IR 05000344/1987044

Insp Rept 50-344/87-44 on 871122-880102.No Violations Noted. Major Areas Inspected:Operational Safety Verification,Maint, Surveillance & Event Followup

ML20149J540
Person / Time
Site:	Trojan File:Portland General Electric icon.png
Issue date:	02/03/1988
From:	Rebecca Barr, Mendonca M, Suh G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20149J507	List: IR 05000344/1987044 ML20149J505
References
50-344-87-44, NUDOCS 8802230105
Download: ML20149J540 (13)

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U.S. NUCLEAR REGULATORY COMISSION

REGION V

Report No. 50-344/87-44 Docket No.'50-344 License No. NPF-1 Licensee: Portland General Electric Company 121 S. W. Salmon Street Portland, Oregon 97204 Facility Name: Trojan Inspection at: Rainier, Oregon Inspection conducted: November 22, 1987 - January 2, 1988 Inspectors: - AM 'A7 M .2///R R. C. Barr Date Signed Senior Resident Inspector

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G. Y. Sub

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2_4 fry Date Signed Resident Inspector Approved By: * * ' "'* .Ah/U M.M. Mendonca, Chief Date Signed -

Reactor Projects Section 1 ,

Summary:

Inspection on November 22, 1987 - January 2, 1988 (Report No. 50-344/87-44)

Areas Inspected: Routine inspection of operational safety verification, maintenance, surveillance and event follow u Inspection procedures 25026,

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30703, 61705, 61726, 62703, 71707, 71709, 71710, 90712, 92700, 92701, and 93702 were used as guidance during the conduct of the inspectio Results:  !

No violations of NRC requirements were identifie ;

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'# 8802230105 880203 PDR ADOCK C3000344

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OETAILS

' Persons Contacted

• Cockfield, Vice President, Nuclear

• C.A. Olmstead, Plant General Manager

• C.P. Yundt, General Hanager, Technical Functions

• R.P. Schmitt, Manager, Operations and Maintenance

• 0.W. Swan, Manager, Technical Services

• J.K. Aldersebaes, Manager, Plant Modifications

• J.D. Reid, Manager, Plant Services

• J.W. Lentsch, Manager, Personnel Protection

• A.N. Roller, Manager of Nuclear Plant Engineering

• T.O. Walt, Manager, Nuclear Safety and Regulation R.L. Russell, Operations Supervisor R.H. Budzeck, Assistant Operations Supervisor *

D.L. Bennett, Maintenance Supervisor R.A. Reinart, Instrument and Control Supervisor T.O. Meek, Radiation Protection Supervisor R.W. Ritschard, Security Supervisor  ;

C.H. Brown, Operations Branch Manager, Quality Assurance

• 0.L. Nordstrom, Nuclear Engineer. Nuclear Safety and Regulation The inspectors also interviewed and talked with other licensee employees during the course of the inspection. These included shift supervisors, reactor and auxiliary operators, maintenance personnel, plant technicians and engineers, and quality assurance personne * Denotes those attending the exit intervie . Plant Status On November 22, 1987, the Trojan y a litty was at 100% reactor powe '

Full power operation continued unt,1 December 6, 1987, when a switch failure in the turbine control system resulted in a major load reduction and an operator initiated reactor tri The facility was restarted on '

December 7, 1987. At 6:35 p.m., with the reactor at 5% power following grid synchronization, the facility was unable to load the turbine generator due to a wiring erro The facility remained at approximately 5% reactor power until December 9, 1987, when the reacto.' was shutdown to investigate unusually high containment humidity. The cause of the high h/midity was leakage from a steam gertrator drain valve. Between 10:18 p.m. and 11:11 p.m. on December 9, 1987, due to excessive seal leakage from the 'A' Reactor Coolant Pump, an unusual event was declared. On ,

