IR 05000344/1989033
| ML20006D738 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 01/22/1990 |
| From: | Mendonca M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20006D737 | List: |
| References | |
| 50-344-89-33, NUDOCS 9002150008 | |
| Download: ML20006D738 (21) | |
Text
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> U. S. : NUCLEAR REGULATORY COMISSION ] U REGION V ~ ' i e . .. - -Report No.
. 50-344/89-33 , ' ? Docket No.
50-344 ' p.
f License No.; NPF-1 f
Licenseet.
Portland General' Electric Company' , 121'S.W. Salmon Street Portland, OR: 97204 g y , Facility 'Name: Tro'jan
. I - . Inspection at: Rainier,-- Oregon ! <
-Inspection conducted: November 26 December 314,-1989c ' . i ' Inspectors: -R.~ C. Barr, - F - . ' . Senior Residert Inspector.- / <- , , ~ J.F.iMelfi,7. i - Resident Inspector i ' v . . .D..B. Pereira, , Operator Licensing Examiner !< . z i 1T. B. Sundsmo, . . . Operator Licensin Examiner 'ApprovedBh:- M - Fot- - 1 3 -30, - -
- M. M. Mendonca, Chief Date Signed
' - ReactorProjectsSection1 . Summary:s $- -Inspection on November 26 - December 31, 1989'(Report 50-344/89-33).
' 1 Areas' Inspected: - Routine inspection of: operational. safety verification,.
- maintenance, surveillance, event follow-up,
- system engineering,.and open item-
' ' . follow-up.
Inspection procedures 30702, 30703, 37702,~40500, 61726, 62703, ' 71707,192700,; 92701,: 92702 and 93702, and Tem)orary Instruction (TI)2515/104 were used as; guidance during the conduct.of~tle inspection.
c Results- - ' This; inspection discussed two events where licensee 3rocedural noncompliances . !;:- contributed to licensee-identified violations of tec1nical specification ~ L requirements ~that will be followed as unresolved items (Paragraph 6).
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Further, numerous events throughout the inspection report reenforce the need ). ~ forcontinuedmanagementevaluationof-Trojan'sperformanceandevaluationof the effectiveness of. initiatives implemented to address'past performance problems.
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,4 . u ' ' DETAILS
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Persons Contacted-H.
- 10.
W.' Cockfield, Vice President, Nuclear - +*C. P. Yundt, General Manager, Technical Functions-Plant General Manager +*T. D.- Walt, - . A..N. Roller, Manager,; Nuclear Plant Engineering , +C.- K. Seaman, Manager, Nuclear Quality Assurance . '*D W. Swan, Manager, Technical Services M. J. Singh, Manager, Plant Modifications J. D. Reid, Manager, Quality Support Services -
- J.-W. Lentsch, Manager, Personnel Protection
+D. R. Swanson, Manager, Nuclear Safety Branch J. F. Whelan, Branch Manager, Maintenance J.
Mody, Branch Man.iger, Plant. Systems Engineering
- D. L.:Nordstrom, Branch Manager, Quality Operations
' - -J. P.-Fischer, PM/EA Branch Manager T. 0. Meek,-Branch Manager, Radiation Protection
- R. A. Magnuson, Branch Manager, Security
- E. F. Petersen, Branch Manager, Maintenance
- R. L. Russell, Branch Manager, Operations R. N. Prewit, Supervisor, Quality Systems J. C. Heitzman, Acting Assistant Operations Supervisor N. A. Regoli I
+*J.A. Benjamin,nstrumentandControlSupervisor . Supervisor, Quality Audits - J. D.1 Guberski,' Nuclear Safety-and Regulation Department Engineer +*W. J. Williams, Compliance Engineer +M. H. Schwartz, Systems Engineering +R.
Neiman, ISI Engineer +L. G. Dusek,. Licensing Engineer
- P. G. Nelson, Licensing-Engineer
+B. L.-Baker, Nondestructive Engineer - . Volt Personnel +T.
Childress, Quality Assurance Supervisor United Energy Services Corporation Personnel- . +M. - Degraff, Team Leader,. Safety System Functional Inspection Team U; S. Nuclear Regulatory Commission
- +R. C. Barr
+*J._F.Melfl,SeniorResidentInspector . Resident Inspector +D. B. Pereira, Licensing Examiner +T.
Sundsmo, Licensing Examiner The inspectors also interviewed and talked with other licensee employees during the course of the inspection.
These included shift supervisors, i l
m , ' , . . .) ' . > o . reactor and auxiliary operators, maintenance personnel, plant technicians and engineers, and quality assurance personnel.
-
- Denotes those attending the exit interview on, January 11, 1990.
L + Denotes those attending the' exit interview on December 1, 1989.
, ' > j ' 2. - plant Status ' TheLfhcilityoperated-at97%powerfromNovember 26, 1989 through , December 26, 1989, when power was reduced to repair a leak on the D steam ' L ? generator upper secondary manway and a failed gasket on an air system . P.
