with ball bearings on the pump impeller shaft. During disassembly for overhaul in early 1989, it was noted that the pumps installed at North Anna had sleeve-type bearings. The quality assurance group initiated the appropriate technical manual revision request, and Ingersol Rand technical mar.ual file 1-32 was procured. The PM card had not been appro-priately revised because not all cognizant departments received notification of A manual revision affecting their activitie The licensee had undertaken a configuration management project and design-basis docurent update in 1988. One of the fundamental attributes of the program was establishing the physical configuration of the station and obtaining the compo-nent design infonnation for major components. On a system basis, auxiliary feedwater was a priority for the first 2 years, along with service water, containment spray, recirculation spray, instrurrent air, emergency power, and safety injection. The team concluded that a program was in place that should correct the type of problem identified above with regard to the plant docurenta-tion reflecting the wrong AFW pum .5 Plant Preventive Maintenance Program k'eaknesses

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'The inspection team reviewed the licensee's program end implementation for preventive mainter.ance on spare parts stored in the warehouse and on in-plant equipnent. Seseral concerns were identified and are discussed in the following section i 3. Implementation of the Instrumentation and Control Preventive Maintenance Program The team reviewed the implementation of the instrumentation and control preven-tive maintenance program and determined that the program was implemented on all

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safety-related and equipment qualification (EQ) program instruments. Hewever, the team also determined that not all of the preventive maintenance had oeen )

implemented on non-sefety-related instruments. The balance-of-plant quality 1 I

assurance (BOP-QA) program approved August 21, 1987 indicated that heating,

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ventilation, and air conditioning (HVAC) systems were to be included in the program. The BOF-QA program indicated that preventive maintenance was to be developed for the systems included in the program. The program also indicated that all systems were to be in the program by March 31, 1988. However, as of May 26, 1989, the instrumcnt department had failed to implement a preventive -

. maintenance program for the HVAC systems. The licensee stated that there were insufficient resources available to develop or implement this part of the program at presen The team then reviewed the instrument department organization and determined that the department had no engineer reporting to the instrunent department supervisor to aid in the development of such programs as the preventive main-tenance program. In contrast, the maintenance departnent had four engineer If the instrument department supervisor needed engineering assistance, he was required to request this assistance fron outside his departnen It appeared to the team that staffing plans for the nuclear instrument techni-

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cians shculd be reviewed. The inspector reviewed the five year staffing plan, which was written in 1987, and determined that there was little or no increase in staffing from 1987 to the present. However, there had been an increase in work load over this same time period as a result of such things as the implemen-tation of the BOP-QA progra .5.2 Preventive Maintenance Procedure Adequacy The team reviewed the maintenance requirements for two major pieces of in-plant equipment and noted several concern The computer work planning and tracking sy& tem (WPTS) reflected a requirement to perform preventive maintenance (PH) Code M-10-P/R-15, Auxiliary Feedwater Pump Inspection (Electric)," and to use procedure MMP-C-FW-1, on the turbine-driven auxil u ry feedwater pump. However, a new procedure, MMP-C-FW-2, had been prepared in February 1989 and the PM code in the KPTS had not been changed accord'ngly. The team noted that there was a program for submitting changes to the PM system, but it apparently was not use PM Code M-10-P/R-15 referenced the Ingersol Rand technical manual *I-129" in the document control library. This technical manual was noted to cover an

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pump with ball bearings on the shaft. However, during a pump on.rhaul disassembly in early 1989. the North Anna AFW pumps were discovered to have sleeve-type bearings. AlthouSh the technical manual index was updated in the library, the FM code was not corrected to reflect the proper pum PM Code M-00-LO/M-1 provides for lubrication sampling of various system pumps, including the AFW pumps. The tean,noted that the procedure states that samples may be taken with the pump running or may be taken after the pump is shut dow If pump configuration required shutdown, the sample had to be drawn within 15 minutes after shutdown. However, the PM procedure implemented this provision with the statement, " samples must be taken right after the pump is shut down,"

rather than specifying the quantitative time limi The team noted that coordination of PM procedures with other plant activities, such as performance or operability tests, was recessary to ensure proper condi-tions for conducting PM. The maintenance oepartment PM coordinator has prepared-E6- _ _ _ _ - _ _ _ _ _ _ _ _ _ _ - _ _ -

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an infornal coordination matrix for personal use. However, the licensee should consider formalizing the program into the scheduling system of related PM proce-

,dures.to ensure the program remains coordinate PM Code E-10-M/W-1 described the maintenance for the spare reactor coolant pump motor. The spare motor was repaired and refurbished by the vendor on about May 1, 198g. Since the motor had fixed contamination, it was stored in a con-tainment tent in the lifting bay of the turbine building. The weekly PM code was not incorporated into the kPTS tracking system when the motor was returned to the licensee, and no PM was performed on the motor. The Westinghouse tech-nical manual, WR70, stated that the motor shaft must be rotated on a periodic basis to prevent babbitt bearing damage. The technical manual also outlined the methodology to initiate the oil lift system and stated that the internal space heaters should be connected and energized. These provisions were not included in the PM requirement The team determined through discussions with the PM coordinator and the superin-tendent of maintenance that PM procedures for in-plant equipment have evolved from some combination of vendor recommendations and skill of the craft personnel since the plant became operational. However, at no time in the history of the plant was an evaluation performed to determine the difference between vendor-recommended preventive maintenance and the licensee-implemented program. The team was concerned because of the number of inconsistencies identified within a relatively small sample siz .5.3 Preventive Maintenance for Stored items The inspection tean, attempted to detennine whether preventive maintenance was being perforned on stored spare parts in the warehouse and whether the PM procedures were in accord with vendor recommendations. However, the team was advised by the superintendent uf station materials that essentially no documented preventive maintenance was being performed on approximately 150 items identified as requiring maintenance while in storage. Although several licensee procedures were in effect, (e.g., ADM-13.0, " Handling, Storage and Shipping;" ADM-13.1, * Maintenance of Items in Storage;" and Mechanical Depart-ment ADM-8.1, * Maintenance of Items in Storage"), the provisions of the procedures were not being implemented. The team was advised that a quality assurance audit (N-88-17), initiated in late 1988, had previously identified this deficiency. The team also noted with concern that the same problem was

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found in the previous audit (N-86-19). During the period of the inspection, the licensee initiated correcti'e action to the recent aboit findir.g and provided the inspecticn team with the details of the anticipated action. The team concluded that the planned corrective action was adequat .6 Followup on Self-Assesst(nt Corrective Actions While the licensee appeared to be very effective in critically analyzing its activities and in identifying actions necessary to correct or improve deficient areas, the follow-through of these ections to successful implemen-tation is inadequate. Several broad areas were identified in which specific actions had been provided and, in some cases, entered into the North Anna consitzent tracking system, but these actions had not been implemented within a reasonable time frare and/or with an adequate technical basi _ _ _ _ _ _ _ - _ _ _ _ - - _ _ - _ _ _ - _ _