December 24, 1987, the reactor was restarted, reached 100% power on December 25, 1987 and remained at full power the rest of the inspection ,

perio t Operational Safety Verification l

During this period, the inspectors observed and examined activities to '

verify the operational safety of the licensee's facilit The

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observations and examinations of those activities were conducted daily, weekly or biweekl Each day the inspectors observed control room activities to verify the licensee's adherence to limiting conditions for operation as prescribed in the facility technical specification Logs, instrumentation, recorder traces, and other operational records were examined to obtain information on plant conditions, trends and compliance with regulation On occasions when a shift turnover was in progress, the turnover of information on plant status was observed to determine that all pertinent information was relayed to oncoming shift personne Each week the inspectors toured the accessible areas of the facility to observe the tollowing items: General plant and equipment conditions, Maintenance requests and repair Fire hazards and fire fighting equipmen Ignition sources and flammable material control, Conduct of activitie, in accordance with the licensee's administrative controls and approved procedure Interiors of electrical and control panel Implementation of the licensee's physical security pla Radiation protection control , Plant housekeeping and cleanlines Radioactive waste system Proper storage of compressed gas bottle ,

Each week to determine that the licensee complied with technical !

specification limiting conditions for operation the inspectors examined e the licensee's Equipment clearance control with respect to removal of equipment from service. Active clearances were spot-checked to ensure ;

their issuance was consistent with plant status and maintenance '

evolutions. The inspectors examined logs of jumpers, bypasses, caution -

, and test tag Each week the inspectors conybrsed with operato % in the control room,

and with other plant personnel. The discussions centered on pertinent ,

topics relating to general plant conditions, procedures, security, '

training, and planned or in progress work activitie To confirm that quality related deficiencies were identified and tracked ,

by the nonconformance reporting system, the inspectors exLmined the '

nonconformance reports (NCR). Identified nonconformances were being ;

tracked and followed to completion.

Routine inspections of the licensee's physical security program were performed in the areas of access control, organization and staffing, and detection and assessment system The inspectors observed the access control measures used at the entrance to the protected area, ve.ified the integrity of portions of the protected area barrier and vital area ;

barriers, and observed in several instances the imniementation of '

compensatory measures upon breach of vital area barriers. Portions of the isolation zone were verified to be free of obstructions and the '

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3 central and secondary alare stations were verified to'be functioning, including use of CCTV sor.<itors. On a sampling basis, the inspectors veriffed the required minimum number of armed guards and an individual

authorited to direct s=

urity Activities were on sit The irspectors conducted routine inspections of selected activities of the licensee's radiological protection program. A sampling of radiation work peroits (RWP) was reviewed for completeness and adequacy of information. During the course of other inspection activities and periodic tours of plant areas, the inspectors verified proper use of personnel mon?toring equipment, observed individuais-leaving the radiction controlled area and signing out on appropriate RWP's,-and observed the p7 sting of radiation areas and contaminated areas. Posted radiation levels at several locations within the fuel and auxiliary buildings v; ara verified by the inspectors using both NRC and licensee portable survey meters. The involvement of health physics supervisors and engineers and their awareness of significant plant activities was assessed through conversations and review of RWP sign-in record The inspectors verified the operability of selected engineered safety feature This was done by direct visual verification of the correct position of valves, availability of power, cooling water supply, system integrity and general condition of equipment, as applicable. Systems verified operable during this inspection period included the Component

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Cooling Water Systein and the "B" train Emergency Diesel Generato No violations of NRC requirements or deviations were identifie . Maintenance Emergency Diesel Generator Maintenance The inspectors observed maintenance being performed on the east emergency diesel generator. The work was performed under four separate maintenance requests and consisted of electrical and mechanical semi-annual preventive maintenance, replacement of six control relays and repair cf the west engine of the east emergency diesel generator soak back oil pump. The semi-annual preventive maintenance was performed in accordance with Maintenance Procedure J

MP 12-0 Through observations and discussions with the maintenance personnel perforning the work, the inspectors determined that required administrative approvals and clearance tagouts ware obtained prior '

to work initiation. Quality control coverage specified in MP 12 07 ;

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was provide Appropriate work packages and procedures were on {

han The maintenance requests specified appropriate installation checks prior to returning the equipment to service. Functional ,

a testing of the east eAergency diesel genst4 tor was perfoimed upon completion of the maiatenance wor ,

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b. Inspection of Containment Air Cooler Units During the December 1987 forced outage, the licensee performed an inspection of the eight containment air cooler units to determine the source of leakage observed coming from the 205 foot elevation area. The inspection performed by four maintenance personnel identified no leat;ge frot the ball float traps in the component cooling water lines which service the containment air coolers, One of the traps was found to be missing a support bracket, which was subsequently replace The work was controlled by Maintenance '