97% power. gulator.
pressure 4 re On December 29, 1989, the reactor was returned to ' ' . - + 4 : ! L 3.
Safety Verification (71707)~ , Operational Safety Verification i During this inspection period, the inspectors observed and examined Lo - activities to verify the operational. safety of the licensee's facility.
X)* The observations and examinations of those activities were conducted on a <-
daily, weekly or biweekly basis.
- , Daily the inspectors observed control room.-activities to verify the - licensee's adherence to limiting conditions for operation as prescribed in the facility Technical Specifications.
Logs, instrumentation, . recorder traces, and other operational records were examined to obtain - information on plant conditions, trends and compliance with regulations.- On-occasions when a shift turnover was In progress the turnover of information on plant status was observed to determine that: pertinent information was relayed to-the. oncoming shift personnel.
Each week the inspectors toured the accessible areas of the facility to observe the following items: , a) General plant and equipment' conditions.
b) Maintenance requests and repairs.- c) Fire hazards and fire fighting equipment, d)? Ignition sources and flammable material control.
-(e) Conduct of activities in accordance with the licensee's administrative controls and approved procedures.
(f) Interiors of electrical and control panels.
-(g) Implementation of the licensee's physical security plan.
(h) Radiation protection controls, i) Plant housekeeping and cleanliness.
j) Radioactive waste systems.
k) Proper storage of compressed gas bottles'. Weekly, the inspectors examined the licensee's equipment clearance control with respect to removal of equipment from service to determine that the licensee complied with technical specification limiting conditions for operation.
Active clearances were spot-checked to ensure that their issuance was consistent with plant status and maintenance - - - - - . - - -
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- evolutions.' Logs. oft jumpers, bypasses, caution and test tags were examined by the inspectors.
- Each. week the inspectors conversed ~with operators in'the control room, ' ' and with other plant personnel.
The discussions centered on pertinent topics relating-to general plant conditions, procedures, security, > -training and:other topics related to in progress work activities.
Theinspectorsexaminedthelicensee'snonconformancereports(NCRs)to - = confirm that deficiencies were identified and tracked by the system.
Identified nonconformances were beingLtracked and followed to the completion of corrective action.
Routine inspections of the licensee's phys.ical security program were performed in the areas of access control, organization and staffing, and detection and assessment. systems.
The ins)ectors observed the access control measures used at the entrance to tie protected area verified the integrity of portions of the protected area barrier and vital area barriers, and observed-in several instances the implementation of compensatory measures upon breach of vital. area barriers.
Portions of the isolation zone were verified to be free of obstructions.
Functioning of central and secondary alarm stations (including the use of CCTV ' monitors) was observed.
On a sampling basis, the inspectors verified that.the required minimum number of armed guards and individuals authorized,to direct security. activities were on site.
The inspectors conducted routine inspections of selected activities of the licensee's radiological protection program.
A sampling of radiation work permits (RWP) was reviewed for completeness and adequacy of informatien.
During the course of inspection activities and periodic tours of plant areas, the inspectors verified proper use of personnel monitoring equipment, observed individuals leaving'the radiation controlled area and signing out on appropriate RWP s, and observed the posting of radiation areas and contaminated areas.
Posted radiation levels at locations within the fuel'and auxiliary buildings were verified using both.NRC and licensee portable survey meters.
The-involvement of-health physics supervisors and engineers and their awareness of significant plant activities was assessed through conversations and review of RWP sign-in records.
The inspectors verified _the operability of selected engineered safety-features.
This was done by direct visual verification of the correct position of valves, availability of power, cooling water supply, system integrity and general condition of equipment, as applicable.
No violations or deviations were identified.
-. 4.
Maintenance (62703) The inspector observed the licensee perform corrective maintenance and troubleshooting on the A Reactor Trip Breaker (RTB).
At 7:58 pm on December 2,1989, a control room operator identified that one of the closed indication lamps for the A Reactor Trip Breaker was not lighted even though that trip breaker was closed.
The operators changed that . M
pe ~< , .... - -4 p a ,, light bulb to assess-if the bulb had failed; however, the replacement - bulb also did not light.
To understand the operational significance of,the indication circuitry. . malfunction, the operators reviewed the RTB electrical schematic.
They - identified that the-light bulb was in series with the' shunt trip coil.
- The shunt trip coil provides an alternate (backup) trip to the breaker on failure of: the undervoltage coil circuitry.
The operators verified that-the undervoltage coil circuitry was operable and concluded that the shunt
circuitry was-not operable.'- Therefore, the operators concluded Trojan Technical Specification (T.T.S.) 3.3.1, action 12 (RTB to be restored within 48 hrs.), was applicable.