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e 3.6.1 Root-Cause Analysis Program The absence of an effective RCE program had previously been identified by INPO, NRC, and the licensee as a significant shortcoming in the licensee's program Through 1988 and early 1989, the licensee prepared the initial program proce-dures. Those procedures and the RCE program were nct yet fully implemented, as discussed in Section 3.2.2. The procedures were very general in nature and relied heavily un personnel training to provide the techniques and structured evaluation methodologies. Personnel training had only just begun during this inspection with initial training sessions conducted in May 198 .6.2 Procedure Problems and heaknesses The licensee had generally acknowledged significant problems with the e,uality and coverage of procedures for safety-related activities and had initiated a company-wide procedures upgrade program. Various licensee representatives briefed the inspection team on the various aspects of the program. Begun over the past year, the program is intended to ensure good' correlation among the North Anna, Surry, arej corporate headquarters procedures and to improve site-specific procedures over the next 3 year The inspection team identi-fled the following specific problems with procedures reviewed or observed during this inspection:

Lack of Instructional Detail and Objective Requirements The maintenance implementing procedures and, in some cases, the main-tenance administrative procedures generally were found to be lacking

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'in instructional detail relative to the step-by-step method for accomplishing a task. For example, Procedure W.P-P-EG-4, " Preventive Maintenance of Emergency Ciesel Generators," condensed very extensive maintenance tasks, such as removal of pistons and crankshafts from an opposed piston diesel engine, into single line summary step Although the inspection team found the maintenance staff and craft personnel to be ucusually well trained and possessing good knowledge, skills, and abilities, the lack of step-by step detail for complex activities provides the potential for significant variation in perfom.ance and prevents the accurate documentation cf the actual actions performe .

Instrument Calibration Procedure, ICP-NI-N-41, " Instrument Calibration Procedure Power Range Channel N-41-Protection Channel 1," stated that a Fluke 8110A digital voltmeter, or its equivalent, should be used. The team determined that the Fluke 8110A had not been used at the North Anna station for approximately a year. The team determined that the actual digital voltmeter used on site was a satisfactory equivalent. However, there appeared to be no mechanism in measurement and test equipment (M&TE) place to was introduced at update the site. procedures as new Instrument department memoranda were used in lieu of instrument department administrative procedures in many applications. For exemple, It. trument Department Memorandum 25.0, " Preventative Maintenance," dated April 1,1987, defined the nuclear instrument department preventive m6intenance requirements. This memorandum dio not accurately describe-28-

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the way the program was actually administered. It did not discuss the interface between the work planning and tracking syster (WPTS) and the instrurnent department computer data base program (PMP-ID). The licensee was preparing a revision to the memorandum to incorporate many of the needed changes, k'hile the inspection team observed the overhaul of a low-head safety injection (LH5I) pump mechanical shaft seal, mechanics removed the seal housing currs and scratches with a fine polishing stone and other mild abrasives. Although Maintenance Procedure MMP-C-SI-1, "LHSI Purap Inspection Repair, and Seal Replacement." Revision 6 had extensive cautions and steps to protect the precision seal surfaces from damage, it provided no guidance with respect to the above deburring operatio The licensee's maintenance staff stopped work and, in conjunction with r the quality control staff, evaluated the conditions and issued a proce-dure deviation to permit the deburring activities on a limited basi Procedure MMP-P-EG-1, " Mechanical Maintenance Procedure for Emergency Diesel Generator Engines," Revision 16. Section 7.10 (and others)..

provided for removal and cleaning of lube oil strainers but did not provide instructions to note the cleanliness condition of the strainers nor to document any anomalies. The team observed a mechanic perform this operation exactly in accordance with the procedure and begin solvent and rag cleaning of the strainer without looking for any entrapped material, lhe responsible maintenance supervisor told the team that the procedure would be revised to include examining of the strainer prior 1o cleanin Preventive Maintenance Code E-11-DC/C-1, " Clean and Service Battery Charger " performed on charger 01-BY-C-1H, required that the charge voltage indication be in agreement with actual. battery voltage. No tolerance was provided and the actual battery and charger voltages were different by about 5.2 volts, which could have been the result of a high charging current. Craf t personnel deferred evaluating the voltages until after the charging was completed and battery conditions stabilize ADM-2.2, " Station Training Programs," dated December 15, 1988, discussed the training requirements of the various station department '

however, the procedure did not discuss any training requirements for the nuclear instrument department. The licensee could not identify any other administrative procedure that did address the training requirements for this department. The licensee submitted a procedure change request to add the nuclear instrument technician development .

prop. ram to ADM- ADM-16.1, * Station Deviation Reports," did not properly reference ADM-16.12 as the RCE procedure. The licensee submitted a procedure change request to correct this discrepanc _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _

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The team concluded that, while the licensee's procedure upgrade program appeared to be beneficial and should generally address the kinds of deficiencies observed, there did not appear to be a high level of assurance that the program would be fully successful in correcting "

the *

Extensive Use of Procedure Dentations Procedure deviation (PD) processing and incorporating into the affected procedure are governed by ADM-5.4 and ADM-5.8. The PDs are generally attached to the front of the procedure and the affected procedure pages are annotated to refer to the applicable PD instead of incorporating the changes directly into the body of the procedur No limitation was.apparently placed on the total number of PDs that may be effective simultaneously for a single procedure. For example, MMP-P-EG-4, * Preventive Maintenance of Emergency Diesel Generators "

was in use during May 1989 for inspection and overhaul of the lh diesel engine. Nine PDs had been issued for the procedure since March 1989 and were in effect when the procedure was released for work on the IH engine. Two additional PDs were issued during the team's observation Further, as part of the procedure upgrade program, procedure engineers in the maintenance department had identified a backlog of about 600 to 700 outstanding PDs for all plant departments, with about 150 PDs outstanding against just the mechanical maintenance prc<edures. The inspection. team was concerned that the extensive use and accumulation of PDs increased the probability of both incorrect changes being implemented and personnel errors being made during performanc *

Use of Procedure Write-in Steps Maintenance procedure ADM-27.0 permitted pen and ink changes to mechanical and electrical maintenance procedures without normal review and approval to accommodate such activities as general electrical troubleshooting. The administrative procedure places some restrictions on'the write-in steps; namely, that the purpose of the procedure cannot be changed, that the change be consistent with the vendor manuals, and that the change be reviewed by the innediate work supervisor before work

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is started. Although ADM-27.0 does not permit write-in changes to affect the scope or purpose of the procedure, in several cases changes to the procedure had changed the scope and acceptance criteria of maintenance procedure The inspection team observed performance of mechanical maintenance procedure MMP-P-EG-4, " Preventive Maintenance of Emergency Diesel Generators Unit No. 01-EE-EG-1H." MMP-P-EG-4 provides instructions for the refueling frecuency inspection and preventive maintenance recuired by Technical Specification (TS) 4.6.1.1.2.d.1. The original procedure had been approved by station managetent and the Station Huclear Safety and Operating Committee (SNSOC) in accordance with TS 6.8.2.