Request MR 87-751 The inspector observed that the requirements of Radiatior Work P.ermit RWP 87-128 were followe The inspectors observed that the as-found containment air cooler drain collection system did not appear to positively collect all condensat This was evidenced by the lack of positive drainaga features such as the presence of rust and corrosion on the outside surfaces of the collection pipe and the presence of a white residue in the vicinity of the drain pipes for each containment air cooler unit. Upon the inspectors request, the radiation protection technician measured activity levels. The levels were found to be slightly higher than background near the areas of the white residu The inspectors shared these observations with the operating crew and the system engineer. In response, the shift supervisor prepared a

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Request for Evaluation and an event report was prepare A temporary modification, that installed a piece of t'.exible tubing

into the drain collection funnel, was subsequently implemented to ensure positive drainage into the collection system. Because ;

condensate collected from the containment air coolers is used as one measure of reactor coolant system leakage per the plant technical specifications, the related plant procedure was initially declared ,

to be deficient. Subsequently, the procedure was revised to account for the potential deficiency in the drain collection system. The white residue found near the drain pipes was determined to be boron precipitate carried over from reactor coolant system leakage condensed by the cooler units. An evaluation concluded that corrosion damage to the cooler from the boron residue was minima The event report evaluation recommended that the bcron be cleaned during the upcoming refueling outage. The actions taken are an instance of responsiveness to an NRC identified concern. While ,

the temporary modification assured positive collection, the licensee was continuing to search for the source of leakage at the end of the inspection period c. Reactor Coolant Pump'A' Seal Replacement

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Following the December 1987 reactor trip, while conducting a ,

I cooldown to Mode 5 to repair a leaking check valve in the alternate charging line, high seal leakoff flow ( in excess of technical specifications limits ) past the first seal on reactor coolant pum;T (RCP) 'A' occurred and resulted in the declaration of an unusual ,

event. The leakoff Sine was isolated, and the unusual event

. terminated upon determining the second seal was functioning properl ,

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The inspectors observed portions of the 'A' RCP disassembly, inspection and replacement. The inspection of.the seals was controlled by Maintenance Requast MR 87-7527 and Radiation Work Permit RWP 87-13 The inspectors observed the removal of the lower seal housing which contained the insert and ring assembly for the first sea The work was performad by a crew of four maintenance personnel assisted by a vendor field technical representativ Radiation protection and quality control coverage was observed. Per PWP 87-130, ventilation was installed to minimize potential airborne activity and all workers wore full face respirator The work area d

n the vicinity of the reactor coolant pump had been prepared to minimize the' spread of contamination. The inspectors reviewed clearance number 87/2457 and determined that it placed appropriate equipment, lines and circuits out of servic Several clearance tags were visually confirmed to be in plac Inspection of the seal runner, ring, and insert for the 'A' RCP first and second seals was performed by the vendor field representative.in the decontamination shop spray booth and observed by the inspectors. Inspection of the third seal was performeo

'inside containment. No defects were found on the ring assembly and runner of tae first seal. Minor wear vac observed on the insert of the first real aad the ring assembly, runner and insert of the second sel Although indications of minor wear were identified, the cause of the high first seal leakoff for the pump was not de*.e rmi ned. A review of the ' A' RCP equipment history file revealed that a disassembly and inspection of the seals had been performed during the 1987 refueln g outage as scheduled preventive maintenance. The inserts on the first and second seal and the ring ascambly of the eecond seal were replaced. Also during the 1987 outago, the seal injection lines to all four reactor coolant pumps were flushed to verify cleanliness and remove any foreign particles that may have been introduced as a result of related maintenance activitie Ne contributing causes for the high seal leakoff were identified. All three 'A' RCP seals were replaced and the pump i returned to service. At the end of the inspection period, the pump was operating satisfactorily. In the seal inspection activity, the- ,

inspectors notea that the radiation protection technician closely l followed the requirements of the radiation work permit. Surveys of newly exposed surfaces were performed during the disassembly process prfor to the per'ormance of detailed inspections, i

5. Surveillance l

Following completion of preventive and corrective maintenance, the '

inspectors observed operability testing of the east emergency diesel generato The test was performed in accordance with Periodic Operating ,

Test POT 12-1, titled "Monthly Idle - Start and Loading of Emergency j Diesel Generators". The inspectors noted that the operator had the test procedure and data sheets in hand during the performance of che tes The inspectors observed the conduct of test activities and the restoration of the system to standby statu ,

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A review of. surveillance procedures was-conducted to. verify that applicable technical specifications requirements were being addressed.