To troubleshoot and repair.the loss of closed indication on the A RTB, ' the operators wrote urgent Maintenance Request-(MR) 89-50028. 'The resident inspector observed the licensee conducting portions of this maintenance activity.
l The' licensee drafted work instructions and bypassed the A Reactor Trip
Breaker.using the RTB bypass breaker.
Electricians verified that the ' indicating light was receiving voltage at the RTB terminal comaartment
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and behind the control panel.
The electricians then removed t1e resistor! at the lamp socket'and determined that the resistor had failed.
The' ' licensee removed the resistor from the B.RTB. bypass breaker o en . I indication and put it in the A RTB closed indication.
The'li ht ' indication was verified to work.
The licensee subsequently o tained a replacement resistor from the warehouse and put it on the B RTB bypass '
breaker.
p No violations or deviations were identified.
, 5.
Surveillance (61726) ' On December 8, 1989, an inspector observed portions of-the performance of '., Periodic Operating Test (P0T) 5-1, " Auxiliary Feedwater System Pumb and ' Valve Inservice Test," on the Steam Driven Auxiliary Feedwater (AFW) pump. -This surveillance satisfies the requirements of technical specifications 4.0.5 and 4.7.1.2.1.c.
' The inspector noted that the procedure was reviewed by the appropriate licensee personnel.
The equipment was tagged out before the' test was started, and the instrumentation used during the performance of the test was within its calibration cycle.
The inspector observed the operator remove the system from service and L perform portions of the-test.
The operator conducted the test with the
' ap3ropriate procedure sections in hand.
The pump started smoothly and ac11eved: rated pressure and flow.
s The inspector noted that the procedure was not followed step-by-step. Step 7.2.3.c requires the controlling air supply to the steam supply . valves.be isolated.
Specifically, on step 7.2.3.c, the first part of.the step is to close Instrument Air (IA) valves 68 through 71.
These valves are in individual bays located in the main steam support structure.
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pg ---,. m ~ . 9. m , , , ' C j',. " i:, S-i l @ ' , ,2 f-l ' ' ' ji < next part of the step was to open the pressure plugs (PP!2480 through -
' . y c 2483) to the control valves in order to bleed any trapped.(residual) air.
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F-There is one pressure plug'in the vicinity of each IA valve. -The-- ' . . operator. closed an IA valve and then removed its associated pressure plug _ , , for a particular steam supply valve so that he would not have to go to - e ', each bay and shut each valve and then-return and' remove each plug.
The'
< operator did not seek guidance on whether-his approach'was acceptable.
' ' ~Further-inspector review'found that plant administrative procedures require step-by-step. compliance only when specifically stated and in this ~ " instance step-by-step compliance was not required.-
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The test results met the technical specification requirementsc j , No violations or deviations were identified.
L6.
Event Follow-up'(93702, 62703, 92701 and 40500) , Incomplete Reactor Coolant System Power Operated Relief Valve (PORV) ' Channel Functional Calibration U On' December 5,'1989, it was discovered that the' required surveillance - testing had not been )erformed for all of the-circuitry of the PORV.
The licensee discovered t1e deficiency when performing a design' change as a result of a commitment made to the NRC.
The licensee was evaluating methods-to test the new' design change while near the completion of the design package.
The licensee then discovered that there was no . pre-existing procedure which tested the auxiliary relays in the PORV control circuit.
= To comply with technical specifications, the licensee declared the valves inoperable and closed the PORV block valves.
To inform the. operating staff, the licensee wrote night orders describing the-situation.
The
-- inspectors. reviewed the night orders and concluded that the direction'in ' the night orders could'have more explicitly defined when the PORVS were R '. _ .to be used. 'As airesult of discussion with licensee management,' H additional l guidance was provided to the' operators to only operate the
- . PORVs if there was a danger to the plant'per 10.CFR 50.54 (x).
The-W Llicensee' determined'that the event was. reportable and issued LER 89-32 on J .this event.
Since the'non-tested relays were not designed to be-. ' ' -routinely tested, the licensee wrote a Tempo'rary Plant Test (TPT) to lift ' ~ leads 'and check this circuit.
The licensee performed this TPT and the valves.were cycled: satisfactorily. The' licensee also determined that r this surveillance had not been performed since technica1' specification- ' amendments:in'1982 (amendments 73 and 78) implemented PORV testing.
This / -will be followed as an unresolved item pending evaluation of licen3ee " 1 corrective actions (89-33-01).- An unresolved-item-is=a matter about which more information is required to ascertain whether it is an '! x faccepteble item, or deviation, or'a violation.
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Containment Air Lock Surveillances ) .0n. December 26, 1989, the licensee performed the six month local Leak ' W > Rate Test (LLRT).oa the containment air lock.at the 45 foot elevation.
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, , - well'as _a pressure integrity boundary against a' design basis loss of - , r coolant accident.
' 4 - .The licensee performed this activity under Maintenance Request'(MR) ' ' 89-10942.= The workers installed clamps on the inner door and started a . pressurizing the air lock to design pressure (60 p(based on previous - ', si)..They had reached ,. approximately 30 psi when.the workers determined ! tic experience) that the air lock was taking excessively long to pressurize.