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EP-P-EG-4. Section 7.36, had been supplemented by about' five pages of handwritten steps covering topics such as removal or shipping of fuel injection pumps for vendor overhaul, and the removal or

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modification of various engine components, that involved disassembly, inspection, reassembly, torquing, and parts replacement. Thes changes had been reviewed and initialed by a maintenance supervisor and implemented without-further management or safety committee review The team considered the write-in changes inappropriate and generally not in compliance with the requirements of.TS 6.8.2, which' requires.that c.hanges to maintenance and surveillance procedures be reviewed and

' approved by SNSOC before implementation. Although procedure devia-tions discussed herein were cor.sidered excessively used, they did provide the level of review and approval required by TS 6.8.2; the write-in changes did no The site quality control (QC) group also had challenged several of the

_ write-in changes associated with MMP-P-EG-4,-especially.those involving

' changes to the. scope of the procedure, such as removal and vendor overhaul of' injector pumps. QC maintained that the changes did not comply with ADM-27.0 guidelines, that the changes also modified the scope of the original work ' order authorizing performance of the procedure, and that the additional scope required review per TS 6. and the procedure oeviation process. Additional examples of electrical and nechanical preventive siaintenance or disassemble / inspect procedures permitting or encouraging the addition of repair steps included several MOV procedures and MkP-C-FW-2, " Disassembly, Inspection, and Rcassembly of Turbine Driven Auxiliary Feedwater Pumps." The laiter procedure appeared to permit the repair steps of the ASME Section XI repair program to be written in, for repairs that involved welding, grinding, or machining of the pump casin .6.3 Maintenance Self-Assessment

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In response to an INPO recowendation, the licensee performed a self acsessment

- of its. maintenance program and published the results in December 1987. The self-assessrent report eddressed the activities of the licensee's maintenance organization-using INP0's guidelines for the conduct of maintenance at nuclear power stations (INPO 85-038). The team reviewed the findings of;the self-

. . assessment and the corrective actions taken in response to the findings. The self-assessment included a statement that recomended developing an action plan by February 1988, addressing the deficiencies a.nd noncompliance listed in the report. Additionally, the executive suntriary stated that the assessment would be periccically revised as other assessments were performed. However,

'e on the basis of discussions with the licensee's staff, the team discovered

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that no forn.a1 corrective action had been initiated at the time of this inspec-

. tion. The team made two observations in reviewing this area. First, on the basis of the responses to the INPO-recommended self-assessment attributes, the scif-assessment appeared to be somewhat cursory. Second, several deficiencies identified by the self-assessment were later identified as deficiencies within the framework of other programs. For example, the lack of preventive main-tenance for stored equipment was identified as a weakness in the self-assessmen _ _ _ _ - _ _ -

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Quality assurance audit N-SS-17 also identified this deficiency. The team ques-

tioned the licensee's thoroughness in following up on self-identified weaknesses-under the maintenance self-assessment. The team concluded that management sup-port of maintenance appeared to be lacking in that, despite the effort to identify weaknesses in the North Anna maintenance program, s.anagers were giving inadequate attention to ensuring that timely corrective actions were implemente .6.4 Service Water Review Team Findings

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In 1988, as a result of an NRC safety system function inspection (SSFI) at the Surry Nuclear Power Station, significant deficiencies were identified in the design and upkeep of the Surry service water s,ystem. Because of similari-ties between the Surry and North Anna systems and programs, the licensee

- fomed an ad hoc task force, the service water review team (SWRT), to review the Surry experience and recommend responsive actions for North Anna. The SkRT issued its evaluation and recommendations via memorandum on December 15, 198 In turn, the individual SWRT recommendations were issued to the responsible North Anna managers as action items under the commitment tracking system (CTS).

The team reviewed the licensee's handling of the SWRT findings with the two-fold purpose of evaluating the licensee's problem self-identification processes and of evaluating the effectiveness of the commita.ent tracking system. A sample of 5 of the 10 SWR 1 items was selected; problems in action formulation and execution were identified in 4 of the 5 items. In general, the items had either: (1) no neaningful action defined since their identification by SWRT and initial assignment or (2) the actions had been defined but were not effectiv Specific examples include:

• In CTS Item 02-88-2731-001, the SWRT icentified pest-maintenance testing activities as requiring additional effort to avoid the Surry problems and noted that a management decision for action was require A December 28, 1988 memorandum from the station procedures group to the assistant plant manager recommended an extensive task force approach to resolving post-maintenance testing program problems. The CTS item was subsequently assigned to the station services group which recommended it be closed without action because the existence of a problem had not been confimed. The safety and licensing group then reissued the CTS item to the technical services group requesting confirmation by October 15, 198 The team considered the delay in achieving visible progress in evaluat-

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ing the item to be excessiv * CTS Item 02-88-2731-004 addressed the SWRT concern that incorporation of vendor technical information into plant procedures and activities was potentially inadequate. The SWRT recommehoed that the nr.aintenance engi-neering group should be procedurally required to ensure that vendor input is controlled. The item was initially assigned to the maintenance engineering group which responded on February 13, 1069, that the problem was the responsibility cf the records n,anagement grcups and that no main-tenance department action was require The CTS Item was reissued for action by the records management group as CTS Item 02-88-2731-007. On March 13, 1989, the records management supervisor responded by memorandum stating that the existing procedure-32-

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program was acceptable but that a personnel awareness and training problem existed with respect'to forwarding newly received vendor information for incorporation into the records system and into applicable

= procedures and' activities. Although this second response seemed to state that further action was required, the safety and licensing department closed the CTS item but did not require further actfon. Ince the l inspection team noted this inadequacy, the item was reissued for L completion of the actio Inthiscase,forthreemonths(fromthetimetheproblemwasidentified through the first round of action assignments) essentially no action was taken except for memoranca written to transfer the responsibility for taking action. Further, in the cases discussed above, the MTI team-found that either incorrect vendor information or defective handling of vendor information directly affected the availability of the vendor information to support maintenance activitie * CTS Item 02-88-2731-002-involved establishment of a root-cause evalua-tion (RCE) process. The SWRT noted that a formal RCE process was already planneo for December 31, 1988, using maintenance engineers to perform the RCE. However, the SWR 1 believed that maintenance engineer staffing was likely inadequate and that the plans should be reevaluate The C15 item was issued to the station services group on December 15, 1988, to revise procedures to ensure the system engineer has the primary respon-

-sibility for root-cause analysis. The CTS item was closed on April 3, 1989, based on the initial issuance of the administrative procedure for RCEs. Although the procedure was indeed issued to assign the responsibil-ity, the initial concern regarding the establishment of a valid and effective.RCE process, including adequate stafiing, had still not been adoressed_(discussed elsewhere in this report). The system engineering group was only about 50 percent staffed; the administrative procedures for RCEs did not provide an effective instruction for when and how to perfom RCEs, and the RCEs performed since establishment of the program were poo In this case, the licensee appeared to have ineffectively closed the item on the wrong basi a 3.6.5 Valve Maintenance The licensee reviewed NUREG-1195 " Loss of Integrated Control System Power and Overcooling Transient at Rancho Seco on December 26, 1985." The overcooling event was aggravated by the inability of the plant staff to close an ATW manual valve. The valve had not received any maintenance coverage and

_,had " seized" because of inadequate lubrication. The licensee had reviewed the situation with respect to North Anna alone; the limited scope of the review

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focused on just the AFW manual valves. The team is concerned that other manual valves in the plant were not reviewed, particularly those which are addressed by emergency operating procedures (EOPs). This is an inspector follow-up item (89-200-04).