, T.S. 4.8.1.1.2 requirements were addressed in the following plant

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procedures: POT 12-1; POT 12-2, titled;"Emergency D 4sel Performance, Loss of Offsite Power, Diesel Automatic Start, and- Auxiliary Feedwater -

! Valve Actuation;" P0Y 12-4,, titled '! Semi-Annual Manual Start and Loading ,

i of Emergency Diesel Generators from Ambient Conditions;" POT IF2,. titled

. "Cross-connected System Performance;" MP 12-7, titlad "Emergency Diesel e

Generator Plant;" and CMP 3,-titled "Sampling Diesel Fuel Oil Tanks."~ The !*

inspectors also reviewed a st,mple of 1987 data sheets and chemistry log for the above procedures. The review revealed no discrepancies and- .

indicated that the surveillance requirements of T.S. 4.8.1.1.2 were me In the review of POT 12-1, the inspectors identified several  !

4 discrepancies in the procedure. The inspectors discussed these items, !

j which were primarily administrative in nature, with the cognizant '

l- engineer, who committed to make appropriate changes-in the next procedure j revision. The review of 1987 data sheets indicated these procedural- .

discrepancies had not resulted in failures to perform required l l surveillance testin !

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" The inspectors reviewed plant records to confirm that appropriate i action statements were'followed when an emergency diesel generator set +

had been taken out of service for maintenance. A records review of'the j most recent "A" and "B" train outages identified the failure to verify [

offsite circuit availability within one hour on November 2 when the "A" :

emergency diesel generator was taken out of service. Licensee personnel !

had previously ideatified this failure and initiated an event repor LER 87-34 w.s subsequently issued. Review of LER 87-34 indicated that {

the LER was inaccurately written in that it discussed a one hour .

requirement to detaonstrate the other emergency diesel generator to be !

operable. The actual requirement was to verify offsite power  ;

availability within one hour and the operability of the other emergency l 4 diesel generator within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The inspectors discussed this item l

' with the LER engineer for. accuracy of future rc; orts. The inspectors i

. committed that LER 87-34 would be revise !

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i 6. Follow-up of Onsite Events J

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Turbine Trip and Reactor Trip On December 6, 1987, with the plant operating at 100% power, the i turbine and reactor were manually tripped at 10

10 a.m. following a j major load rejection. The licensee's investigation indicated that ;

the microswitch for the generator load decrease pushbutton had- !

failed in the closed position. All safety systems functioned as !

expected with.the exception of the "A" train of the auxiliary l feedwater system. The trip and throttle valve, MO-3071, for the [

Terry turbine was found to be in the closed position and did not i open on the automatic start signal. Subsequent troubleshooting  !

revealed an unlanced leed in the automatic start circuitry.-

Because a spare switch was unavailable, the failed microswitch !

associated with the generator load decrease pushbutton was replaced with the switch installed in the "ADS-in" location which is not i

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employed at the Trojan plan This repair was controlled by Maintenance Request MR 87-7366 and Temporary Modification 87-10 '

Upon plant restart on December 7,1987, and following grid synchronization, the turbine generator was unable to assume loa The inspecto.'s observed portions of the subsequent troubleshooting and repair performed on the generator control circuitry. The following observations were made:

(a) The initial troubleshooting was performed with no engineering review or oversigh (b) Work was initiated prior to the preparation of work instructi'is.

j (c) Upon arrival of the system engineer, there was apparent

! disagreement between the system engineer and instrumentation and control personnel on how the circuit functione (d) There appeared to be an unauthorized jumper in the circui (e) Lifted leads in the electro-hydraulic control (EHC) cabinet were not tagged in accordance with administrative instruction The inspectors discussed these findings with licensee maaagement,