They also noticed that the equalizing valve was not holding pressure.
P They depressurized and examined the equalizing valve.
The workers noticed that the equalizing valve mechanical interlock linkage arm had a " - . ,- standard threaded nut.vice a NYLOC nut.
The workers then tightened the ", nut in an attempt to correct the leakage.
A separate maintenance request-was written to install the correct type of-nut (NYLOC).
The workers then . successfully performed the test.
After the test, the worker discovered c ' ! the old NYLOC. nut-approximately 12-inches away from the valve, installed , o, E it,'and documented it on MR 89-10942.< The workers had not considered the 'first'LLRT-test to have failed and, therefore, did not report the test as e a failure.
A shift su)ervisor was informed by a maintenance engineer of what occurred on Decem)er 29 1989 The failure of the first test' immediatelyraisedoperabililyconc. erns'with the shift supervisor.
L A failure of a containment air lock LLRT places the plant in a 24 hour ,
. action statement by Technical Specification 3.6.1.3.
The on-shift I~ -maintenance supervisor also did not recognize the importance of'failing ' "~ [' to reach full pressure.' However, the second test of the air lock was i successful;and was conducted within'the 24 hour requirement of the L technical specifications.
, ~ The 1icensee did verify that similar e'qualizing valves have the correct nut installed.
The licensee was also evaluating the potential ' contribution of scheduling surveillances with the system engineer not. d onsite.
- The licensee was still evaluating.this event at the end of the reporting period.
The~ licensee's actions to address this: event will-be assessed by the inspector during a follow-up inspection as an unresolved. item '!' , (89-33-02).
' Load. Rejection During Surveillance Performance On. December 28, 1989, at 11:43 pm, with the reactor at 30% power, a 30.MW: > V' turbine: load rejection occurred while the o erating staff was performing- -POT-18-2 " Main Turbine and Generator Week 1 Operating Tests." As soon
, , as tho' operating crew recognized'a load _ rejection was in progress, the j surveillance-was disco'ntinued and the load rejection terminated.
To investigate the cause of the turbine runback,.the operating: crew i initiated internal event-report ER 89-273.
The investigation was.in-i progress at the' completion of the inspection period.
A preliminary finding of the licensee's investigation was that direction
provided in the Initial Conditions section of POT-18-2 stated not to i if the i perform step 7.1.3, " Power Load Unbalance Circuit. Testing,"'ine runback l turbine was at less than 40% load.
At tne time of the turb
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Va an'd with the turbine at 30% load, step 7.1.3 was being performed. =The
- licensee investigation noted that the procedure was being used but that the initial conditions had not been referred to by t N operator
conducting the test nor were precautions contained ia che procedure just prior to step 7.1.3.' The-licenseehasyettodeterminewhytheturbineloadrejection-occurred.
An engineering review of the power load unbalance circuit has been completed.
The review concluded that performing testing of the power load unbalance circuitry at 30% aower should not have resulted in aL turbine-loadrejection.
The licensee.ias reperformed the test several times, and no runback has been experienced.
Licensee evaluation continues.. At:3:30 am, December 29-1989, the resident inspector, while conducting routinedeepbackshiftInspectionandreviewingshiftlogs noted that 'therunbackhadoccurred.--Theinspector,.indiscussionswithshift-supervision and the' control operator, was informed that P0T-18-2 had not been followed even.though.this non-safety related-test procedure was being:used at the time of the event.- The inspector was informed that event report 89-273 had been initiated.
Additionally, crew personnel had-not yet reviewed circuit diagrams to determine why the runback had , occurred.. The~ ins)ector also attended the licensee critique of the event conducted on Decem)er 30,-1989. The inspectors will continue assessing the licensee evaluation of this event as it relates to procedural compliance.
Inoperable Chlorine Detectors On December 12, 1989, at 5:08 pm, the licensee declared both. trains of the chlorine detection system inoperable because the chlorine sensing devices (AIS 9000A.and AIS 90008) could not be verified to meet the response time requirements assumed-in the Final Safety Analysis Report' (FSAR).
The facility, therefore, entered Technical Specification , 3.3.3.6, action b., which requires the control room emergency ventilation: to be :31 aced in the recirculation mode within one hour of discovering both c11orine detection systems inoperable.
This action was: completed:at'- 5:18 )m.
Additionally, the licensee, per 10 CFR 50.72,. informed the NRC
via tie Emergency Notification System (ENS) that these actions had been implemented.
, Technical; Specification 3.7.6.1 requires two independent control room . emergency ventilation systems to be OPERABLE which includes the capability to automatically initiate on a safety injection. With one control room emergency ventilation system having its makeup dampers-in - ,.. . pull-to-lock, as was required due to the chlorine detector inoperability, that train would not function as required by T.S. 3.7.6.1.