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3.7 Maintenance Department Steffing On the basis of discussions with plant managers and a review of the most recent staffing plan, the team identified several areas in which staffing levels poten-tially could impact plant operations. The North Anna Fower Station staffing plan, dated September 16, 1987, forecast virtually zero growth in the maintenance and planning departments for the years 1988 through 1992. However, during this inspection, the team identified several areas in which manpower constraints precluded the accomplishment of iraportant tasks. For example, the maintenance department staff allocated three positions for maintenance engineers. The posi-tion responsibilities were, in part, the performance of periodic equipment trending and root-cause determinations. However, on the basis of personnel interviews, the maintenance engineers indicated that performance trending was performed only in response to requests by other parts of the organization, such as from licensed operator As another example, the predictive maintenance staf f consisted of two engineers and one supervisor. The predictive maintenance program appeared to be a strong, proactive program for the identifying impending equipment failure at an early stage. Analytical techniques included in .this program consisted cf vibration analysis er.d oil analysis. The licensee had recently purchased thennography equipment and was in the developmental stages of implementing a thermography-monitoring program. However, although the administrative proce-dure for the thermography program had been issued, the plant str.ff stated that manpower constraints affected the implenientation of the progra As a further exampic cf staffing problems, the licensee issued ADM-20.47 in 19E7 for monitoring balance-of-plant (BOP) equipmenr. performance. The ADM stated that the BOP program would increase the relii;bility of nonsafety-related equipment, which in turn would minimize the challenges to safety-related systems that result if BOP equipnent fails. However, because of reorganiza-tion efforts and manpower shortages, only minimal progress had been made in this area since 198 .8 Conclusions Plant housekeeping was found to be good as a result of the implementation of the area-by-area plant cleanup and painting program. Two areas that were deficient were the auxiliary building penetration areas and the service water purphouse are The team noted that plant instruments were affixed with calibration stickers

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which indicated that the instruments were out of calibration. Actually, the instrunent database reflected that the items were co rectly calibrated and the tags were wrong. This could affect operations persunnel with respect to their judgment about instrument accurac Equipment clearances were not all hung in accordance with the operations-approved tagout. This creates the potential for equipment damage or personnel injur _ _ -_- _ _ _______

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I Vendor technical manuals were updated without proper coordination with the I responsible station staff to ensure that site procedures are updated as require Corrective actions were inadequate to ensure that components in storage received preventive maintenance coverage in response to a quality assurance organization finding. Further, evidence exists that corrective actions in response to both the maintenance self-assessment and root-cause analysis reviews have not been implemented in a timely or effective manner. These concerns indicate inadequate management support to ensure that identified deficiencies will be resolve Since the engineering organization was reorganized, the staff has been working

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without the benefit of procedures that describe the responsibilities and authorities of the new organization. No method was procedura11 red to guide the neutron detector calculation. This calculation was performed as an engineering study and contained a mathematical error that could have been prevented. humerous other procedural deficiencies were found with respect to insufficient instructional detail, incorrect references, and inconsistency with vendor technical manual Maintenance personnel were well trained, knowledgeable, and skilled. However, staffing problems have contributed to the failure to implement site program enhancements including a thermography program and the BOP-0A preventive main-tenance program for HVAC equipnent. Insufficient staff resources have also l impeded the implementation of the RCE program and the scope of implementation l for the HPES program. As noted in Section 3.5.1, the team also identified a i

shortage of I&E technicians and engineers.

l l 4.0 MANAGEMENT EXIT MEETING The inspection team conducted an exit meetir.g on May 26, 1989 with licensee managen,cnt personrel identified in Appendix B. During the meeting, the findings of both the 550MI and MTI efforts were presented, The team provided clarifications in response to licensee questions regarding the inspection findings. Other NRC personnel present at the exit included: Mr. Charles Haughney, Mr. Keyne Lanning, Mr. James Liebennan, Mr. Leon Engle, and Mr. Gus

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Laines of the headquarters staff. Representing Region II were Mr. Frank Jape and Mr. Jim Caldwell. The NRC management personnel emphasized some areas of the inspection team's finding . _ _ - _ _ _ _ _ - _ - _ _ - .n

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c APPENDIX A MAINTENANCE IXSPECTION DATA 1.0 DIRECT MEASURES The. team'found that this element was functioning satisfactorily. Direct'

. measures of plant perfomance associated with maintenance were evaluated from data compiled by the NRC perfomance indicator. program, data reported by the licensee in monthly operating data reports to the NRC, NRC Systematic Assesscent of Licensee Perfomance (SALP) reports, and licensee internal reports on performance goals and indicator From these sources, the following principal direct measures of perfomance were evaluated to assess overall plant performance related to maintenanc .1 Historical Data The team assigned a satisfactory rating to this area. There is no distinction between the ratings for program adequacy and implementation ddequacy in this are The team reviewed the historical data for both units, dating back to January 1988. On the basis of this review..the team found the plant to be average in this are .2 Plant Walkdown Inspection The team assigned a satisfactory rating to this are .There is no distinction between the ratings for program adequacy and impler- 'Ttion adequacy in this cre BASIS: Walkdown of service water (SW), instrument air (IA)

. systems and general plant tour The STREhGTHS noted in this area included:

- Plantwide painting and labeling program. The licensee had

- implemented a long-term painting and relabeling of plant buildings and equipment. With the exception of some residual areas that were poorly maintained, such as the H auxiliary building penetration area and the SW pump and valve houses, the material condition of the plant was considered to be a strengt The WEAKNESSES noted in this area included:

- SW pump and valve houses: Miscellaneous hrdware and housekeeping deficiencies were found. Deficiencies included an empty eyewash 1 reservoir adjacent to additive chemicals, a broken air intake damper actuator (NRC-identified), and various labeling and posi-tion indicator discrepancie I A-1

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- Penetration areas: Similar findings to those above, plus j extensive system leakag misting was causing heavy oil film on the floors of the

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charging pump cubicle and on equipment. In the cubicle of charging pump 1A, there was a packing valve leakage from valve 1-CH-251 onto valve 1-CH-254. Also, possible excessive corrosion of the I-CH-254 cap studs and nuts from the packing leakag .0 MANAGEMENT COMMITMENT AND INVOLVEMENT COMPOSITE RATING: Satisfactor Overall program elements appeared to be adequately addressed. Instances were noted where either missing or inadequate implementation was approximately offset by better performance in other area BASIS: Problem identifiers such as the maintenance self-assessment and

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SW review team were successful in identifying significant deficient conditions but followup systems have not been successful in achieving correctio .1 Application of Industry Initiatives Program elements appeared to be adequately addresse Irelementation was determined to be in place, but could be strengthene The STRENGTHS noted in this area included:

- Reliability-based preventive maintenance (PM) program developmen The first project involved the emergency diesel generators (EDGs).

