IR 05000344/1989009
| ML20247C171 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 08/22/1989 |
| From: | Kirsch D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20247C147 | List: |
| References | |
| 50-344-89-09, 50-344-89-9, NUDOCS 8909130265 | |
| Download: ML20247C171 (39) | |
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U. S. NUCLEAR REGULATORY COMMISSION
REGION V
Report No. 50-344/89-09 Docket No. 50-344-License No. NPF-1 Licensee: Portland General Electric Company 121 S. W. Salmon Street Portland, Oregon 97204 Facility Name: Trojan Nuclear Power Plant Inspection at: Rainier, Oregon Inspection Conducted: May 22 - June 9 and July 19-21, 1989 T
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P. Narbut, Sr. Resident Inspector W. J. Wagner, Reactor Inspector J. Burdoin, Reactor Inspector C. Clark, Reactor Inspector A. Hon, Resident Inspector Consultants:
J.' R. Houghton, Houghton Engineering J. T. Haller, Consulting Engineer D. L. Jew, Engineering Analysis Services Inc.
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F. Kirsch, yef, Reactor Safety Branch ITate Sighed Summary:
hsyectiononMay22throughJuly 21, 1989 (Report No. 50-344/89-09)
Areas. Inspected: A special, announced team inspection to assess the effectiveness of the licensee programs in identifying and correcting design related plant vulnerabilities. Specifically, the team examined the licensee's Self-Safety System Function Inspection (SSFI), licensee progress in design basis document development, and progress in specific committed improvements in the engineering area. Inspection Procedure Nos. 30703, 35702, 37700, 37701, 37702, 41400, 41701, 42700, 56700, 61700, 61725, 61726, 62700,
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62702, 62703, 62704, 62705, 71707, 71710, 92700, 92701, and 92720 were used as I
guidance for the inspection.
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Results:
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General Conclusions Licensee's Self SSFI The NRC inspection team concluded, as did the licensee, that the licensee's self-SSFI was limited in scope, was a first-of-the-kind effort, and did not have extensive, direct licensee involvement. At the time of the inspection the licensee had not yet developed a plan of action for specific changes but acknowledged that a second self-SSFI would be conducted with more direct licensee involvement. The licensee was still dealing with the self-SSFI findings but had documented Justifications for Continued Operation for the more significant findings.
The NRC team found that, although the self-SSFI had determined valid and important findings, the NRC team was able to find additional unaddressed problems. Examples included omissions en calculations, ventilation supports installed differently than the construction drawings and failures in recent PGE design changes to account for important design considerations such as the affect on vital bus and diesel generator loadings of adding new 480 volt motor loads.
These NRC findings lead to the conclusion that the licensee's current self-SSFI methods are not sufficiently probing and complete to ensure design vulnerabilities are understood and dealt with appropriately. The NRC findings also led to the broader conclusion that the licensee's present efforts to reconstitute the existing design basis will not be sufficient to uncover absences and errors without a more systematic and comprehensive approach to verify design basis adequacy.
Design Basis Documents The team found the licensee to be progressing in accordance with their schedule for the development of design basis documents. As noted above, the effort appeared to be limited to reconstituting available information and dealing with open items, but without a systematic evaluation and verification of the information collected. The licensee was noted to have undertaken some limited design basis verification activity, such as the one self-SSFI and some calculation reviews by contractors, but the findings indicate a more systematic and comprehensive approach is required.
Progre:s in Specific Programs The team found that the licensee had made progress and improvement in the specific programs examined such as the technical manual update program and the drawing control program. The team identified specific problems in these programs such as the li g.see's technical manual update program
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focused on updating existing technical manuals but did not identify the fact that there were missing technical manuals. Likewise, in the drawing control program the licensee program focused on ensuring the latest issued drawings were maintained at controlled drawing stations but did not identify the fact that certain important drawings for newly added ventilation systems had not been developed and provided in a timely manner.
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P general, the team concluded that.anagement programs for improvement
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are focused too narrowly.to ensure that the general area was functioning properly.
Summary of Violations and Unresolved Items One violation was identified dealing with incomplete consideration of the
effects of a design change which added a supplemental cooling system to the control room ventilation. The violation involved failure to properly perform technical specification surveillance testing (paragraph 5.c.7).
One violation was identified, invceiving several examples of licensee failure to follow procedures for engineering calculations (paragraphs 5.a.3,5.b.3)a,and5.b.3.)b).
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Additionally, three violations were identified dealing with incomplete actions for design change which replaced vital inverters. Specifically, failure to issue a nonconformance report for inverter frequency instability (paragraph 5.a.4), failure to calibrate the inverter instruments (paragraph 5.e.3) and failure to change an emer procedure to reflect annunciation changes (paragraph 5.d.1)gency
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The addition of the supplemental control room cooling also resulted in an unresolved item (paragraph 5.c.1) regarding whether the change was an unreviewed safety question.
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DETAILS 1.
Persons Contacted a.
Portland General Electric Company i
+*D. Cockfield, Vice President, Nuclear
+*A. Roller, Manager, Nuclear Plant Engineering
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- R. Steele Project Engineer, Design Basis Documents
- G. Zimmerman, Manager, NSRD i
- J. Willson, Acting Manager, Radiological Safety
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- T. Walt, General Manager, Technical Functions
- J. Benjamin, Audit Supervisor
+*D. Nordstrom, 0A Manager
- D. Swan, Manager Technical Services
- W. Williams, Regulatory Compliance Engineer
+*S. Bauer, Branch Manager, Nuclear Regulation
D. Bennett, Branch Manager, Maintenance M. Cooksey, Supervisor, Electrical Maintenance i
R. Fowler, Supervisor Maintenance Support
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P. Ryan. HVAC System Engineer S. Johns, Inverters System Engineer D. Connelly, Records Clerk M. Malmros, Supervisor, Instrumentation and Control Maintenance M. W. Hoffman, Mechanical Branch Manager L. G. Dusek, Nuc~ lear Regulation Branch Supervisor G. E. Mitchell, Mechanical Branch Supervisor
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B. Kershul, NSRD
+J. Guberski, Regulatory Compliance Engineer
+R. M. Nelson, Manager, NSRD b.
Bonneville Power Association B. Mazurkiewier, Chief, Operations Branch c.
- R. Barr, Senior Resident Inspector, RV
- R. Bevan, Project Manager (Trojan), NRR
- J. Burdoin, Reactor Inspector, RV
- A. Chaffee, Deputy Director DRSP, RV
- C. Clark, Reactor Inspector, RV
- J. Haller, Inspector / Consultant j
- C. Haughney, Chief, Special Inspection Branch, NRR
- A. Hon, Resident Inspector, RV
- J. Houghton, Inspector / Consultant
- D. Jew, Inspector / Consultant
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- M. Mendonca, Section Chief, RV
+*P. Narbut, Inspection Team Leader
- C. VanDenburgh, Senior Operational Engineer, NRR
- W. Wagner, Assistant Inspection Team Leader
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Indicater attendr * at June 9,1989 Exit Meeting.
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Indicates attendance at July 21, 1989 Exit Meeting.
2.
Inspection Objectives This team inspection was conducted to assess the effectiveness of the licensee programs for identifying and correcting design related plant vulnerabilities and program weaknesses relating to engineering activities.
In this assessment the following elements were examined by
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the team:
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a.
The team examined the licensee's self-SSFI performed in December 1988 to assess the effectiveness ef the licensee's approach both in identifying and resolving design related vulnerabilities. The NRC review independently examined the same two systems examined by the licensee's contractor; specifically the Control Room emergency heating and ventilation system and the 120 volt AC preferred power system.
b.
The team evaluated licenser progress in specific pregrams which the licensee had committed to improve. These included 'he technical manual update program, the drawing update program, the update of specific design documents such as the valve / material list and the 0-list, and the program to improve engineering procedures.
3.
Inspection Results a.
Effectiveness in Identifying and Correcting Design Vulnerabilities 1)
Weaknesses in the Identification of Visually Apparent Design Problems by Plant Personnel During a walkdown on May 23, 1989, of the emergency ventilation system for the control room, system CB-1, the inspector noted a ventilation support which did not appear to be properly installed. Specifically, the support for train B make-up air to CB-1 had a support for the make up duct which appeared to be designed to rest on the CB-1 filter housing. The support as observed was not in contact with the filter housing except for one toe of the support plate, which was embedded in the epoxy coating of the filter housing. The remainder of the support plate was not resting on the filter housing (as appeared to be I
the design intent) and formed a gap between the support foot and the filter housing of about 1/2 inch.
The inspector requested the licensee to determine if the observed condition had been noted and evaluated by the licensee. The licensee representative responded on June 7, 1989, that the condition had not been noted previously, that a i
drawing for the support did not exist, and that the licensee had consequently written a nonconformance report (NCR 89-223 dated May 31,1989).
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The licensee's'avaluati on the NCR determined that cont...aed use of the support was acceptable since the unit was in Mode 5
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and technical specifications at that time did not require CB-1
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operability until Mode 4.