After - evaluating methods to' operate the control room emergency ventilation
system, tie licensee concluded that the definition of being in the recirculation mode for control room ventilation included having the-recirculation fans in automatic, but not operating, and the make-up supply air dampers in automatic but shut.
In this lineup, the emergency controlroomventilationsystemwouldauto-startonasafetyinjection
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3 . , ,e, L; +.. ' h signal' and the licensee was no longer in the T.S. 3.7.6.1 action-statement.
- l _ On December 19, 1989, at 2:49 pm,.the licensee shifted the emergency ~ control. room ventilation system to this lineup.
At-3:29'pm, on December . 19, the operating crew who shifted the lineup, recognized that the make_-up dampers for' the off-service emergency control room ventilation 3.0.3 by not complying with T 5.the facility was unknowingly in T. S.
system were open and,.therefore 3.3.3.6 (chlorine detector operability).
' The licensee immediately shut the make-up dampers and initiated an internal event. report (ER 89-260).
At 4:29 pm the licensee notified the-NRC via the ENS of this event.
Preliminary lic,ensee event findings indicated that at 2:49 pm when the change in lineup for the emergency control room. ventilation lineup occurred the operators conducting the +^ evolutiondidnotrefer'tooruseoperatinginstruction 01-10-2.1, " Control _ Building HVAC-Control Room Ventilation," revision four.
Additionally, this procedure had not been changed to indicate the desired . mode of operation.
Licensee evaluation of this event was continuing at- , the conclusion of this inspection period.. , , The inspectors met with licensee management immediately following the
event to discuss procedural compliance and control of off-normal evolution.
The inspectors reviewed 01-10.2.1 and operator training on +0 ' .the control room emergency ventilation system.
The inspectors concluded thetrainingtheoperatorsreceivedinconjunctionwiththeprocedure ' + content.should have been sufficient to prevent this event from occurring.
' The= inspector will continue assessing licensee evaluation of this event during routine follow-up.
- -dioxide levels increased-to the point that the licensee ntrol room carbon With-the control room outside air dampers closed the co had to open .outside air dampers and' conduct air exchanges.
The licensee-had done this using T.S. 3.0.3, and had reported this to the NRC via the ENS.
The licensee 3roposed an emergency technical.specitication changeito T.S.
3.3.3.6 w1ica would permit venting the control room for periods up to one ,'., , hour with'approariate compensatory measures.
This emergency technical specification caange was approved on December 28, 1989, and will be in effect until the licensee satisfactorily demonstrates chlorine monitor response or at the latest March 15, 1990.
No violation's or deviations were identified.
7.- Follow-up of Licensee Event Reports (40500 and 92700) LER 88-39, Revision 1~(Closed), " Incomplete Calibration of RTDs Due to Assumed-Drift Value of Zero."
lh15 revised licensee event report provides conclusions reached as a result of performing long term actions and updates actions planned with respect to calibration of reactor coolant system wide range RTDs.
The licensee concluded that sufficient margin existed in temperature parameters used in the reactor protection system to accommodate a potential one degree Fahrenheit error.
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.1'nspectors' discussed the-LER with the compliance engineer, and reviewed- > , - RTD calibration: data and data gathering techniques.
~ ~ , , r LER 89-17, Revision 1, (Closed), " Reactor Trip on Over Tem>erature Delta Temperature-Signal." This revised licensee event report, 3ased on a " continuing investigation, provided licensee conclusions as to the most , probable cause of_ the August.9,.1989, reactor trip on over temperature delta temperature.
The licensee concluded that-the most likely cause'of - i the trip was an intermittent open in channel four OT Delta-T reactor trip ' logic due to an inadequate connection.
The inspectors performed ! ' - extensive follow-up of this event as reported in inspection reports y 150-344/89-20-and 50/344/89-24.
' 15" 89-21, Revision 0, (Closed), "High Head Safety Injection Inoperable 'oI W s of Volume Control Tank Isolation Due to Procedural Error." This.
Ti ensee event report described the potential inoperability of both , centrifugal charging pumps due to a procedural deficiency, if a safety.
.injectionweretooccurwhlleconductingEmergencyCoreCoolingSystem . ' (ECCS) valve in-service testing (IST).
The licensee concluded that the cause of the event was an inadequate review of a 1976 change to a-s surveillance test.
The licensee concluded this surveillance had been conducted quarterly since 1976 with the potential for gas binding of the + . centrifugal charging pumps if a safety injection were to occur in
conjunctionwithperformingthesurveillance.
Further, the licensee
L concluded that no safety injection signal had occurred while performing L' performing the surveillance testing until appropriate procedure changes ' the surveillance.
As corrective action, the licensee has discontinued - are.made.
Additionally, the licensee will alert the reactor vendor to i e L' this deficiency as the concern may be generic to Westinghouse reactors.