- The system engineering initiativ The nuclear plant reliability data system (NPRDS) was in active us The cuality assurance (OA) Performance Group activities to idsntify emerging Lafety and regulatory issues.

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The WEAKNESSES noted in this area included:

- Self assessment programs not effective in correcting identified deficiencies with untimely followup for the maintenance self-assessment, SW review team report, and the balance-of-plant quality assurance (B0P-QA) progra .2 Management Vigor ano Example Program eierents for corrective action management and escalation appeared to be adequately established. Program initiatives were ( inadequately implemented and, in some cases, were not in place.

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! OBSERVATION: Managenent initiative for procedure improvement program is a positive indicator.

The STRENGTHS noted in this area included:

- The practice of performing the 90-day safety-related work order and pre-startup safety-related work order revie he self-administered SALP was viewed as a positive action in analyzing plant and management perfomanc The WEAKNESSES noted in this area included:

- See basis for section 2.0 abov A 50P-QA Program, dated August 21, 1987, was established to increase the reliability of B0P equipment and minimize challenges to safety-related systems caused by the failure of BOP equipment. This program had not been implen,ented yet at the time of this inspectio .0 MANAGEMENT ORGAh!ZATION AND ADMINISTRATION COMPOSITE RATING: Satisfactory. Overall program elements appeared to be adequately adoressed. Implementation was determined to be in place, but could be strengthene BASIS: Staffing was lean in several areas, including maintenance planners, maintenance and system engineers, and instrumentation and control (I&C) technicians and engineers. General staff quality was found to be good with effective communications and routine decision-making processes in place. Document control systems such as work processing and tracking system (WPTS) were found to be effectively managec and efficient. Problems were noted in some areas, such as control of vendor manual .1 Identification of Program Coverage for Maintenance Program elements appeared to be adequately addresse In:plementation was determined to be in place, but could be

. strengthene NO STRENGTHS were noted in this are NO KEAKNESSES were noted in this are .2 Establishment of Policies, Goals, and Objectives for Maintenance Program elements appeared to be adequately addresse Implementation was determined to be in place, but could be strengthene No STREhGTHS were noted in this are No WEAKkESSES noted in this are A-3

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3.3 Allocation of Resources Program elemerits appeared to be adequately addresse Implementation was detennined to be in place, but could be strengthene The STRENGTHS noted in this area included:

- Span of_ control for mechanical and I&C supervisor-to-worker ratios was very good and well within industry norms. The I&C ratio of supervisors to technicians was reasonable (approximately 1-to-7). This led to good consnunications and adequate supervisory coverage and understanding of the work being perforned by the supervisor's cre ho influence to sacrifice safety for production goals at craft level. Craft and supervisory personnel responsible for actual work were partially insulated from schedular pressure to minimize the effects on individual safety-related job The k'EAKNESSES noted in this area included:

- Maintenance engineering appear to be understaffed. This led to some job assignirents not being perfened, such as ongoing trending, cursory root cause evaluations, and general workload problem Maintenance planning appeared to be understaffed. This also led to assigned job assignments not effectively performed, such as inadequate pre-job walkdowns and difficulty in supporting planned maintenance with work preparatio Predictive maintenance staff work load prevented full in:plementation of the recently established thermography progra ILC staffing was inadequate to completely implement the B0P-QA preventive maintenance progra '

- ho I&C engineering positions authorized, which caused apparent irrpacts on the ' ability to support preventive maintenance program development and improvement Operations and health physics (HP) staffing levels delayed initia-tion of mau.tenance work due to an inability to prepare tinely tagouts and inability to prepare tinely radiation work permits (WPs) respectivel .4 Definition of Maintenance Requirements Program elements appeared to be adequately addresse Implementation was determined to be ira place, but could be strengthened.

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The STRENGTHS noted in this area included: l

- Clearly established requirements for preventive and corrective maintenanc Preventive maintenance requirements consisted of periodic, planned, and predictive maintenanc The WEAKNESSES noted in this area included:

- Preventive maintenance specified by vendor technical manuals was not, in some instances, implemented by the licensee's progra Preventive maintenance requirements were not always accurate-in their conten Preventive maintenance' requirements were developed in an evolutionary processes end were based on the skills of the crafts. personnel when initially implemented; No collective effort has been taken to ensure that all technical manual requirements have been identified, evaluated, and incorporated. No safety significant consequences were identified in the san.ple reviewed by the maintenance inspection tea .5 Conduct Performance Measurement Program elements appeared to be adequately addresse Implementation was detemined to be in place, but could be strengthene The STRENGTHS noted in this area included:

- Procram for post-maintenance debrief established in accordance with ADM 2.11, " Quality Maintenance Teams," for aspects of aiaintenance improvement by identification of barriers to effective safet Use of job perfomance measures to asress employee performanc The WEAKNESSES noted in this area included:

- The root cause evaluation (RCE) program and its implementation are weak. A consistent methodology is not in place and the quality of

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RCEs was poc Designation of the threshold for rework and evaluation of retest failures was poo .6 Document Control System for Maintenance Program elements appeared to be adequately addresse Implementation was in place and functioning well, No STRENGTHS were noted in this are A-5

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The WEAKNESSES r.oted in this area included:

- Vendor technical menuals could be revised without the responsible department superviser's awareness that the manual change affected procedures'ano activitie An improper technical manual reference to the wrong equipment was noted on at least one preventive maintenance card because the licensee was unaware of what type of auxiliary feedwater pump had i been installe .7 Maintenance Decision Process [DaytoDay]

Program. elements appeared to be adequately addresse Implementation was determined to be in place, but could be strengthene ,

The STRENGTHS noted in this area included:

- Good vertical communications between the foreman anc management with balanced information for decision making. An effective feedback mechanism is in plac Open. work croers were subjected to proceduralized, periodic reviews for restart and at 90-day intervals during operation. The reviews were aimed at ensuring that safety-important repairs (or trends)

were not overlooke h0 WEAKflESSES were noted in thir sre .0 TECHNICAL SUPPORT COMPOSITE RATING: Satisfactory. Overall program elements appeared to be adequately addressed. Implementation was detemined to be in place, but coulc be strengthene BASIS: As a result of the recent reorganization, the old programs did not in many instances reflect the new organization. Additionally, some of the programs appeared to be inadequat For example, engineering study calculations were loosely controlled, the femal root cause

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analysis program was in its infancy, and many of the system engineering programs were neither formalized nor in place. These weakncsses were offset by adequate performance in other areas.

l 4.1 Internal / Corporate Communications Channels This area was not inspecte .2 Engineering Support The team assigned a satisfactory rating to this area. Program elements i.ppeared to be inadequately addresse Implementation was detemined to be in place, but could be strengthene i A-6 l

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l The STRENGTHS noted in this area included:

- Equipment qualification (EQ) program requirements were well documented and implemente The WEAKNESSES noted in this area included:

- Site engineering functions not fully defined by existing procedure programs. A coordinated program involving the corporate office and Surry was just starting. Problems with engineering support effectiveness include poor RCEs and poor engineering study calcula-ticn Procedures for control of fomal calculations as opposed to control of engineering study calculations were inconsistently applie This resulted in the calibration of the power range nuclear instruments utilizing an erroneous calculatio .3 Role of PRA in the Maintenance Process This area did not apply to North Anna. North Anna did not have a plant-specific probabilistic risk assessment (PPA).