The licensee imposed a Mode 4 entry J
restraint until the adequacy of the support could be
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determined.
The licensee's imediate actions in response to the inspector's findings appeared to be appropriate. The licensee did not-resolve the corollary concerns of (1) absence of a drawing for the support and (2) the reason for not self-identifying the-condition prior to the NRC observation.
Further discussion with the licensee on June 14, 1909, indicated that the licensee would address the absence of a drawing for the support in conjunction with another NRC identified issue (section 5.b),
dealing with a walkdown of all CB-1 supports to reconcile as-built conditions with design drawings. The licensee further stated that the question of the lack of self-identification of the support would be, addressed in the nonconformance.
At a meeting with the licensee on June 8, 1989 the inspector questioned licensee management regarding the programs they had in place that would identify such deficient conditions which could affect proper design basis implementation. Licensee management stated such deficiencies should be identified by system engineer walkdowns and that obvious deficiencies could be identified by any member of plant, engineering, or management staff.
The inspectors noted that other NRC findings such as:
the lack of calibration stickers on Inverter Y-26 (section 5.e.); the identification of auxiliary building (doors which affect control room positive pressure capabilities section 5.f.); coupled with the licensee's self-SSFI findings, such as the absence of filter housings for volcanic ash on the CB-1 make up ducts, the lack of calibration of room cooler unit manometers, the lack of complete corrective action for room cooler water side silting and corrosion, and the lack of maintenance on room cooler filters due to excessive dirt loading, are all indications that personnel involved in plant operations are not effectively identifying and resolving visually apparent discrepancies which may affect plant design assumptions. Licensee management committed to address needed actions to increase the recognition and evaluation of visually apparent problems in their response to this report.
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2)
Weaknesses in the Correction of Identified Design Challenges The SSFI Follow-up Inspection Team reviewed the licensee corrective action programs applicable to correcting design vulnerabilities. Theseprogramsincluded: NCRs/NCARs generated as a result of the licensee s Self-SSFI; the CB-1 Action Plan and Justification for Continued Operation (JCO) 88-17 (instituted for Control Room Emergency Ventilation System
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CB-1); engineering procedures (Pr1 :dures Improvement Program);
Licensing Commitment Tracking List; and the design basis document DBD Calculations Update program.
Certain weaknesses were identified in corrective actions related to NCRs/NCARs
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generated by the Self-SSFI and/or identified by the team in the course of this follow-up inspection. These weaknesses are detailed in Section 5 of this report.
The team's review of design related NCRs/NCARs determined that the scope and completeness of disposition of these NCRs/NCARs was less than complete in some areas. Among these disposition inadequacies were:
lack of recognition of the fact that a roof mounted chiller (CB-16) could act an a hazardous tornadic missile to the emergency ventilation system CB-1 (NCR 88-608);
'and inappropriate cancellation of an NCAR by Quality Assurance personnel without recognizing, addressing and resolving the problem.
The team identified several instances where the licensee failed to identify significant engineering oversights.
Included in this category are the following:
Failure to account for the effect of adding motor loads on
the 480V system and Emergency Diesel Generator System for recent design changes.
Failure to identify and resolve inverter output
requirements which differ between the DBD/NSSS Supplier specifications and the Vendor (ELGAR) technical manual.
b.
Assessment of Design Basis Document (DBD) Program The team reviewed the Licensee Design Basis Documents (DBDs) for the Control Building Ventilation Systems (DBD-30) and the 120-Volt Preferred Instrument AC System (DBD-57), including DBD Backup Files, DBD Open Items List, DBD Calculation Update Program, DBD Procedural Control, and DBD adequacy to reflect the Design Basis of the systems reviewed. The team determined that the licensee program was progressing in accordance with their plans but that certain areas
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for needed improvement were evident (eg: program for timeliness of I
update, methods of identifying Open Items, DBD Calculations Update.
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These areas for improvement, detailed in Section 5. of this report, are as follows:
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Timeliness of Update i
The team's review of the design basis document for control room l
ventilation (DBD-30) major modifications to the Control Building Ventilation Systems had been completed during the 1988 outage, but
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l revision of the design basis document had not been accomplished.
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DBD Calcul'. tion Update The present PBD Calculation Update Program is limited to review and evaluation of a sample of calculations for the DBDs. Although the team's review of this program determined it to be adequate in methodology and content, the limitation of scope to existing calculations only may be inappropriately narrow. No inclusion has'
been made to this program for evaluation of new calculations for the app 1 5 ble systems.
Inclusion in this program of new calculations or calculation updates, was indicated and identified as necessary in l
Self-SSFI corrective action dispositions (NCRs/NCARs).
DBD Program Scope i
The overall list of DBDs was reviewed by the team for completeness.
The team identified that the licensee did not have plans for any generic DBDs, such as Cable and Raceway Systems or concrete anchor bolts. The licensee comitted to study and address the need for such generic DBDs in response to this report, c.
Adequacy of the Licensee Self-SSFI The team reviewed the licensee's self-SSFI for the Control Building Ventilation Systems (System 30) and the 120-Volt Preferred Instrument AC System (System 57). The team noted that this was the licensee's first such endeavor and that the licensee plans to do another self-SSFI in 1989.
d.
Progress in Specific Programs 1)
Technical Manual Update The Technical Manual Update Program was controlled by three (3)
governing procedures. They are as follows:
Procedure No. Rev. No. Title NDP No. 100-3
Technical Manuals
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NDEP No. 200-2
Technical Manual Task Force Updating of Technical Manuals NPEP No. 200-2
Technical Manuals The NRC team reviewed the above mentioned procedures and determined that proper implementation of these procedures would
account for a sound technical manu6l update' program. They were thorough and provided sufficient guidance to accomplish their goals (i.e. adequately update PGE's vendor technical manuals).
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2)
Drawing Updates The licensee's drawing update program was discussed with the licensee.
Responsible management personnel outlined their
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status as having performed walkdowns and drawing updates for all safety related systems. They indicated the current effort was to validate all vendor drawings and upon validation,
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convert the drawings te PGE drawings. All drawings are being completed using computer assisted design (CAD) methods.
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Approximately 10,000 drawings have been completed, with approximately 120,000 balance of plant drawings remaining to be done. The licensee considered the accuracy of drawing
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distribution to be good based on periodic Quality Assurance l
audits. The licensee stated that distribution of drawings was l
slow, taking two to four weeks, but that control room distribution was prompt. The licensee was working toward
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i computer drawing availability to make information available
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more quickly.
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3)
Maintaining Design Documents for Site Use The inspector examined licensee progress in specific programs such as the safety related equipment list and the valve list.
Regarding the safety related list, the licensee recognized the lack of accuracy in the list in 1987 and contracted outside assistance to generate a computerized listing. That effort was completed in the beginning of 1988, however the contractor had
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identified on the order of 1000 open items. The licensee's action plan to resolve these open items continues with one
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engineer assigned to the task full time. The licensee has procedures in place to control the safety related list. The licensee is actively considering generating a second list, the
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Quality-Related list for such areas as Fire Protection and Security equipment. The licensee has commenced a spare parts program for the dedication of parts for safety related applications. The program was initiated in late 1988 and completion is targeted for 1992.
In regards to the licensee's valve list program, the initial revision of the valve list was issued in 1988 and was finished in 1989. Tin list was generated by an outside contractor from records and from an uncontrolled list maintaine.d by site maintenance personnel. Maintenance performed a walkdown to detennine the actual item installed in those instances where information was missing. The licensee did not perform a walkdown verification of the list accuracy. During the discussion, the licensee committed to perform at least a sample verification of the valve lists accuracy. The licensee's verification of their valve list accuracy is an open item (5'0-344/89-09-01).
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4.
Plant Material Condition The inspection team conducted a walkdown of the plant and noted that the plant material condition appeared well maintained. Lighting was good, pump skids were painted and clean, there was a notable absence of boron j
accumulations, and temporary pressurized bottle gas was soundly secured to structures. Although closer examination of specific areas identified
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some maintenance concerns, the overall appearance of the plant equipment
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and spaces indicated care and attention to equipment spaces.
5.
Specific Examinations a.
Electrical Design The team examined licensee progress on electrical design basis j
documents, the licensee's self-SSFI findings, and the licensee's actions in response to the findings.
1)
Design Basis Documents in the Electrical Area
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The inspector noted that the design basis documents for the 480 I
volt Load Center and 480 volt Motor Control Center systems were not scheduled for issue until 1990 in accordance with the licensee's schedule. The inspector noted that design basis documents for these systems were important and that earlier preparation would appear to be warranted.
The inspector also noted that the licensee did not have a design basis document for raceway systems.
In a conference held on July 21, 1989, the licensee agreed to consider whether such a design basis document should be generated and to provide the rationale for their decision in response to this report.
2)
Evaluation of the Licensee's Self-SSFI Findings The inspector reviewed the self-SSFI findings in the electrical area and licensee corrective actions. The inspector found the licensee's findings and actions to be generally complete and acceptable.