! The inspectors verified'that surveillance testing of M0-1128 and M0-112C - l has been discontinued and that safety injections had not occurred during previous surveillance testing.
- LER 89-22, Revision 0,-(0 pen), "100% Power Reference Temperature Used in
, Rod Control System Program Different Than the Value Used.in the Safety D Analysis." -This licensee event report described using a nonconservative value.for the reference temperature.used in the rod control system automatic program.
In the Trojan safety analysis, the vendor assumed a ' 'value of 584.7 degrees F. for Treference.
In 1976, the licensee changed .Treference to 586.4 degrees F. to' achieve design bulk average temperature; however, the licensee did not fully recognize the affect that' raising Treference would have on the Accident Analysis.
As corrective actions, the licensee immediately. returned Treference to less than 584.7 degrees F. and performed a safety evaluation to determine the impact of operating at an elevated Treference.
Additionally, the vendor, j inconjunctionwiththelicensee,.isperforminganevaluationofthe impact on the safety analysis for the affects of operating at a Treference of 586.4 degrees F., for the loss of coolant accident and , h steam generator tube rupture accidents.
This event report will remain l open until the result of this evaluation is completed.
LER 89-23, Revision 0, (Closed), " Containment Integrity Violated During Local Leak Rate Testing." This event report described the violation of Technical Specification 3.6.1.1, " Containment Integrity," that occurred ! ! , t - a . - _ - - - -. -.. - - - _ _. - - - -, . . - -. . - - - - - - - - . -. - - -
%. " -10 - g.< , I while conducting local leak rate testing of containment electrical-b penetrations when in Modes 1-4. 1The licensee has not yet established the [r, - cause-of the event, is continuing the evaluation and will submit a revised report.
To date, the licensee has identified that a lack of " technical understanding of how the electrical penetration serves as a containment boundary and deficiencies in the surveillance' procedure-have contributed to the event.
To prevent similar events, the licensee has ,
- discontinued leak rate testing of containment electrical penetrations
.while in' Modes 1-4 and will revise the-surveillance procedure prior to 0 'x 4 aerforming leak rate testing of electrical containinent penetration.- This LER~is closed based on actions taken to date and plans to submit a i " revised LER upon determination of root cause.
o , ' ew LER 89-25, Revision 0, (Closed), " Required Trending of Control Building > Through Wall Bolts Not Completed Due to Personnel Errors." This licensee + C event report described a violation of Technical Specification 4.7.11.1.e ' i , that required trending of non-retensioned bolts used to strengthen the H
~ - ? control building walls.
The licensee concluded that even though the requiredisurveillance had not been-performed the tensioning of the bolts ' was within technical specification requiremen,ts. -Additionally, as i
a J documented in inspection report 89-29, NRC inspectors identified that the '
surveillance-interval-had been exceeded one time (a non-cited violation).
i The-licensee determined the'causes.of'the event to be personnel error in ! that personnel-failed to track and document bolt tensioning, and a change ' , to the technical--specifications that was not properly processed.
The NRC inspectors also identified that the licensee surveillance tracking system.
, did not include the tracking and evaluation of.this surveillance.
To { !F prevent recurrence of this event, the licensee plans to add this - , surveillance to their tracking' system, complete the fifth year ' surveillance. report, and evaluate a change to the: technical
specifications.
Additionally, the licensee has organized a task force to
' evaluate the surveillance tracking system and provide recommendations for ' , improvements.
" ! k LER 89 27, Revision 0, (Closed), " Containment Ventilation Isolation;Due to Electronic Noise Spike." -lhis licensee event report described a >
, containment ventilation isolation generated by, a signal' from the ! containment: intermediate level noble gas process radiation monitor , (PERM 1 D).- The licensee had initially concluded the cause of the event to be an electronic noise-spike, but due to many previous similar events, is continuing the evaluation of this event and will provide a revised LER.. The licensee concluded that the isolation was an electronic malfunction because other radiation monitors measuring the activity of the-effluent did not indicate abnormal (elevated) radiation levels.
This ' LER is. closed based on actions taken to date and plans to submit a , , revised LER when:the root cause-is determined.
- LER 89-28, Revision'0, (Closed), " Personnel Error in Preparing Procedure u Results in Missed Rod Position Surveillance." This licensee event report ' described a violation of technical specification surveillance requirement 4.1.3.2, " Position Indication Channels Surveillance Requirements."
> Monitoring of the shutdown bank rods was not performed every four hours as required when the Rod Position Deviation Monitor was inoperable.
The licensee concluded the cause of the event was personnel error due to a , '
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=i / i failure to include space:for recording the rod position for the shutdown-banks lon the surveillance data sheet and a contributing cause of operators not recognizing a disparity in the frequency in which the control and shutdown bank rods were recorded.