4.4 Role of Quality Assurance in the Maintenance Process Program elements appeared to be adequately addresse Implementation was detemined to be in plac The STRENGTHS noted in this area included: None The WEAKNESSES noted in this area included: None 4.5 Integration of Radiological Controls Into the Maintenance Process Program elements appeared to be adequstely acdresse Implementation i

has determined to be in place.

l The STRENGTHS noted in this area included:

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- horker awareness of cs-low-as-reasonably-achievable (ALAPA)

principles and practices was particularly evicen Increased levels of management attention were applied to ALARA considerations based on expected man-rem expenditures.

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l l - The licensee had implemented a program of qualifying craftsmen as advanced radiation wurlers who could be assigned to quality main-tenance teams (OMTs) thus providing continuous, equivalent health physics (HP) technician coverag The WEAKNESSES noted in this area incluced: None l A-7

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. sfety Review of Maintenance Activities Th.'s area was not inspecte .7 Integration of Regulatory Documents Into the Maintenance Process This area was not inspecte .0 WORK CONTROL COMPOSITE RATING: Satisfactory. Overall program elements appeared to be adequately addressed. Implementation was detemined to be in place and functioning wel BASIS: The n.ajority of the team's inspection effort was applied in this area. The team was favorably impressed with the quality of the craftsmen and technicians, and the overall quality of the work observed. The team also considered the proceduralized and periodic review of safety-related work orders to be a strength. The strengths in Section 5.1 were approxi-mately offset by the weaknesses noted in Section .1 Review of Maintenance in Progress Program elements appeared to be acequately addresse Implementation was detemined to be in place and functioning wel The STRENGTHS noted in this area included:

- Maintenance personnel, in general, clearly understood the work centrol proces Appropriate support group reviews, such as fire protection, were performed on work orders requiring such attentio Techr.ical specification (TS) limiting conditions for operation (LCO)

and equipment clearances for maintenance functions were evaluated as part of the work urder authorization process (see related weaknesses below).

. - Quality Control (00) staff was notified upon cornmencement of each safety-related work order, and QC presence was noted at routine work locations, including pre-briefing Special equipment, measurement and test equipment, and required spare parts were well integrated into the process of preparing work order For work activities observed, the craftsoch and technicians dcronstrated good skills, knowledge, and abilitie The licensee exercised good control over the temporary modification (jurrper and lifted lead) program. The process ensured a minimum number of installations with good management oversigh A-8 i l

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- Housekeeping and cleanliness on the job sites were well maintaine Attention to ALARA practices and contamination control at the job I sites was noteworth For the maintenance activities observed, the practice of having one craftsman reed the procedure while another performed the work step was viewed as a positive control measure to ensure procedural complianc The WEAKNESSES noted in this area included:

- Tagouts were not perfomed in accordance with applicable instructions for modification or engineering work request activitie .2 Establishment of Work Order Control Program elements appeared to be adequately acdresse Implementation was detemined to be in place ano functioning wel The STRENGTHS noted in this area incluced:

- The work order contro~ program was well documente Lines of authority for work order review and authorization, were clearly established and adhered t The WPTS computer data base for work order preparation, processing, and tracking helped to ensure work order accurac The WEAKNESSES noted in this area included:

- Work request 531226 was inappropriately cancelled without correcting the packing legk on the A charging pump suction valve (1-CH-497).

5.? Maintenance of Equipment Records and History

. Program elements appeared to be acequately addressed. Implementation was determined to be in plac Cb5ERVAT10H: WPTS and KPRDS function extremely well as equipment history I systems. However, WPTS is an example where the administrative procedure was substantially out of date and inconsistent with how business was actually conducteo on a day-to-dey basi .4 Conduct of Job Planning Program elements appcored to be adequately adcressed. Implementation

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l l The STRENGTHS noted in this area included:

- The overall planning process was effective (see conenents in Section5.3,above).

The WEAKNESSES noted in this area included:

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- Not all persons received pre-job briefings in accordance with ADM-2.11, " Quality Maintenance Teams," and the briefings were occasionally perfunctory. In one instance, when a crew member got sick after the pre-job briefing had been given, the substitute did not receive an equivalent briefing. In this case, the work involved safety-related equipment in a high-radiation area. No safety significant consequences resulted from this omissio .5 Perfumance of Work Prioritization Program elements appeared to be adequately addresse Implementation was detemined to be in place, but could be strengthene No STRENGTHS were identified in th 5 are No WEAKNESSES were identified in this are .6 Maintenance Work Scheduling Program elements appeared to be adequately addresse Implementation was determined to be in place and functioning wel The STRENGTHS noted in this area included:

- Post-maintenance testing prescribed by work order but deferred because of plant conditions was controlled, effectively tracked, and related to the TS for mode change and surveillance schedul No WEAKNESSES were identified in this are .7 Establishment of Backlog Controls

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Program elements appeared to be adequately addresse Implementation was detemined to be iri place and functioning wel The STRENGTHS noted in this area included:

- Program for pre-startup and ongoing (90 dey) review of work order backlogs (Plant Procedures ADM 16.11 & 16.20, also discussed in Section 3.7, above).

No WEAKNEf:ES were identified in this are A-10

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5.8 Maintenance Procedures Program elements appeared to be adequately addresse Implementation was determined to be in place, but could be

. strengthene OBSERVATION: Licensee initiative for procedure upgrade program was noted as a positive indicator. Iniplementation was not sufficiently progressed to assess its adequacy, but initial staffing levels and production rates for new or revised procedures appeared to be lower than desirabi No STRENGTHS were noted in this are The WEAKhESSES noted in this area included:

- Some procedures lacked detail, resulting in craft personnel using their own discretion in interpreting what should be done (examples included EDG preventive maintenance procedure, battery charger preventive maintenance). For the instances noted by the team, th knowledge level, skill, and abilities of the craftsmen offset the procedural wtaknesses. However, the missing detail was well outside-the limits of ANSI 18.7 definitions related to skill of the craftsme Maintenance Department ADM-27.0, " Preparation and Content of Maintenance Procedures," permits workers in the field to write in procedure changes without management or safety committee revie Write-in changes can result in a change in both procedure and work order scope without proper managenent and/or TS reviews. Examples included preventive maintenance procedures fcr MOVs and the ED .9 Conduct of Post-Maintenance Testing The team did not evaluate program elements in this crea because NRC Region 11 personcel and the licensee had pre-identified the program as inadequate. For the activities observed by the team, program elements appeared to be adequately implemented. Implementation was determined to be in place, but could be strengthene '

The STREhGTHS noted in this area included:

- Electrical craft personnel were well trained in performing MOVATS testing for MOV The control room operators had documentation to identify deferred post-maintenance testing for valve The WEAKNESSES noted in this area included: None 5.10 Review of Contpleted Work Control Documents Program elements appeared to be adequately addresse Implementation was deters.ined to be in place, but could be strengthened.