3)
Engineering Use of an Unverified Assumption in a Design Change Calculation The inspector reviewed a significant design change (RDC-86-031)
which replaced vital AC inverters in 1987 and 1988, and also changed their source of DC power.
Specifically, the inverters that supply Class IE power to the 120 volt Preferred Instrument AC system were replaced by units
of a different design and manufacturer. The original units took primary power from the 480 Volt system and backup power from the 125 Volt DC system. The new units take primary power from the 125 Volt DC system and backup power from the 480 Volt
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system. The inspector reviewed the licensee's design study and noted that the licensee's design change process did not identify that important calculations were based on assumptions which were unverified and in error. The licensee's use of unverified assumptions in their calculation is contrary to the licensee's procedure and an apparent violation (50-344/89-09-02).
4)
Actions to Deal With a Potentially Significant Problem With New Inverter Performance In reviewing the licensee's design basis document for the 120 volt preferred AC power, the inspector noted two licensee identified problems recorded as design basis document open items (licensee open items 57-1-01 and 57 ~r 02). The first problem dealt with post-installation frequcncy swings on the inverter output greater than the design oasis of 60 Hertz plus or minus 1%. The second problem dealt with the fact that the vendor's statement of output voltage tolerances was different than the design basis document required output voltage tolerances. The licensee's design basis document output voltage tolerances were based on the NSSS supplier requirements.
In both cases the inspector considered that the differences in inverter output frequency and volt, age might affect the performance of safety and balance of plant instrumentation from an accuracy and actuation standpoint. The inspector also considered the licensee action in dealing with this problem was not sufficiently timely given the importance of the issue.
The licensee was requested to commit to a completion date for technical resolution of the frequency and voltage differences and to provide a technical assessm,ent of the impact on instrument performance. The failure to determine the technical acceptability of the inverter voltage and frequency swings is contrary to the licensee's procedures for nonconforming conditions and is an apparent violation (Item 50-44/89-09-03).
During discussions held on July 21, 1989, the licensee stated that their initial technical assessment of the impact of the
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inverter frequency and voltage swings indicated that there was no technical consequence.
5)
Analysis of the Safety Impact of 480 Volt Motor Load Additions
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The inspector reviewed the design change which added a supplemental cooling system (CB-16) to the control room ventilation system. The design change was numbered RDC-86-045 and was physically accomplished in 1988. The design change added electrical loads to the vital 480 volt systems and motor control centers including two 20HP compressor motors, two 15HP fan motors, two 2HP condenser fan motors and two 2HP circulating pump motors.
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The licensee's engineering staff had not performed a study of the impact of these additional loads on the 480 volt bus loading or the emergency diesel generator loading which could impact the operability of these vital systems. This is considered an additional example of licensee failure to follow
' design change procedures, as discussed in paragraph 5.a.4 above.
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In response, the licensee provided analysis and justification for the additional loading and supplemented the design change record. The justification was provided in memorandum JLH-0003-89M, dated June 2, 1989. The licensee also committed to revise the calculation of record for loading (TE-124) by September 1, 1989. The licensee advised the inspector that the load additions were made by engineering judgement and that ;ne
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licensee's long term plan to maintain an assessment of future
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additional loading was a computer program which was being prepared and was scheduled for implementation by the end of 1989.
Findings (4) and (5) above, involve basic fundamentals which should have been addressed by the ifcensee at the time the design change was implemented and likewise should have been noted in the self-SSFI review of this design change.. The NRC team concluded that the licensee's design change process needed further improvement to identify such fundamental oversights.
Furthermore, the licensee's self-SSFI methodology requires improvement to increase the focus for identification of this type of oversight, b.
Mechanical / Structural Design
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The inspector examined civil engineering calculations which had been reviewed for PGE by TENERA Corporation. The TENERA review was part of the licensee's action plan to assess the adequacy of their existing design basis calculations. The inspector also examined the licensee's self-SSFI findings in the civil area and the technical manual update program.
1)
Design Basis Calculation Review Ac. tion Plan The inspector's review concluded the licensee's sample of design basis calculations was a worthwhile effort in identifying potential design vulnerabilities and should be continued.
2)
Vendor Technical Manuals The inspector's review concluded t" hat licensee actions to improve the updating of vendor technical manuals appears to be effective and should be continued.
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3)
xamination of Licensee Structural Calculations a) Improper Concrete Anchor Bolt Factor of Safety The control room emergency ventilation (C8-1) requires makeup air. The roof mounted makeup air structure was moved by design change RDC 86-021. The revised structure was required to be qualified for seismic and wind loads since it was a portion of CB-1, which is a safety-related system. This qualification was performed urder calculation no. TC-351, "CB-1 Intake Pipe at 4 Supports RDC 86-021," dated 6/17/86. The inspector reviewed the a
calculation for technical content and adequacy, design inputs, and conclusions. Technically, the calculation was found to be acceptable and all proper design inputs were utilized; however, there was a problem with the final
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conclusions of the calculation.
When checking the concrete anchor bolts, a maximum load of
4215 lbs was calculated for the bolts. This load was then
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compared to the allowable concrete anchor bolt load of k.
2880 lbs and identified as being overstressed. At this e{ j point, the calculation failed to either justify this allowable stress condition or go through another iteration i
of the calculation to lon.er the maximum anchor bolt load to less than the allowable of 2880 lbs. What the calculation did do was show that, based on the load of 4215 lbs and an allowable load of 2880 lbs, the factor of safety for the anchor bolts was now 2.7 instead of a gvq factor safety of 4.0 required by NRC IE Bulletin 79-02 and g
committed to by the licensee.
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concrete anchor bolts is considered an apparent violation (Item 50-344/89-09-04).
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requirements for a factor of safety of 4.0 were clearly understood and expressed in the calculation, discussicn u
with the licensee representatives identified that there is no design guide, or equivalent document, available to establish designer requirements for concrete anchor bolts.
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During post inspection discussion with the licensee on July 21, 1989, the licensee committed to include in their response to this report a discussion of the availability of appropriate design guidance such as design manuals or design guides generally used by designer organizations.
b)
Failure to Account for Wind Loads The inspector reviewed the following calculations for technical content and adequacy, oesign inputs, and conclusions:
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Number Revision No.
Title TC-496
CB-1 Fan Coil Unit Supports
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TC-508
Roof Mounted Chiller Support for CB-1
TC-514
CB-16 Duct Supports L
Calculations TC-496 and TC-514 were found to be technically acceptable with all proper design inputs utilized and conclusions justified. Calculation TC-508 was technically sound; however, the inspector identified a problem with the design inputs utilized, as explained below. Because all proper design inputs were not used, the design conclusion, could not be fully justified.
The CB-16 HVAC system is not classified as safety-related; therefore, it does not have to be Seismic Category I design. Nonetheless, Calculation TC-508 checks the l
adequacy of the CB-16 chiller support for seismic loads.
However, the calculation neglected to check the adequacy of the chiller supports for both the design basis 125 MPH wind loads or tornado winds of 300 mph. Even though CB-16 is not currently considered safety-related, the integrity of the supports must be adequate.to preclude the chiller unit itself from becoming a missile object during wind and tornado loadings and causing damage to a safety-related system (i.e.CB-1intakestructure).Thisrequirementhas not been demonstrated in the calculation.
The above concerns were discussed with the licensee. The licensee explained that CB-16 was not currently safety-related, but would probably be upgraded at a later time. The system was not and could not be designed for tornado wind loads of 300 mph. The intended design basis wind loads were intended to be 125 mph, but, these were
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apparently not accounted for.
i The tornado wind loads of 300 mph were applicable to the emergency control room ventilation system CB-1 and i
equipment in the immediate vicinity that could become a l
damaging missile. The licensee understood that CB-16 would not meet current NRC general design criteria requirements i
for consideration of tornados. However, the licensee was conducting a probabilistic risk analysis to justify not designing for tornado winds. This was being done to eventually classify CB-16 as safety related (with NRC approval). Consideration of the CB-16 chiller units as a potential damaging missile to the CB-1 system had not been addresse _
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The inspector, in di ussion witi licensee representatives suggested that the procedure for safety evaluations (Procedure 100-5 Revision 4) should be reviewed for improvements and that the licensee might consider reviewing a sample of past safety evaluations for similar omissions. The licensee was requested on July 21, 1989, to consider these suggestions in their response to the apparent violation. The licensee has issued a major revision to the procedure for safety evaluations which has made significant improvements to recent safety evaluations.
Qualification and training for cognizant personnel has been performed.
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The failure to include wind loads for the CB-16 chiller supports to demonstrate that the units would not become a damaging missile to the CB-1 system is considered an apparent violation (Item 50-344/89-09-05).
While reviewing the drawings of the recently modified ventilation in the control room; the inspector found that Drawing M-244 Sheet 1, " Heating, Ventilating and Air Conditioning Control Building Air Flow Diagram," Rev. 29, i
did not include CB-16, nor a Design Change Notice (DCN) to
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reflect the current configuration.