To prevent recurrence of the event, licensee corrective actions included deviating the surveillance procedure data sheet to include both the shutdown and , , control bank rod positions, issuing a training bulletin that clarified the operation of'the rod deviation monitor, and-changing the plant ' computer's software to insure rod position updating-following a computer restart.
The inspectors conducted a follow-up inspection of this event and issued a violation at documented in inspection report 50-344/89-20.
The inspectors concluded a clntributing cause of the event to be the lack ' of knowledge by the operators-of the-technical specification requirement to increase the surveillence of rod position monitoring from twelve hours to four hours when the rod-deviation monitor is inoperable.
. Additionally, no licensee administrative control was implemented to - verify the operability of-the rod deviation monitor prior to shifting
, from four to twelve hour surveillances.
The licensee training bulletin ' discussed these deficiencies.
.4 ' LER 89-29, Revision 0, (Closed), " Fire Dampers and Penetrations- ~ ' Surveillances Not Performed Within Required Time Frames Due to Personnel
- Error." This licensee event report discussed the violation of Technical ' 5pecification 3.7.9 " Penetration Fire Barriers," due.to missing the surveillance periodicity requirement.
The licensee has not yet ' determined the cause of the event and will submit a revised LER,
Licensee corrective actions included immediate implementation of the-e ' compensatory actions of checking local smoke detector operability and L establishing hourly fire patrols.
Subsequently, the licensee tested fire L dampers, as required, by November 30, 1989.
Additionally,'the licensee
recognized that the surveillance tracking of Appendir R associated , technical: specification requirements employs a different tracking system-than used by operations therefore, the surveillance task force will also l evaluate this area.
ThisLERis:closedbasedon'actionstakentodate - E and'the licensee commitment to submit a revised LER.- No violations or deviations were identified.
8.. Followup on Corrective Actions for Violations (92702) L L Enforcement Item 50-344/89-17-01-(Closed), "NCAR/ER per PGE-1080 Was Not l Initiated Within-a Reasonable Time (Boiling in RHR/CCW Heat Exchanger)."
The licensee responded to the Notice of Violation via letter dated October 12, 1989.
The licensee' attributed the violation to the personnel error-of failure to comply with the procedure.
As corrective actions, the licensee issued Event Report 89-105 describing this event and counseled all operating crews and members of the plant staff involved in this event; ? .' Enforcement Item 50-344/89-17-02 (Closed), " Inadequate Procedure (01-T-61 Rev 0) RHR/CCW Heat Exchanger Exceeded Design Analysis Temperature." The licensee responded to the Botice of Violation via letter dated October 12, 1989. The licensee attributed the violation to personnel error in not performing an adequate safety evaluation and tec1nical review, ,
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. ( resulting in an inadequate procedure.
As-corrective actions, the licensee counseled members of the plant staff involved in the initial ' - safety evaluation, performed a walkdown of the associated systems, reviewedthesystems'designbasestoensure-designlimitswerenot exceeded, and distributed a " lessons learned" not4ce to employees.
Plant procedures G01-4 (Plant Shutdown From Hot Standby to Cold Shutdown) and 01-4-1-(Residual Heat Removal) were revised to limit Component Cooling-Water (CCW) temperature and minimum RHR flow through the RHR. heat exchanger. : Actions have been initiated to replace RHR heat exchanger valves by 1991 to allow RHR flow to the heat exchanger to be more effectively throttled.
' Enforcement Item 50-344/89-17-03 (Closed), "Use of Procedure That Could Not Be Performed as Written." The licensee responded.to the Notice of Violation via letter dated October 12 1989. The licensee attributed the violationtothepersonalerroroffalluretocomplywiththeprocedure.
> As corrective actions, the licensee revised procedure 01-T-61 in accordance with A0-4-4 (Procedure Additions,' Revisions Deletions, DeviationsandCorrections)andcounseledindividualsInvolvedwiththis-event concerning their responsibility to follow procedures. The inspectors verified that 01-T-61 was revised.
Enforcement Item 50-344/89-17-04 (0 pen), " EPA-BZ03 Wires Pulled Without Changing Work Instructions Or Obtaining Supervisor Approval.".The licensee, responded to the Notice of Violation via, letter dated October-12, 1989.
T1e licensee attributed the violation to personnel. error, ' namely, -failure to comply with A0-3-9, Section 4.9.1 (MR Package Revisions).
As corrective action, the incident.was discussed with the Plant System Engineering Department regarding the requirements of A0-3-9.
The licensee has also committed to develop guidance to specify activities that can be performed by-designers and engineers during equipment walkdowns-and ins)ections by January 31,.1990.' Development work on this . guidance has not 3een. initiated. - This-item remains open pending completion of actions to' prevent recurrence, as stated by the licensee.
' . .EnforcementLItem 50-344/89-17-05 (Closed), " Plant'Housekeepinc." The ' licensee responded to the Notice of Violation via letter datec. October 12,11989.T1e licensee attributed the violation to a basic misunderstanding of A0-10-1.(Plant Housekeeping) and lack of control of . material (oily rags,' oil in buckets, and. insulation).