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who arrived on site shortly after the discussio Plant management ,

evaluated the circumstances of the work being performed and stopped work pending management revie Management review, assisted by the Performance Monitoring and Event Analysis group, concluded that a failure to follow procedures in implementing Temporary Modification 87-106 resulted in the inability of the turbine generator to assume load. A jumper was installed in the circuit without proper engineering and management review after the original temporary modification had been prepared and approve The licensee concluded that the generator would have functioned ,

properly if TM 87-106 had been installed as originally planned. In response to this instance of procedural non-compliance, the licensee developed a training program on procedural compliance, disciplined the personnel involved, and increased efforts to convey management expectations on procedural compliance to Nuclear Division personne Training on procedural compliance was given to plant personnel and will be given to all employees as part of the annual general employee training progra In response to NRC nbservations that the restart documentation did not adequately record management reviews and approval for restart, licensee management committed by April 1988 to develop an abbreviated ready for startup procedure that would address plant status prior to recovery from plant trips or forced outage Licensee management has also initiated efforts to improve  ;

performance in the areas of work instructions, troubleshooting and post-maintenance testing. Troubleshooting on December 6 to '

, investigate the cause of the turbine load reduction, and on

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December 7 to investigate the inability of the generator to increase  :

load, were performed using "urgent" maintenance _ requests.. A5  !

d observed by the inspectors, troubleshooting was initiated without

adequate work instructions developed with appropriate engineering ,

L input. Plant procedures permitted the performance of 3aintenance  ;

i work prior to the preparation of written work instructions, and on- '

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the sole approval of the shift supervisor in cases'which involved  ;

reductions in plant output, personnel danger, or reactor safety. In '

l response to the events of December 6'and 7, the' licensee has revised f

the procedure-(Administrative Order A0-3-9, Revision 26, titled  ;

i "Maintenance Requests") with_ regard to "urgent" maintenance 1

. requests. In the revised procedure - duty general manager approval i

is required for initiation of work on "urgent" maintenance _ requests J

which involve reductions in. plant output. The shift supervisor  ;

retained the authority to initiate "urgent" maintenance requests i

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which involve reactor safety or personnel danger. In the' area of 1 post-maintenance testing, a functional test of the turbine generator '

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was not performed after implementation of Temporary Modification

87-106 on December 6. Because the generator failed to increase load >

4 subsequent to the installation of TM 87-106, licensee' management has -

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committed to review the policy on functional retesting and  !

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troubleshooting by March of 1988. The Performancs Monitoring and

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Event Analysis group will also perform an independent evaluation of i

possible improvements in the maintenance area. Licensee actions  !

j will be followed as-an open ites. (0 pen Item 50-344/87-44-01), i i *

The licensee's post trip review following the turbine trip and [

J reactor trip of December 6,.1987, determined that the "A" train of }

] the auxiliary feedwater system did not start on a valid automatic  !

i start signa The "A" train auxiliary feedwater pump was started i manually by the operator in the control room upon discovery of its '

, failure to start automatically. The "B" train functioned av ,

require Troubleshooting of the auxiliary feedwater system i

identified the presence of a loose lead in the automatic start

l circuit for the "A" auxiliary feedwater pum A review of the [

equipment history file indicated that the loose lead may have -[

j resulted from work performed on the circuit in 1985 which did not i j require independent verification of lead terair.atio During this j inspection period, both "A" and "B" trains of the auxiliary

! feedwater system were checked for loose leads and operability

testing performed on the "A" train prior to plant startup.

i Subsequently, during the forced outage following the reactor trip, j i the licensee identified an additional instance of a loose lead on a '

control room flow indicator associated with the centrifugal charging ,

pump safety injection discharge line. The flow indicator failed to  ;

j provide a reading during scheduled inservice testing. A review of i g the maintenance files indicated that the flow indicatcr had been *

last calibrated in August 1987, at which time the lead was lif ted #

4 and should have been reterminated. This appeared to be an instance

of personnel error and inadequate verification of roterminatio !

i In response to these two instances of inoperable equipment due to l loose leads, the licensee committeJ to review post maintenance >

{ testing and independent verification guidelines by March 198 !

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During a management meeting held on January 4,1988 (documented in Inspection Report 50-344/88-02), the licensee discussed the following additional actions:

(1) Perform an evaluation to determine if the loose lead found in the auxiliary feedwater system would have been prevented by current requirements for independent verificatio ,

(2) Review the adequacy of the instrumentation and control calibracion program, given the discovery of the loose lead 'on flow instrument FI-91 (3) Evaluate the need to modify Trojan's practice, based on assessment of programs for control of lifted leads in place at other Region V nuclear plant The inspectors will follow licensee actions in this area. (0 pen Item 50-344/87-44-02).