In response to the inspector's finding, the licensee issued a DCN to Drawing M-244 on May 25, 1989 to include CB-16 as the current plant configuration.
c)
Ventilation Duct Supports
The CB-1 HVAC system is classified as safety-related and seismic class I (SCI) per section 3.1, " Seismic Criteria" of DBD-30, " Control Building Ventilation Systems." The safety-related portions of the CB-1 system must be designed, constructed, and maintained to SCI requirements in accordance with paragraphs C.I.n and C.1.g of Regulatory Guide 1.29.
The inspector performed a review of the calculations for the supports for the CB-1 HVAC system. There were two generic support types which applied to this system; they are the types I-2A cnd I-23. Only two pages of the original calculatican performed in the early 1970's, pertinent to these two support types, could be retrieved by PGE. Upon inspector review, it was determined that these calculations were insufficient to qualify the supports due to a lack of technical content (i.e. checking stresses for anchor bolts, welds, and baseplates) and the uncertainty as to whether the existing supports in the field conform to the original design drawings. PGE
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concurred with the NRC finding and committed to generate
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calculations qualifying these supports and make them available for review.
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During the course of gereratirr the calculations, PGE performed a walkdown on some HVAC supports to determine whether the "as-builts" conformed with.the support design drawings. The walkdown identified that several co:' figuration discrepancies existed; including missing crcss-bracing rods, different size and number of concrete i
anchor bolts, smaller member sizes than those required by
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the design drawir:g, and missing welds. Due to the i
numerous discrepancies' identified by the PGE walkdown,
Nonconformance Report (NCR) No.89-228 was initiated on
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June 2, 1989. The NCR stated, "do not enter Mode 4 and suspend all operations involving core alteration or
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positive reactivity changes until adequacy of supports is de tenni ned.... "
Conversations with the Nuclear Plant Engineering (NPE)
Civil Engineering Branch Chief and Supervisor revealed that a plan was being developed to walk down all safety-
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related, SCI HVAC supports in the Control Building and then perform an assessment of each support to either (a)
verify the " operability" of the support or, (b) identify what modifications would be necessary to adequately qualify the support. The licensee committed that prior to returning to Mode 4, all Control Building HVAC supports which are classified as safety-related and SCI (CB-1 and other CB systems) will be analytically qualified and any necessary support modifications instituted.
It should be noted that Trojan Nuclear Station has been identified by the NRC as one of the operating plants which must review Unresolved Safety Issue (USI) A-46 (NUREG-1030, 1211),"SeismicQualificationofEquipmentinOperating Power Plants" and determine its applicability. Trojan has made a 4 year commitment to implement the requirements necessary to resolve USI A-46.
Implementation of this program will ensure that all other situations similar to the CB-1 HVAC supports (no backup documentation verifying adequacy) will be identified and resolved.
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On July 21, 1989, the licensee briefed the inspector on the results of their actions regarding ventilation supports. The licensee stated that during original construction the balance of plant constructor had subcontracted design and installation of the ventilation system and supports. The subcontractors design drawings for supports were "typicals" and not specific for each support. The licensee found about 25% of the supports were not per the drawings in a total CB-1 population of about 50 supports. The licensee reperformed calculations and performed modifications to the unsatisfactory supports. The current supports meet operating basis and safe shutdown basis earthquake criteria. Five of the as found supports would not have met safe shutdown earthquake criteria but due to the conservative nature of the calculations methods used, licensee engineers considered that the ventilation system would have remained functional.
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The lir 'see performed inspection and cor' ction of all other safety related ventilation systems as well.
l In light of the licensee's findings and actions, the inspector discussed the point that this case study clearly showed the apparent need for greater licensee attention to identifying design basis vulnerabilities through a more intensive problem identification program than they appeared to have in place.
The licensee's response to this inspector identified problem was prompt and thorough. The fact that this problem area was not uncovered by the licensee's design basis document reconstitution program and the licensee's calculation verification program indicates that improvements in both programs are required. Licensee actions in this regard are requested in the cover letter of this report.
c.
Mechanical Systems Design The inspector for Mechanical Systems Design reviewed the licensee corrective action programs for effectiveness in identifying and correcting design vulnerabilities; assessed the Design Basis Document (DBD) for System 30 (Control Building Ventilation Systems),
including revisions applicable to this DBD; and evaluated the adequacy of the licensee's self-SSFI performed for System 30.
The detailed review included: the self-SSFI Report; DBD 30 and backup files; significant modifications to Control Building safety related HVAC systems, including applicable Safety Evaluations; calculations specific to self-SSFI and DBD 30, including DBD calculation update program portion for mechanical systems; HVAC flow diagrams and applicable logic diagrams; engineering procedures and selected corollary plant procedures; applicable FSAR sections and Technical Specifications; licensing correspondence, including reports applicable to control room habitability and CB-1 PRA for tornado winds / missiles, in-house regulatory guide positions, and recent licensing change amendments; and corrective action programs, including CB-1 action plan, Justification for Continued Operations, JC0 88-17, self-SSFI generated NCR/NCAR program, DBD Open Items List for DBD 30; and Licensing Commitment Tracking List for System 30.
Although the licensee has exhibited strengths by early commitment and implementation of programs for procedure update, Design Basis a
Documents (DBDs), and self-SSFI, the team noted weaknesses in these programs where improvements could increase their effectiveness.
The specific details for the mechanical systems discipline findings and observations are as follows:
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1)
Incomplete Evaluations-3r Control Building HVAC System e.
CB-16 Modifications Unresolved Item The licensee had in the past made extensive modifications to the Control Building HVAC systems, as permitted by 10CFR 50.59.
Each modification included some form of safety evaluation, which evolved from a simple checklist (in the early eighties)
to the present comprehensive checklist and safety evaluation.
CB-16, as a supplemental HVAC system to enhance the Control Room cooling when the CB-1 operates, was included as a modification in Request for Design Change (RDC) No.86-045, Detailed Construction Package (DCP) No.s 11, 12, and 13.
The licensee's self-SSFI conducted in December 1988 identified that the supplemental control room cooling system CB-16 was not designed for and does not meet the requirements for tornado winds and missile protection.
The licensee dealt with this finding by issuing a Justification for Continued Operation which, in conjunction with other responses, indicated that the decision to not design for tornado winds and missiles was consciously made in the 1986 time frame and that the licensee considered the situation currently acceptable due to the low probability of a tornado in conjunction with a design basis accident.
The subject of whether the licensee should have submitted the design change to add supplemental cooling to the control room emergency ventilation system for NRC approval prior to implementation under 10CFR 50.59 was not established during the inspection. This matter is considered unresolved (Unresolved item 50-344/89-09-06).
Indecision of Safety Status of CB-16 The NRC review of this item concluded that the licensee's management actions in this matter were confusing. The licensee had described the system CB-16 as "somewhat safety related" at the teams arrival. The original design change described the system as safety related except for tornado and missile qualification. When the licensee's self-SSFI challenged the propriety of this description, the licensee's written response to their self-SSFI (reference: Trojan Nuclear Power Plant Safety System Functional Inspection Westec Report, dated February 1, 1989) stated, on page 7, that the NRC "was i
consulted" on this matter "and agreed." The team examination
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of this statement showed that the " agreement" referred to nothing more than a telephone call discussing possible design i
approaches. The team was concerned that PGE management
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approved such a preliminary unfounded response to an important self-SSFI finding.
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- u Licensee management, having made- "somewhat safety related
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a system" decision in 1986 and having stood by that decision in 1988, made a contrary decision' during the team inspection that
CB-16 was not safety related for the time being and would probably be upgraded later. This lack of clear direction reflected itself-in the plant staff dealing with the NRC team.
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The issue of.the design classification and the selection or rejection of certain design-criteria could have been properly-focused, decided, and processed in accordance with applicable licensing processes with clear and open communication with the NRC licensing organization.
It was not, and is the subject of the unresolved item earlier in this report.
When a second ' opportunity arose (in the form of the self-SSFI finding) to properly resolve the issue, licensee management
.again failed to focus on the issue and accepted the unsubstantiated rationale that the design decisions made on CB-16 had been agreed to by the NRC.-
On July 21,'1989, this issue was discussed with licensee management. Licmsee management committed to provide an analysis of the avents and identify any corrective' actions
- termined to be appropriate. ' The licensee's actions will be examined in a future inspection (Item 50-344/89-09-07).
2)
Engineering Procedures for Design Change Control and Safety-Evaluations
.The licensee has instituted an extensive program for-engineering procedures update applicable to modifications, e
including design change control, quality-related calculations,
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detailed construction package preparation and control, and preparation of safety evaluations.
.The team reviewed the significant Engineering design procedures applicable to modifications, including preparation and control of Request for Design Changes (RDC), with design inputs and calculations; preparation and control of detailed construction
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packages (DCPs); and preparation of safety evaluations. The inspector had some comments regarding the procedures which were offered to the. licensee for consideration. These comments are detailed below:
NDP 200-1, " Design Change Control": In accordance with paragraph 5.5, " Alternate RDC Process", an RDC may be written which encompasses a broad scope.
In those cases, specific Safety Evaluations are required for each DCP, in addition to the RDC. The use of this method requires prior approval of the Manager, NPE.