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The STRENGTHS noted in this area included: None The WEAKNESSES noted in this area included: None 6.0 PLANT MAINTENANCE ORGANIZATION COMPOSITE EATING: Satisfactory. Overall program elements appeared to

.

be adequately addressed. Implementation was determined to be in place.

l but coulo be strengthene BASI 5: The process for identifying deficiencies in the plant appeared to be an easy system to use and was effectively implemented. Development of work analysis process was in its infanc ,

6.1 Establish Control Of Plant Maintenance Activities Program elements appeared to be adequately adcresse Implementation was detersincd to be in place, but could be strengthene No significant findings beyond these discussed under Section .2 Contracted Maintenance This area was net inspecte .3 Establishment of Deficiency Identification and Control System Program elements cppeared to be adequately addresse Implementation was determined to be in place, but could be strengthene The STRENGTHS noted in this area included:

- The work request program is an easy and efficient means to identify and report deficient conditions and plant personnel appeared to use it effectivel The recently established deviation report (DR) system was similarly easy to use and, if properly implemented, appeared to be effective as a centralized corrective action

- syste The WEAKHESSES noted in this area included:

- Some Sh review team recommendations had not bean effectively addressed. Most of the specific items reviewed by the inspec-tion team had cither been transferred from department to department (with no action over a 0-month period) or had been closed out with what appeared to the team to be questionable resolution Although previously identified as a weakness or concern, RCEs for equipnent failures and performance problems (with the exception of human performance) appeared to be ineffectiv A-11

_- - _ _ - - - - _ __

, __ _ ___

e

, ;.7 %,

..~ l

.

1 6.4 ~ Performance of Maintenance Trending l Program elements were not inspecte Implementation was determined to be l in place, but could be strengthene ,

The STRENGTHS noted in this area included: I

-

Use of plant-specific NPRDS information in trending equipment problems.

,

The WEAKNESSES noted in this area included:

-

No trending performed by maintenance engineers because of manpower constraint .5 Establishment of Support Interfaces Program elements were not inspected, implementation was in plac .0 MAINTENANCE FACILITIES, EQUIPMENT, AND MATERIALS CONTROL COMPOSITE RATING: Satisfactory. Overall program elements appeared to be adequately addressed. Implementation was determined to be in place, but could be strengthene BASIS: With the addition of the hot shop that was under construction at the time of this inspection, facilities appeared to be adequat Some problems were noted with vr.aintenance of equipment in storag .,1 Prod ston of Maintenance Facilities and Equipment Pro pam elements were not inspected, implementation was in plac .2 Establishment of Material Controls Program elements appeared to be adequately addressed. Implementation was determined to be 40 place, bu+ could be strengthene The STRENGTHS noted in this area in;1uded:

- The established material control program appeared to successfully ensure that materials and equipment were procured from qualified vendor Craft personnel exercised care that safety-related parts and components were the material required by work order and were properly segregated from other nonsafety-related material The KEAKNESSES noted in this area included:

- A PM program for spare components was in place (ADM-13.0), but was not implemented for approximately 150 item A-13

- _-_-__ _ _ - _ _ _ _ - _ _-_ _ - -___ _ _ - _ _ _ - _ _ _ _ - ___ - ___- _ ___ - - _ - _-_ _ _ _ _ _____ _ _____ -

VL b ' h,.. . . _

'

j

.

F 7.3 Establishment of Maintenance Tool and Equipment Control

'

, Program elements appeared to be adequately addresse Implementation was determined to be in plac The STRENGTHS noted in this area included:

- The measurement and test equipment (M&TE) usage log was considered exemplary based on types of data recorde No WEAKNESSES were noted in this are .4 Provide Control and Calibration of Meter and Test Equipment

,

Program elements appeared to be adequately addresse Implementation was determined to be in place, but could be strengthened.

i'

No STRENGTHS were noted in this are No WEAKNESSES were noted in this are .0 PERSONNEL CONTROL COMPOSITE RATING: Satisfactory. Overall program elements appeared to be adequately addressed. Implementation was detennined to be in place and functioning well, BASIS: The team was impressed with the knowledge level of craftsmen and technicians who were observed during maintenance activities, particularly considering the impact of maintenance on plant safety. Other noteworthy strengths included the licensing of several management superintendents, quarterly craft and technical training instructor in-plant crew evalua-tions, and the financial incentive for craftsmen to complete their qualification .1 Establishment of Staffing Control

. Program elements were not inspecte .2 Provide Personnel Training Program elenients appeared to be adequately addresse Implementation was determined to be in place and functioning wel OBSERVATION: The training program and implementation seemed to be effective and appeared to overcome procedure weaknesse The STRENGTHS noted in this area included:

- The team observed numerous activities of preventive and correc-tive maintenance including: major overhaul work on the EDG, major disassembly of a rod-drive motor generator for inspection, cleaning, A-14

_ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ -

__

~<.,- ,s-e

..-

'

.

.

. 1 and repair; component replacement and post-maintenance testing of a charging system MOV; and other miscellaneous component and system tests and repairs. For each of the observed activities, the team noted a high degree of skill on the part of the craft personne . Their skill overcame the situation where- procedures occasionally _

lacked detai The licensee established a well documented, Institute of Nuclear Power Operations (INPO)-accredited training program for maintenance trainin The power training services program guides detailed the classroom and on-the-job training (oral / written / practical factors) that constituted the complete qualification process for each craftsma Several key managers had been previously licensed at North Ann The resultant sensitivity to plant operations appeared to contribute to effective support for the Operations Department by other organizational element Quarterly craft and technical training instructor in-plant crew evaluation and proficiency maintenance activitie Employee motivation to complete training steps was high because of financial incentive No WEAKNESSES were noted in this are B.3 Establishment of Test and Qualification Process Program elements appeared to be adequately addresse Implementation was determined to be in place and functioning wel The STRENGTHS noted in this area included: See Section No WEAKNESSES were noted in this are .4 Assessment of the Current Personnel Control Status

'

Program elements were riot inspected.

,

!

A-15 L - - - - - - - _ _ - - - - - - - _ _ _ _ _ _ _ _

p-

~ ~ s, , f, . ., '

.

.