b. Notor Operated Valve Maintenance ,

During the December 1987 forced outage, various inservice tests were performed for the safety injection system pressure boundary check valves per Periodic Operating Test POT 2-6, Revision 6. In the performance of the tests, various motor operated valves were called upon to open and close under various degrees of system differential  !

pressur Five motor operated valves failed to travel to the fully closed position during testing. For these valves, a limit switch is i used to stop valve travel in the open direction and a torque switch ,

controls travel in the closed direction. It should be noted that valve exercising per ASME Section XI requirements for these five r valves had been performed using a different test procedure which did not impose system differential pressure on the valves during cyclin '

Valves, M08802 A and M0-8802 8, located on the safety injection l lines to the reactor coolant system hot legs, did not fully close i under differential pressure and were subsequently shut at lower  !

pressure after the safety injection pump was atopped. The licensee determined that these valves were not required to operate under  :

differential pressure, and committed to revise the procedure as appr*priat ;

i Vaive MO-8835, located on the safety injection line to the reactor coolant system cold legs, did not indicate fully closed when shut  ;

under differential pressure and was subsequently closed at lower l

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pressure af ter the safety injection pump was stopped. MO-8835 is '

required to operate under system differential pressure. The l licensee determined that the apparent cause for the failure of the valve to fully close was lack of adequate lubrication of the valve ste The valve stem was lubricated, and, as an added precaution, the torque switch setting was raised to increase margin. The j inspectors reviewed the vendo* technical manuals for lubrication frequency requirements. Aside from directions to lubricate the I

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valve stems upon valve reassembly following work on valve internals, no rpecific, lubrication requirements for valve stems were foun ;

Thr, inspectors reviewed the licensee's current preventive  !

maintenance program for lubrication of valve stems. Valve stems in che valve packing area are lubricated whenever the valve packing is replaced. Valves at Trojan are repacked during refueling outages '

either on a one, three, four, or five year cycle basis. The five motor operated valves mentioned above were on four or five year ,

schedules. The portion of the valve stems which engage the motor '

operator drive sleeves are lubricated on a three year basis as part of the routine preventive maintenance performed on motor operator In view of the failure of MO-8835 to fully close, the licensee has committed to evaluate the lubrication requirements for motor operated valves by Harch of 1988. The inspectors will follow licensee actions in this area, particularly for those valves which are cycled only under cold shutdown conditions in the inservice testing progra (0 pen Item 50-344/87-44-03). '

For the remaining two valves, M0-8801 A and MO-8801 B, located in the centrifugal charging pump discharge line (safety injection into reactor coolant system cold legs), the valves failed to fully close I under differential pressur The licensee's evaluation determined [

that the torque switch settings did not provide adequate margin to !

, ensure closure under differential pressure condition The torque switch settings were raised following discussions with the valve vendor which establishea that higher thrust settings were ,

acceptable. The failure of the above motor operated valves to fully !

close had no immediate safety significance because the facility was I in Mode 5 which does not require safety injection system i operability. In the event these valves failed to fully close, while in a higher mode, operators indicated they would have isolated j redundant valves. The licenr,ee committed to a review of the torque switch settings for other valves which are required to operate under !

differential pressure and to reset the torque switches as required

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in the upcoming refueling outage. At the exit meeting held on .

< January 7, the inspectors noted that the licensee's December 15, !

1987, submittal in response to IE Bulletin 85-03 may need to be

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revised or supplemented in light of the events described above. IE ,

Bulletin 85-03 dealt with common mode failures of motor-operated i valves during plant transients due to improper switch settings, i Licensee management stated that a supplement or revision will be l issued. Licensee actions will continue to be evaluated in the i follow up of IE Bulletin 85-03 and Temporary Instruction 2515-7 ;

No violations or deviations were identifie Followup on Licensse Event Reports (LERs) and Open Items LER 87-17 (Closed) Control Room Penetrations Leaking - The licensee ;

tested the Cable Spreading Room Smoke Exhaust System (CSRSES) to verify l the integrity of the refurbished control room boundary and the emergency t ventilation system. With the 'B' emergency ventilation system and the l C5RSES in operation, control boundary pressure was maintained greater !

than technical specification requirements of 0.125 inches of wate I i  !