In accordance with this procedure, all such DCP Safety Evaluations must be reviewed and approved by the NPE Manager and the Plant Review Board (PRB) prior to issuing the DCP for construction; and by the plant safety review organizations
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(NSRD/TNOB) afterwards. This signifir- ' improvement was
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not used for RDC 86-045, with its multiple DCPs, and resulted in inadequate Safety Evaluations. Although the word " required" is used, prior approval is necessary by Manager, NPE. The procedure implies that this process
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will not be invoked without such approval. This process should be clarified.
Attachment B, " Request for Design Change", item II.
I includes a check for " Safety-Related" as "Yes" or "No",
but makes no differentiation for portions of systems which are safety-related or for multiple DCPs, within an RDC scope, which are either safety-related, nonsafety-related, or have portions that are safety-related. No instructions
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are provided in the procedure for determination of such l
classifiestion.
- Attachment B, item V.C. includes Yes/No checks for
" Regulatory Approval Required" and "Unreviewed Safety Question". No instructions are provided for this determination, especially where it may differ from the Safety Evaluation, nor are there instructions as to revision of this section when the Safety Evaluation differs.
- Paragraph 5.2 and Attachment D, " Design Input RecoiJ" (DIR) provides no specific instructions for calculations.
Inputs may be existing, unmodified calculations or revised /new calculations. Since no " Design Output Record"
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type document exists, the DIR appears to be the only RDC j
or DCP document which could include such information. No such listing was included for calculations in any of the Control Building HVAC modifications reviewed by the team.
Although calculation indices are utilized extensively by the licensee, this does not assure that calculations applicable to modifications have been reviewed, revised, or new calculations issued.
Attachmer.t F, " Detailed Construction Package" (DCP)
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Turnover Checklist provides no inc'usion for Design Basis i
Document (DBD) update. Such information should be available at turnover to assure timely update of DBDs.
NDP 200-4, " Quality-Related Calculations": There is no l
requirement to include calculations in the DIR for i
existing or revised /new calculations or alternately to include revised /new calculations in a " Design Output
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Index" type document (See Comment to Procedure NDP 200-1).
l There is no assurance that significant in-process calculations or revised /new issued calculations are
included in the DBD or in the DBD Open Items List.
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NPEP 200-14. " Detailed Construction Package Prep- -tion and Control":.The procedure does not provide specific instructions or requirements for the description of the DCP when it is part of a multiple DCP RDC. Such.
requirements, including boundaries of the DCP and interface or constraints by other in-process or planned DCPs were not identified in Control Building HVAC DCPs reviewed by the team.
Presently some DCPs, within a multiple DCP/RDC (i.e. RDC 86-045), have the same DCP_ number for both mechanical and
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electrical disciplines, with the latter identified as
"(Elect)" only. This may be confusing as work scope, boundaries, and interfaces differ with each of these disciplines and completion may occur at different periods or outages (upon proper review and approval).
When multiple DCPs are used for an RDC, and portions are safety-related, this procedure does not establish that Safety Evaluations are required for each safety-related DCP as normal practice, not as an option (see comments to procedure NDP 200-1).
- NDP 100-5, " Preparation of Safety Evaluations Required By 10CFR50 and Trojan Technical Specifications:" The procedure does not include guidance for when revisions to Safety Evaluations are necessary.
3)
Plant Administrative Procedures and Engineering Procedures The licensee has incorporated extensive changes to the plant modification process to assure complete documentation through construction turnover of installation and test and for as-built
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The inspector reviewed the Plant Administrative and Engineering procedures applicable to Turnover and as-built Packages and identified potential areas of clarification or improvement.
These were discussed with the licensee for their consideration as detailed below.
- NPEP 200-15. " Processing of ' As-Built' Packages": The " Top Document Listing, Attachment C", does not include safety-related HVAC system flow diagrams, although the sample "Affected Document List" (Attachment "D") does have
"HVAC Drawings" listed. The team identified that Flow Diagram M-244 hsd not been updated and a current revision, including new supplemental HVAC System CB-36, was not available in the Control Room in a timely manner.
'his procedure does not provide guidance for the timely sue of documents applicable to the update of the system L 3.
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4)
Design Basis Documents (DBDs)
The licensee has committed a Design Basis Document (DBD)
Program for plant systems, including " Generic" type DBDs, as applicable. Presently, thirteen DBDs have been issued with approximately forty-five in-process or planned over the next five years. These documents are prepared and controlled by Engineering procedure NDP 200-6.
The inspector reviewed the latest revision to this procedure (Rev.1), as well as proposed (Draft) Rev.2. The NRC had no connents regarding the format and content of the DBD's as this is a matter currently being reviewed by NRC headquarters personnel on a generic basis.
The inspector reviewed the implementation of the licensee's design basis document program and observed certain problem areas as detailed below:
Untimely Update The pending revision to the present DBD 30 for the Control Building Ventilation System has been untimely in its issuance. Consequently, updated infonnation has not been provided to design engineers, plant system engineers, and other plant personnel or organizations. Major design changes to the Contrcl Building HVAC systems, included in the 1988 and 1989 outages, are not reflected in this document, especially the major modification RDC 86-045 (Control Room Habitability Modifications). Licensee procedures allow delaying such an update until the
"As-Built" Package -(ABP) is completed, which appears to be inconsistent with the licensee's goal of a timely update and maintaining design basis documents as a "living documents."
- Multiple Problem Lists for DBD Problems The Open Items List, included as an Appendix to the DBD, is a listing of problem areas identified that affect the design basis document. The inspector noted that the licensee maintained several other lists of problem areas with design basis documents, such as required calculation i
update lists, NCR's and NCAR's, and licensing commitments.
The inspector considered that multiple problem lists may make it difficult for licensee personnel using the design basis documents to maintain an awareness of the problem or i
l question areas affecting the design. This information was offered to the licensee for their evaluation and consideration.
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Although the Licensee commitment and issuance of DBDs is a significant improvement, improvements can be made to assure timeliness of update, and user knowledge of problem areas.
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i 5)
Evaluation of The Licensee's Self-SSFI The licensee contracted an outside consultant to perform a self-SSFI for the Control Building Ventilation System (System 30) and the 120-Volt Preferred Instrument AC System (System 57). The licensee's contracted effort spanned a seven week period from data gathering until issuance of the draft report
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(Dec.,1988), of which four weeks included data gathering and onsite inspection, and three intervening weeks were for offsite
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analysis and report preparation. The final report was issued February 1,1989 and distributed by the licensee on February 9, c.
1989.
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The licensee's self-SSFI was the first such effort undertaken by the licensee. As such, it was a learning experience for the licensee, as was stated by licensee management. Despite the i
fact that the self-SSFI was limited in scope and suffered from
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a low level of licensee involvement, it identified many important issues of technical and management significance. The additional NRC findings discussed in the report indicate that, quite probably, additional design basis vulnerabilities remain to be uncovered. Consequently, the NRC team concluded that the licensee's efforts were a worthwhile beginning but in need of
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improvement to assure all significant design vulnerabilities
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were identified.
The SSFI Follow-up Evaluation Team's review of the scope and depth of the Self-SSFI identified the followi.ng weaknesses.
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The time span and human resources used in the licensee's l-self-SSFI was similar to an NRC SSFI. However, licensee self
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evaluations are ordinarily intended to be more comprehensive
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than the NRC's narrow slice approach. Despite the licensee's i
limited approach, significant findings were made indicating
that the licensee has significant improvements to make. The
additional NRC findings described in this report indicate the licensee's self-SSF1 was not sufficiently comprehensive to fully explore the safety system vulnerabilities.
Interaction between the inspection team and licensee was weak, as was readily stated by licensee management. The direct involvement of the licensee was limited to a OA coordination role. The licensee stated that interaction was limited due to an unplanned outage. Licensee management recognized the lack of interaction as a problem and stated future self-SSFI's would be improved.
6)
Evaluation of the Adequacy of The Licensee Corrective Actions Resulting from the Self-SSFI.
The licensee utilized the NCR/NCAR Program to record and resolve problems identified by the self-SSFI. The licensee also prepared a Justification for Continued Operation in response to the self-SSFI findings.
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In general, the team found the' licensee's recommended actions to be adequately defined. However, since problem' areas were
defined in December 1988, corrective action timeliness could be improved. An example, described in the maintenance section of this report, deals with the absence of vendor technical manuals; which the licensee has decided to obtain but has only assigned maintenance personnel to develop a list by July 1989 and hopes to obtain such manuals by December 1989.
One licensee response to a self-SSFI finding was clearly inadequate and involved the improper judgement and action of the Ouality Assurance organizations. The inadequate licensee response is described below.
Inadequate Licensee Corrective Action for a Self-SSFI Finding The inspector examined the findings of the licen:;ee's self-SSFI and noted one finding TR-0A-1, which dealt with the quality organization. Specifically, the finding was stated as "0C failure to perform a critical review of surveillance data."
The self-SSFI contractor had reviewed five data sheets for periodic test of overcurrent devices and found two of.the data sheets had errors. The SSFI contractor noted the data sheets contained an apparent QC sign off and concluded the OC inspector had missed the errors.