APPENDIX B LICENSEE PERSONNEL AT THE EXIT MEETING hane Title M. Gettler Superintendent, Site Services J. Wroniewicz Supervisor, Design Engineer D. Driscol Manager of Quality Assurance (Site)

C. Snow . Supervisor,' Chemistry D. Thomas Supervisor, Mechanical Maintenance l G. Gordon- Supervisor. Electrical Maintenance D. Heacock Superintendent of Engineering V. West Superintendent of Outage Man?gement W. Matthews Superintendent of Maintenance J. Leberstein Licensing Engineer D. Burke Supervisor. O&M Support J. Stsli Superintendent, Operations J. Naciejetiski Manager of Quality Assurance (Corporate)

R. Calder Manager of Nuclear Engineering W. Cartwrigh Vice President, Nuclear Operations M. Bowling Assistant Station Manager G. Kane Station Manager

.

B-1

,

'

N". . 3

. . . , .

.

'4 o

Appendix C-Abbreviations AFW auxiliary feedwater

- AMSAC anticipated transient without scram mitigation system actuation circuit AThS anticipated transient without scram q.' BOP-QA balance-of-plant quality assurance CRDR control room design review CTS commitment tracking system DCP design change package EkP electrical maintenance procedure E0P emergency operating procedure EQ equipment qualification ES engineering study EWR engineering work request FCR field change request HHSI high-head safety injection HPES human performance evaluation system HVAC heating, ventilation and air conditioning IA instrument air ICP instrument calibration procedure IEEE Institute of Electrical sno Electronic Engineers INPO Institute of Nuclear Power Operations LHSI low-head safety injection system M&TE measurement and test equipment MMP mechanical maintenance procedure MOV motor-operated valve MOVATS motor-operated valve analysis test system HTI maintenarice team inspection NAS North Anna specification NRC huclear Regulatory Comission NSS nuclear site services PD procedure deviation psid pcends per square inch differential

,

PM preventive maintenance QC quality control RCE root-cause evaluation RWP radiation work practice SNSOC station nuclear operating safety committee SSOMI safety systems outage modifications inspection SW service water SWRT service water review team TS Technical Specifications Tl temporary instruction VEPCO Virginia Electric Power Company UFSAk updated final safety analysis report WPTS work planning ano tracking e ,

.

um,m_ . .. .

f y , PRESENTATION AND MAIN 1 k

W NT1ATORS

.

! OBJECTfvES: ESTABLISH & IMPLEMENT AN EFFECTT

.

,,,ageggy w p m

. 3, PRA INStGHTS 8. Tortes OP INTenest (cHecat Valves, MoVS,

,3 Ast sysTEMe, eMuseens, INVERTEMS)

• * 4. PREVDOUS INSP9CTION FINDINGS 8. OBSERVATION OF PLANT ACTTVITIES a

.

L l L l MANAGEMENT SuPPod - * - - - - - - - - ~

CPVERALL M / OF MANTENANCE =4---------

PERFORMANCE ,

RELATED TO

-- (I). .0 I I .. I ASANAGEMENT MANAGEMENT TECHNICAL DIRECT ORGANIZATION AND SUPPORT MEASURES AND ADMINISTRATION CORPORATE AND PLANT ~

E F .1 4,9

,,, A

'

APPUCATION IDENTIFY .ESTABUSH INTERNAd IN OF INDUSTRY a PROGRAM m CORPORATE .. u .

m , HISTORIC INITIATIVES COVERAGE FOR CONFJNICATION . DATS M NANCE DIANNEL$ w .tr' .2 MAINTAIN /

EQUIPMENT ESTABUSN POUC RECORDS &

a OOALS,AND yl8 TORY OBJECTIVES FOR MANTENANCE

' .5 i " M CTjTE d PERFORM /

a WORK /

ALLOCATE '0F PRA'M TM ?+. PRIORITIZATION

, ggggg m- , M **' *g MANA U m

DEFINE MAINTENANCE

/ ' OF ROLS

" WALKDOWN yA COURA s INSPECTION REQUIREMENTS 3 CONDUCT PO5T a

CONDUCT PERFORMANCE

/ CONTROLS INTO

' #"

,

a MAINTENANCE

. - MEASUREMENT P SI 3, ,

yRoCcSS

.

APERTURE s ..

- M ENT SAFETY REVIEW /

f(,$., V CARD F m OF MAINTENANCE Also Available On

F i

Aperture Card 87 4,7 f MAINTENANCE

/

.

m . DECISION . MTEGRATE P SS a REQULATOR K ENTS .

.

'

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ . _ _ . . _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ _ _ . . _ _ . _ _ _ _

.__ _ - _ _ -

,

- .

f . . g'

'

ENANCE INSPECTION TREE ss

_

E PLANT MAINTENANCE PROCESS OVERALL PERFORMANCE EVALUATION .

SUFFICIENT ELEMENTS POOR SATISFACTORY 000D NOT NSPECTED <

j vo c1=rro= m i va- I kWWSSSSI N 1 INTERFACE E

--_---______ _p, f.

- - - - ,,, E D B A E _ _ _ _ _ ,,,,,, ,,,,,, _ _ yENTATION ,

E O I I I I WORK PLANT MANTENANCE

/ MAINTENANCE FAC8UTIES PERSONNEL

'

g CONTR EQUIPMENT, af CONTROL is\ j e xN\ .1 7,3 g,y

"

ESTABLISH ESTABUSH CONTRO(

WORK " PROVIOE MAINTENANCE ESTABUSH ,

m

, OF PLANT / , FACILmES & ECUIPMENT

' '

" CONTROL", STAFFING

'

MAINTENANCE D ~~^ '

ApVITIES y,3 *

a 6.1*1 ESTABUSH /  !

,

CONDUCT f m , MATERIAL CONTROLS a JOS MECHANCIAL

"

plNG MAINTENANCE g,3 ,.

g,9,3 ESTABUSH MAIM '

g,g a TOOL & EQUIPMENT , ,

s MAINTENA

'

"

ELECTRICAL /s #

CONTROL '

'

MM NANCE f g,4

^

6. PROVIDE CONTROL / ASSESS INSTRUMENT AND ' u & CAUBRATION OF METER , STATUS

, a CONTROL & TEST EQUIPMENT '

MAINTENANCE PROVIDE / '

m' MAINTENANCE POCEDURES ESTABUSH OONTROt LEGEND

. Or coNrRACTEO

= EvAtuArE sEcnoN u. ELEuEurs

,_,, _

REVIEW OF / HloHUTE< YEnow so*ee ouATELY 3'3 "

u. COMPLETED EErvAtuArEm'"Enumccur oATA Fm tvAtuAto WORK CONTROL m

ESTABLISH DEFICIENCY /

/ -

DOCUMENTS

/ IDENTIFICATION EVALUATE MAINTENANCE PROCESS ELEMENT ADEOUACY ST M HloHUT R ADE SSCo

- '

_ ~ ,.. -_1.o m - ,m --,- PERFORM EVAtuATE MAINTENANCE PROCESS ELEMENT IMPLEMENTATION

, MAINTENANCE *

ESTAKISH TRENCING HloMuT a w wr couto at smom'an

'" u Tc*8$v"Auftlo**m*usu

. # Yr ccEra rm evAtuAro CES

__

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