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., l LER 87-21'(Closed)' Incorrect Fuse Drawer Opened Resultina in112.47 Kv Bus

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Undervoltage - EDG Star The licensee attributed this event to a

combination of personnel errors and procedural deficiency.. The personnel,

errors were due to giving inadequate direction to an operator and .the . *

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operator continuing an evolution with which he' had insufficient knowledge'

to perform. The procedural deficiency was.that'no detailed procedure

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! existed for the evolution being conducted. To correct these,- the licensee counselled both personnel involved on the need to better

! communicate expectations and understanding. Also,- a detailed procedure '!

! is be1r.g prepared to provide instructions on' potential transformer fuse-F replacement. . Additionally,.two human factors improvements will be made - l fuse storage in the_ vicinity of the cabinets and a policy on-as-left . l j

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panel conoition when fuses are removed. All actions will be completed by

April 1, 198 The actions'have been added to the licensee's commitment  :

i tracking lo j

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) LER 87-23 (Closed)-Reactor Trip an High Steam Generator Level and i

! Feedwater Msolation - The licensee oetermined that the event was caused l i: by an out-of position, manual handwheel on a feedwater regulating valv ;

The licensee verified that vibration was not the cause of the j out-of position handwheel.- Reoccurence of the event will be prevented by j d installing locking devices on the handwheel. Further, in order to assure '

l that operators have easy indication of when the handwheel is~in'the- l 1 proper (neutral) position, the licensee plans to disassemble one of the  :

handwheel assemblies to determine equipment conditio ;

1 LER 87-24 (Closed) Turbine Trip and Reactor on High Steam Generator Water  ;

Eeve The licensee attributed this event to cognitive personnel error  ;

, and identified slugg5sh operation of the 'C' feedwater regulating as a $

i contributing cause. The control operator, who had the procedure ope :

l failed to note the automatic speed controller of the south main feed pump i j was not in manual or the govenor switch at minimum as required. The j j operator was counselled on the need to be more deliberate and disciplined l j in operation and attentive to detai ,

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l Subsequent to the event the inspectors evaluated the quality and uer i friendliness of the procedure. The procedure, in one case, required the

repositioning of a drein valve which was titled correctly but not 3

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j referred to by the correct nutbe Additionally, based on discussions ,

{ with several operators, the inspectors concluded the procedure should be- I

, revised to contain more detail for the turbine startup. The valve error i

! was immediately corrected by a procedure deviation. The procedure will l I

be revised as part of the Procedure Improvement Progra :

i The sluggishness of the 'C' FW regulating valve, which was also a I l contributing cause of a previous turbine trip (LER 87-23) but not

recognized, was detert.ined to be due to the valve control system l 1 electronics problem and was subsequently repaired. The quality of event i

! reviews is an open item from a previous inspection (87-40-03). I f

l 87-40-04 (Closed) Nuclear Enthalpy Rise Hot Channel Factor (Fm). Through further analyses of the technique in determining F t

determined, by reevaluating measurement uncertaintIe,s,he-11ceHsee that F was not j actually exceeded. Additionally,thecauseofapproachingthIF g IW

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was concluded to be due to the mirror ~ image exchange of eight fuel assemblies in the last refueling and not due to extended low power operation. In the event report the licensee commited to minimize th" exchange of assemblies that have abnormally large burnup gradients. When exchariges of this type are abso'lutely necessary, the margin to thermal limits will be maximized to the extent possibl (0 pen) Event Report Followup Corrective Actions Insufficient to Prevent Recurrence. In reviewing Trojan event report 87-093, the inspectors noted the cause of the event could not be determined because clearance sheets are not retained and the maintenance request for removal of a plant component could not be found. The inability to reconstruct plant events due to not retaining clearances has occurred in the past and has been a topic of concern expressed by the resident inspector Additionally, ANSI 18.7, Quality Assurance of the Operational Phase of Nuclear Power Plants, which the licensee has committed to portions of, requires records be retained so that significant plant events can be reconstructed. Without the retention of clearance sheets it is doubtful that all plant events will be able to be reconstructed and causes of the events identified and corrected. The inspectors sampled seven nuclear facilities across the country to determine the practice of retaining records of clearances. All the facilities sampled retain clearances for a minimum of six months. The inspector informed the licensee that discarding clearances after tags are removed should be reconsidered. The licensee, in a telephone conversation on January 26, 1988, committed to retaining closed clearance sheets for one yea . Exit Interview l

The inspectors met with the licensee representatives denoted in paragraph 1 on January 7,1988, and summarized the scope and findings of the

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inspection activities.

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