The licensee subsequently recorded the problem on a nonconforming activity report NCAR No. P88-266. The NCI.R was subsequently cancelled, with Quality Assurance approval, on the rationale that the SSFI contractor had misunderstood the meaning of the Oc signature on the data sheets. The DC signature (and the surveillance number following it) had only attested to the fact that the OC inspector had examined only a limited number of work attributes for a limited amount of time as was documented on the surveillance report.
The inspector discussed several points regarding the closeout of this self-SSFI finding and its NCAR with licensee management.
- Failure to Recognize and Deal With Apparent Ouality Problems The licensee review of the self-SSFI finding and closure of the NCAR P88-266 fails to recognize and resolve the readily apparent problem that if two of five data sheets had errors there are likely more errors which should be evaluated to determine the extent of the problem and resolve operability concerns.
Secondly, the fact that there were errors on the data sheets indicates that the existing system / procedure for quality verification is either not sufficient or is not functioning properly. This point was clearly made by the self-SSFI contractor as recorded in a J. W. McKibbon to G. E. Taylor memorandum dated December 23, 1988 (at the time of the proposed NCAR closure) but was not dealt with by the license _
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Failure to Assess the Root Cause The inspector questioned the root cause of the data entry errors and, through review of the licensee's procedure for functionally testing molded case circuit breakers and overload relays (Maintenance Procedure MP-1-7, Revision 4, dated June 7, 1989), determined that the root cause appears to be an inadequate procedure and inadequate independent verification of work performed.
The inspector examined the latest procedure (Revision 4)
and the Revision 0 procedure in place at the time of the self-SSFI. The procedure had been revised to correct specific pieces of misinformation raised in another self-SSFI finding (TR-MT-5), but the basic structure and methodology of the procedure remained the same.
The procedure requires a journeyman electrician to utilire engineering documents, manufacturer's breaker performance curves and NEMA standards to calculate acceptance values for current, time values, and bandwiths. Having performed this research and calculation, the electrician is to enter the calculated acceptance values on a data sheet. The procedure does not provide work sheets for the electrician to record which reference was chosen (e.g. " applicable breaker curve"), what values were picked off the curves, nor is a calculation worksheet provided. Likewise, it is not specified who if anyone should check the accuracy of the calculation and verify the acceptance values calculated.
This process is unusually complex for an electrician to accomplish and borders on engineering work. Additionally, it is inefficient to have such calculations done repetitively for a given breaker when the acceptance values can be calculated once and be captured in a procedure. The fact that the procedural process is not functioning well is borne out by the self-SSFI findings of inappropriate acceptance values entered by the technicians, but not identified during the review process.
The inspector discussed his considerations with quality control supervision and management personnel. The licensee agreed that the problem of identifying additional data errors and the problem of inadequate verification of electrician work had not been dealt with and should have been. The licensee, in response, issued a second nonconforming activity report, NCAR P89-264 dated June 7, 1989.
The licensee did not agree that the procedure for breakers and relays was inappropriate for an electricians use.
However, the licensee agreed the procedure could be improved and made more direc+.
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The lier ?e then attempted to demonstrate that an improvement had been made. Specifically, the electrical t
foreman had appended additional test instructions to a maintenance request (MR 89-1891) for testing overload relays. These additional instructions provided the calculated specific time band and minimum currents for
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several specific relays. Alternately stated, the foremen provided the calculational results that procedure MP-1-7 required. The inspector considers that such information l
should be incorporated in the maintenance procedure where it would receive appropriate procedural review as opposed to being issued as additional work instructions prepared by an electrical foreman and reviewed (for narrow quality control attributes) by OC.
The licensee maintenance and engineering management stated in a meeting on June 7, 1989 that the maintenance instruction had received informal but careful reviews by engineering and maintenance management and was accurate.
They further stated that similar infonnation (ie., performing the calculations) would be done for circuit breakers as well, and both sets of calculated values would be incorporated in the maintenance procedure in the future.
- Failure of Ouality and Management Systems to Recognize and implement Comprehensive Corrective Action in a Timely Manner As explained above the failure of the licensee to fully assess the root cause and surrounding weakness identified by the self-SSFI on breakers and relays and the failure to set a timely course to provide comprehensive corrective actions is perceived as a licensee weakness in the area of management and quality organization overview.
- Improper Maintenance Safety Culture The inspector noted that the self-SSFI team expressed a concern regarding the culture within the maintenance department. The concern was expressed in the self-SSFI report dealing with finding TR-MT-7 which concerned a lack of maintenance action on dirty room cooler filters. The concern was based on statements by maintenance supervision that verbatim compliance with procedures was not necessary and the maintenance workers should not be expected to implement conditions and limits in the body of the procedure if the information wasn't highlighted on data sheets.
The NRC inspector's finding regarding maintenance management's acceptance of a highly complex procedure for electricians' use, coupled with the self-SSFI contractor's finding, indicated that maintenance
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. management had.ot adopted a proper safety culture and has not, in the two cases studied, demonstrated that they understand the fundamental concepts that:
(1) work important to safety should be precisely performed in accordance with procedures; (2) the procedures should be well written and clear for the job; (3) the procedures should provide appropriate acceptance criteria; and (4) that work important to safety should be independently verified.
The failure to perform safety related work adequately as indicated by the self-SSFI physical findings and
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the defensive attitude indicated by maintenance supervisors (in the self-SSFI contractor's write-up and experienced by the inspector) led to the conclusion that management needs to devote additional attention to developing the proper safety culture in the maintenance department.
Discussions with the licensee management were held by the inspector. The responsible manager stated that he had examined the situation depicted in the self-SSFI and determined that there had been a misunderstanding in connunication between the self-SSFI contractor and his maintenance personnel. He did not agree with the assessment of the safety culture of the maintenance department. He stated the self-SSFI finding was being addressed from the standpoint of needing to improve the involved procedures.
The inspector questioned whether the maintenance department had procedure specialists. The responsible manager stated that they had one procedural specialist in I&C and hoped to get more authorized in maintenance in general.
The inspector concluded that the licensee's maintenance organization needed improvement in proceduralization and that factors of resources and culture were involved and interwined. The issue was left for management consideration and will be followed up in the normal course of future inspections.
Additional apparent inadequate or incomplete licensee responses / resolutions to self-SSFI finding were identified.
- NCR 88-608, dealing with the lack of consideration for tornado design for CB-16, identifies that a PRA will be performed for tornado missiles to resolve the issue and implies that the PRA will remove concern for the effects of tornado wind loading.
However, as described earlier in this report, the licensee did not recognize or address the effect of CB-16 as a tornadic missile on the CB-1 Intak u
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.A self-SSFI finding indit ted that.asLcompensatory-action, to maintain adequate cooling to the remote shutdown station, a fire door to the hallway needed to be opened if the room cooler was lost (CB-15).
The inspector _ noted that the licensee had not identified operating procedure c.hanges to ensure this action occurs in all situations. The licensee _is addressing the situation when a control-room fire occurs and the remote shutdown station is used but has not addressed the situation when CB-15 is taken out of service _or fails.
In these situations temperature monitoring and limits for room temperature appear to be required-to maintain operability. This issue was discussed with licensee management on' July 21, 1989. Licensee management committed to examine.the appropriateness of affected operating instructions and revise precedures, as appropriate.
7)
Testing of CB-1 and CB-16 The licensee modified the Control Building HVAC System by RDC 86-045 (DCPs 11, 12, and 13) to include supplemental cooling to the control room (HVAC subsystem CB-16) as an enhancement to prolong equipment life and improve control room habitability. Although the CB-16 subsystem was seismically designed and provided with Class lE power, it was not designed for tornado winds and missiles, and was initially classified as non-safety related. However, CB-16 was designed to operate with CB-1.
The latter caused confusion as to its potentially safety related function, as identified in the licensee recent self-SSFI. This interrelationship and safety function was clarified by licensee Justification For Continued Operation, JC0 88-17, in which the licensee decided that CB-16 would be treated as safety related. However, since the 0C0, the licensee has vacillated in the safety classification, with the status of CB-16 redefined as not safety related (at the end of the inspection).
JC0 88-17, item 11.9. identified CB-1 and CB-16 as interrelated safety systems and that "CB-1 is inoperable without an operable train of CB-16; however if the applicable train of CB-16 is not operable, then the Action Statement (of Technical Specification 3/4.7.6.1) must be entered." The JCO, item 111.9. further clarified the Action Statement as follows: "During performance of Surveillance Requirement 4.7.6.1.a. should CB-16 system fail as indicated ty increase of Control Room temperature, the surveillance procedure implementing the test shall be aborted and the seven day Action Statement shall be entered.
If by the fifth daj CB-16 cannot be restored, the surveillance requirement of Is7.6.1.a. may be tested with CB-1 only.
If CB-1 by itself satisfies the requirements of TTS 4.7.6.1.a.,
then the Action Statement is satisfied and the applicable train is operable."
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Improper Pedormance of Technicc1 Specificati-Monthly Surveillance Testing
' Technical specification 3.7.6.1 requires two independent
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control room emergency ventilation systems be operable.
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Technical specification 4.7.6.1 requires that each control room emergency ventilation system be
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demonstrated operaole by performing a monthly test, on a staggered basis, and verifying that a train operates for at least ten hours with preheaters on and maintains the control room air temperature less than or equal to 100 degrees F.
The Trojan FSAR, Section 9.4.1 defines and describes the control room emergency ventilation system as ventilation system CB-1.
In April and May 1988, the licensee installed a supplemental cooling system in the control room. The system was designated CB-16 and as previously discussed did not meet all safety system criteria and was judged to be non safety by the licensee.
However, the licensee's procedure for meeting the technical specification (P0T 20-1) was revised to require operation of both safety related CB-1 and non safety reinted CP 16 during the monthly technical specification test.
Whereas tests previously done with CB-1 alone resulted in control room temperatures approaching technical specification limits, tests subsequently performed with both systems in operation had no difficulty in maintaining cool temperatures.
Mowever, since CB-16 is not safety related it cannot be counted on to function in an accident and CB-1 must be tested monthly in accordance with technical specifications.
The licensee provided some rationale for their decision to test with both systems in POT 20-1.
The basic rationale stated that CBI had a long history of operating successfully in meeting control room temperature requirements and that the test procedures measured the important CB-1 parameters of air flow and service water (cooling) flow.
The inspector noted this rationale to be faulted on the basis that heat exchanger performance can also be degraded by biological and non biological coatings on th( heat exchanger surface which do not appreciably change flow but do appreciably change heat transfer capability. Secondly, the licensee does not periodically and regularly check for such fouling.
Third and most importantly, the licensee changed the heat load to the control room (during the test) in February 1989. The change involved the duty cycle of the charcoal bed preheaters.
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Whereas the licensee" previous history of tests were p formed with the heater "on" intermittently as controlled by a humidistat, the licensee's current tests are performed with the heaters constantly "on" due to the fact that the heater controls had been jumpered out. The controls had been shown to be malfunctioning (a self-SSFI finding). Due to the unavailability of replacement parts, the licensee decided to char,ge operational methods and leave the heaters "on" at all times that CB-1 was run.
Consequently there is no assurance that CB-1, if alone called upon to provide control room emergency cooling, would
successfully mainta'in required temperature.
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The failure to test CB-1 in accordance with technical
, specification requirements is considered an apparent violation (Item 50-344/89-8).
d.
0_perations 1)
Operating Procedures The inspector examined the licensee's implementation of revisions to operating procedures as a result of
. installing design modifications. The inspector observed, in the control room, that the Off Normal Instruction ONI-46, " Loss of 120-V AC Instrument Bus," Revision 1, dated April 16, 1984, identified that one of the symptoms of a loss of an AC instrument bus was a receipt of the " Preferred AC Bus Undervolt" alarm. However, as a result of design modification RDC 86-31 to replace the inverters during 1987 -
1988, the control room Annunciator panel K-06 was modified. Window D-7 and D-8 previously labeled as " Preferred AC bus Undervolt." were removed and replaced with labels titled " Inverter Trouble".
The failure to provide a procedure adequately reflecting the current plant configuration, as revised by design modification is an apparent violation (Item 50-344/89-09-9).
In explanation the licensee stated that the reason the change to ONI-46 was not included in the RDC closure checklist was due to ar, oversight. When this fact was identified, by the licensee, in March 28,
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1988, it was decided that the alarm window change was i
trivial and a Procedure Deviation (PGE's process for on the spot change of plant procedures) was not needed. The licensee then initiated a change to
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ONI-46 and circulated the draft for comment. A
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licensed operator misplaced the draft during his job i
change and the pending change was forgotten. The
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licensee claimed that ne existing program to review
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would eventually catch all the pending changes to the l
procedures. The control room Alarm Response Guide
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(ARG) had been revised for the new alarm windows.
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2)
Operator Rounds The inspector discussed operator rounds and performed selected walkdowns to determine if design basis information was properly translated for operator use.
The inspector found that generally acceptable l
information was available but noted a problem with the vital inverters. Specifically, the inverter output is monitored each shift through operator routines by verifying the voltage indicator is in the green band on the local inverter indicator. The green band is based on the DBD requirement of 118 Y
+/- 2% or 115.6 V to 120.4 V.
The licensee conducts weekly technical specification surveillance POT 21-2,
"ESF and Off-site Power Availability," and uses these inverter output volt meters to determine the Technical Specification Operability of the 120-V AC preferred bus.
During an examination of inverter output voltages, the inspector found the indicator on inverter Y-15 to be at the bottom of the green band (about 115 V).
Given 1% meter error, it does not appear possible for operators to verify whether the output voltage is still within the acceptance criteria by use of these meters.
In response to the inspector's inquir initiated a Maintenance Request (MR) y, the licensee to verify the inverter output with a calibrated digital volt meter.
The output voltage was acceptable. The licensee plans to reevaluate the proper verification method and the proper tolerance band. The licensee further noted the inverter voltage and frequency output are periodically adjusted and measured with high accuracy and test equipment during outages.
3)
Operator Training on RDC Turnovers The inspector reviewed the licensee's operator training to access whether the recent design changes to the control room HVAC and the 120-V Preferred AC bus were included. The inspector found that the classroom training material appeared to be informative and accurate. However, some of the operators interviewed expressed the desire for more hands-on and plant walk-through training on the control room HVAC. The inspector made licensee management aware of this commen g
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Operations / Support I
l While interviewing the Operations staff in the l
. control room, the inspector received comments which
' indicated that operations personnel had a sense of less than total confidence in management support to the operators. Examples provided were:
l Regarding the CB1/CB16 OPERABILITY question, the
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I-operators were concerned that an excessive time
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was required (12/11/88.12/17/88) to have the l-written JC0 in place. The Shift Supervisors were uncomfortable with the. situation during this l
period because they perceived that they were
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told by plant management to continue plant operation and wait for the JCO. The inspector examined the situation and found that proper levels of management were contacted and made reasonable decisions. The licensee appears to have administrative orders to in place to escalate to management attention situations requiring management or engineering decisions.
The ventilation diagram describing CB16 changes
was not provided at the time of system turnover in 1988. Operators stated that they had asked'
for the drawing but one was not provided until the inspector identified this issue to the licensee. The inspector could find no evidence i
i that such a request had been made. The licensee's turnover process appears to have proper vehicles i
to ensure such requests are acted upon.
Operators indicated design change turnover
packages do not always have all the documents which the operators feel are necessary. No specific examples were provided.
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The inspector brought these operator perceptions to the attention of plant management for their consideration and action, as appropriate.
e.
Maintenance The control room ventilation systems CB-1 and CB-16, alon with the four Elgar Inverters (120 V preferred AC System)g, were inspected to assess and evaluate the effectiveness of the licensee's maintenance program.
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The following components were selected from the two
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ventilation systems to be reviewed in detail for frequency and scope of performed maintenance.
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Components CB-1 System C_B-16 System l
VC-142A Far.
V-136A Fan VE-106A Coil Bank VE-136A Chiller VE-159A Reheater TC-111E6A Instrument VF-147A Filter FS-11156A Flow Switch VF-148A Filter VF-149A Filter VF-150A Filter FS-10360 Instr.
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HE-10050 Humidity Element 50 Sensor, Instrument
A review of the vendor manuals for the above components was conducted. The inspector determined that no vendor manual could be found for Flow Switch FS-11136A.
In response, the licensee added this missing vendor manual to a previously established list of missing manuals to be supplied by December 1989. The recommended maintenance. practices found in the vendor manuals were compared with the maintenance measures found in the following maintenance procedures; MP-9-1, " Fans Motors, Dampers, Heating, and Cooling Coils" MP-9-3, " Filter Inspection and Replacement" MP-2-6, " Miscellaneous Analog Instrumentation" MP-2-30 " Maintenance and Calibration of Control Room Air S0 and Ammonia Monitors"
The maintenance procedures appear to adequately implement the manufacturer's recommended maintenance practices.
2)
Records The maintenance history and maintenance request records, located in the vault, were reviewed for the
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above identified fourteen component samples. The I
periodic operating test (P0T) 20-1-A records, l
performed monthly to demonstrate the operability of ventilation system CB-1, and also on file in the
vault, were examined. The instrument calibration records, located in I&C maintenance, for five instruments included in the sample of fourteen components were examined. The vault records and
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instrument calibration records appeared to be i
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The inspector concluded that the licensee's maintenanc y program, as it applies to the ventilation systems, appears to be effective and adequate.
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3)
Lack of Calibration of Inverter Instruments
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The four Elgar inverters Y-15,17, 26 and 28, which energize 120V AC preferred instrument buses Y-11,
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Y-13, Y-22, and Y-24, were inspected.
Inverter Y-15
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and Y-17 were installed during the 1987 refueling outage under temporary plant test (TPT) 187 while inverters Y-26 and Y-28 were installed during the 1988 refueling outage under TPT-257. These two TPTs (187 and 257) were retrieved from the vault and were examined in detail to ascertain the level of quality control's participation during the installation, checkout, testing and placing in service of the four new inverters.
The Elgar equipment manual was examined and compared with maintenance procedure HP-1-12. " Preferred AC system and Inverters." The maintenance procedure for the inverters appeared adequate and included the manufacturer's recommended maintenance practices.
The initial instrument calibration records for the voltmeter, ameter, and frequency meter, mounted on the front panel of each of the four inverters, were examined in the archives. Calibration records were found for the meters in Inverters Y-15, Y-17 and Y-28. However, no calibration records could be found for the three meters mounted on inverter Y-26.
Tore was no evidence provided by the licensee that the meters on Inverter Y-26 were calibrated before placing the inverter in service following installation.
While examining POT 21-2-D the weekly surveillance of instrument buses Y-11, Y-13, Y-22 and Y-24 required by technical specification 4.8.2.1, it was determined that these instruments (the voltmeter, ammeter and frequency meter) are used to verify the output of the inverter. The failure to assure the initial calibration of the three instruments of inverter Y-26 which are used in the performance of T.S.
I surveillance is an apparent violation of NRC requirements (Item 50-344/89-09-10).
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4)
Evaluation of Self-SSFI Corrective Actions in Maintenance The licensee's corrective actions taken in response to the self-SSFI findings in the maintenance area were examined to assess and evaluate their adequacy.
Thirteen observations found in the maintenance area during the self-SSFI are identified in Attachment 2 of the self-SSFI inspection report, dated February 1, 1989.
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These thirteen' observations and the licensee L
corrective actions were examined in detail. The W
conclusions from this examination establish that the observations fall into three categories:-
Those observations where the licensee corrective
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MT-3, MT-4, MT-7, MT-8, MT-9, MT-11, MT-12, and-MT-13.
y Those observations where the licensee's corrective
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. incomplete are: HT-2 Single failure
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vulnerability of cable spreading room coolers.
- MT-6, Inadequate response to cooler silting.
MT-10, Air venting of cooler units not being performed.
For one observation MT-5, inadequate guidance
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for overload relay ~ testing, the licensee's-
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corrective actions were considered to be untimely in that there was sufficient time following the conclusion of the. SSFI. inspection
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and the start of the-1989 refueling outage to update and provide an~ adequate procedure for testing of safety-related overload relays. This untimely action.is discussed in greater detail insection5.c.7).
For self-SSFI observation MT-1, dealing with
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inadequate calibration / functional check of the charcoal bed moisture protection equipment, the licensee's temporary corrective action, to jumper out the controls, was inappropriate since it caused a different heat load to be applied to the control room and may have made ventilation CB-1 incapable of meeting its functional
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requiremnt. A violation regarding this matter is discussed in section 5;c.8) of. this report.
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f.
Surveillance Testing of Control Room Emergency Ventilation System (CB-1)
The NRC inspector reviewed procedures associated with the operability of the control room emergency ventilation.
The following observations were identified:
Administrative Order A0 3-32, CONTROL OF PLANT 000RS,
Revision 1. dated May 2,1989, provides a reference source for identification.of barrier functions
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associated with plant doors and guidance on operability requirements and actions for those doors e__
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functioning as a barrier. Door 10 was not identified L~
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in this procedure. The licensee is issuing a change to this procedure to add Door 10.
- Periodic Operating Test POT 20-1, CONTROL ROOM EMERGENCY VENTILATION SYSTEM PERFORMANCE, Revision 22, dated April 28, 1989, provides instructions for verification of the operability of both trains of the control room emergency ventilation system (CB-1) and the integrity of the control room pressure envelope.
This procedure does not identify that the position of control building doors will effect the operability of the CB-1 system. The licensee stated they would review this procedure, and add additional instructions, precautions, etc. on control building doors, if required.
- Administrative Order A0-3-21, CONTROL ROOM EMERGENCY VENTILATION BOUNDARY, Revision 4, dated Mey 17, 1989, provides instructions for controlling the control room (CR) emergency ventilation boundary to ensure that the CB-1 emergency ventilation system remains operable. This procedure does not identify that doors outside the immediate control room emergency ventilation boundary, can effect the operability of the CB-1 system. The licensee has been aware of this situation since 1987, that the position.of various control room building doors not identified in A0-3-21, could effect the satisfactory operation of the CB-1 system. The following Event Reports (ER)
document some of this earlier information:
ER No.
Date 87-064 April 18, 1987 88-117 September 24, 1988 88-135 October 22, 1988 89-033 March 28, 1989 The NRC. inspectors reviewed of historical surveillance data and the above ER's identified that the licensee has had several opportunities since 1987 to recognize that there were unidentified paths of communication between the control room envelope, control building, auxiliary building and turbine building, which have prevented establishment of a 1/8" in WG positive pressure in the centrol room envelope during CB-1 operation.. A majority of this unidentified communication has been through doors, some of which were outside the identified control room envelope, as was Door 10 on the 45 ft. level.
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In response to the NRC concerns identified during a May
., _ 26, 1989 meeting regarding how Door 10 position affected the CB-1 system dp in the control room envelope and what corrective actions the licensee was implementing, the licensee provided the following information:
During CB-1 operation, all control building supply and exhaust systems shutdown. Th h essentially isolates the entire control building. However, the
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45 elevation of the control building is exhausted by AB-3 (auxiliary building exhaust system). The 45 ft. control building exhaust creates a negative atmosphere in the area. This negative atmospheric condition exists throughout the control building.
This includes the areas adjacent to the control room as well as the control room itself.
- The pressurization occurring by running CB-1 provides the same change in pressure, but since the control room pressure starts out negative, the result is.not as positive relative to outside.
- When Door 10 is opened it acts like a pressure relief, thus reducing the negative pressure in the areas. Likewise, once Door 10 is closed, the negative pressure in the area increases.
- By administratively controlling doors and by performing a more thorough evaluatica of.the design changes, the effects of doors causing erratic building pressures will be controlled. Action to perform a complete flow balance of the buildings in order to assess the influence of various doors was in progress.
In response to the above identified NRC concerns, and information, the licensee has held a critique, performed and scheduled additional HVAC testing, wrote draft
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procedure changes and is reviewing other licensee procedures for proposed improvements. At this time it appears the licensee is taking appropriate corrective actions to resolve these concerns.
Conclusion The inspector concluded that the licensee's current action in response to the effects of remote control building doors on control room pressurization requirements was adequate.
It was further concluded that the licensee should have recognized and dealt with these effects earlier.
It appears that the licensee's ability to
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recognize and resolve problems could be strengthened.
This was discussed with the licensee on July 21, 1989.
The licensee committed to address this issue in their response to this inspection report.
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Oversigbe Activities
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1)
The NRC inspector reviewed the licensee's oversight groups efforts to become involved in the assessment and follow-up on significant engineering activities.
The Trojan Nuclear Operations Board (TNOB) is an oversight group required by Technical Specification requirements (6.5.2.1) to provide independent review and audit in the areas of nuclear engineering and quality assurance practices. The NRC inspector reviewed the TNOB meeting minutes conducted over the last two years along with any 0A audits initiated by these meetings. The Nuclear Quality Assurance Department (NOAD) was actively involved in the 1988 self-SSFI in areas such as soliciting and evaluating contractor bids, contractor selection, providing 0A engineer support full-time to the SSFI team, and initiating and tracking NCR and/or NCARs for each SSFI team finding. The TN0B minutes did indicate interest in an oversight of engineering activities addressed by the SSFI, e.g. CB-1.
For future self-SSFI's the licensee is planning on having dedicated personnel from all appropriate departments to support the team's inspection.
2)
Indications of Potential OC Weaknesses in Identifying Vulnerabilities The Quality Inspection supervisor for electrical and I&C work was interviewed to determine possible underlying causes for the failure of OC to identify erroneous data entries on molded case circuit breaker and relays which was discussed in section 4.c. of this report. The inspector detennined that QC personnel do not review maintenance procedures or revisions for adequacy. The Oc staff for electrical work consisted of five individuals, four of whom were contractors. The one PGE electrical inspector employee was due to a reduction in force in the mechanical serviceman group. The longest length of service was 1 1/2 years in the group. The update training available for QC was the same as crafts and was INP0 accredited. New hire training was limited to administrative training and did not match the training new hire electricians received (which was slated to be about six months of solid training).
These facts combine to indicate that electrical Oc work is not treated as importantly as the craft work.
Discussions were held with the acting Quality Assurance Manager who stated that management recognized the need to strengthen Quality Control and was investigating enhancements.
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6.
IJnresolved Items,,.
Unresolved items are matters about which more information is required to detemine whether.they are acceptable or may involve violations or deviations. One new unresolved item was identified during this inspection and is discussed in paragraph 5.c.1).
7.
Exit Interview The team met with the licensee representatives identified in paragraph 1 on June 9, 1989. The scope of the inspection and the findings were discussed. A follow-up inspection was conducted and a second exit interview was held on July 21, 1989.
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