A contributing cause was the frequency of supervisory tours of work sites.
As corrective actions, the licensee instructed maintenance personnel on the use of temporary closures, housekeeping, and disassembled parts control.
, , A0-10-1 and MP-3-5 were revised to specifically state temporary closure , requirements.
Enforceme'nt Item 50-344/89-17-06 (0 pen), " Request For Evaluation (RFE) Backl og. " The licensee responded to the Notice of Violation via letter dated October 12, 1989.
The licensee attributed the violation to the personnel error of failure to comply with the requirements of procedure - ' As corrective action, the licensee has contracted for temporary A0-5-5.
-help to develop an RFE backlog reduction plan, reduce the RFE backlog,
and to. develop an action plan for improving the RFE process.
The contract help is on site, but progress on the other action items was not , Ej .. _.
' ~ ,...
> , d' 13- , ,.., ' . l available for review.
This item remains open pending completion of- > corrective actions and actions'to prevent recurrence,-as stated by the- . licensee.- , , . ,,.4 , ' Enforcement Item 50-344/89-19-01 (Closed) " Containment-Sump' Screens . Missing." The licensee responded to the Notice of Violation via letter ' dated Povember 6,1989.
The licensee attributed the violation to an.
original construction error or an-error-in the control of preoperational = testing of the ECCS subsystems.
Failure to recognize the missing screen ,f Learlier than July 1989 was attributed to inadequate implementation of the . design basis for this ECCS subsystem.
- As corrective actions, the licensee has replaced and repaired the .
- containment' sump screens and has-verified that' the design basis of the
.; sump has been restored.
To prevent recurrence, Design Basis Documents ' have been revised to include additional design -information on the containment-sump, initiated. The inspectors.have verified that the sump and a review of other safety 'related systems that use-screens.has been ~ screens.are in place and that DBDs are being revised; , Enforcement ~ Item 50-344/89-19-02-(Closed), " Containment Sump Inspection
Not Performed." The licensee resaonded to the Notice of Violation via > letter dated November 6, 1989.
T1e licensee attributed the violation to I an inadequate-implementation of the design bases for the containment recirculation sump. ' A contributing cause was that the arocedure for . ? ! performing the containment closecut inspection lacked t1e s)ecificity l needed to ensure an adequate inspection was done.
A contri)uting reason
for the' presence'of debris in the containment recirculation sump was i !~ inadequate adherence:to' post-work cleanliness' requirements.
LAs corrective actions, the-licensee cleaned the sump and verified the - ' sump clean.
A0-3-11 was revised to include more specific inspection criteria;and added level of-detail.
Inspection requirements of A0-3-11 were mo'ved to Periodic Engineering Test (PET). procedure PET-5-6.
i Lockwire has been installed on-the containment recirculation sump door to ensure entry into the sump is controlled..The level of detail in - ', procedures is also.being evaluated; this procedure upgrade program is - approximately 35% complete.
DBD Program criteria are being revised and system walkdowns on systems with DBDs are being reperformed.
Employee
- training and tool control measures are also being implemented.
A lock ~ ill be installed on the containment sump door during the 1990 refueling ' w i outage.
The inspectors have reviewed the revised documentation resulting from . this violation and noted that the identified actions either have been or are being completed.
" Enforcement Item 50-344/89-19-03 (Closed), " Failure to Provide Accurate Information for the Inspection-of the Containment Recirculation Sump."
The licensee responded to the Notice of Violation via letter dated ' November 6, 1989.
The licensee' attributed the violation to personnel error.
The error was compounded by an inspection team member ' inadvertently signing off for the sump inspection by mistake.
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.' ' 1~ , , , . - , .. . . - - 14: , & ,.+D - l , As corrective actions, the licensee-took' disci)linary action with the - personnel responsible for failing to perform tie initial containment sump;
, inspection, and the licensee performed the-inspection again using an . upgraded procedure.
A seaarate checklist was developed for inspections
of the containment' sump w11ch requires independent-inspector verification.- To prevent recurrence, senior licensee management l held-meetings with employees to stress procedure compliance and attention to ! ,~ detail.
- Eriforcement Item 50-344/89-19-04'(Closed), " Inadequate Corrective Actions for Quality Assurance Surveillance." The licensee responded to . I.T. Notice of Violation via letter dated November 6,-1989.
The licensee ' N-attributed the violation to an inadequate understanding and , implementation of the. containment sump-design-bases.
.. i 'n As corrective actions, the licensee made changes to the Nuclear Quality Assurance Department (NQAD) management and staff.
The position of ' Manager, Quality Assurance,was elevated to General Manager, Quality t Assurance.
To prevent recurrence, the Nuclear Division Improvement Plan.. ,, ' l . , will be continued; NQAD audit, surveillance-and trend reports are being: ( . . reevaluated for effectiveness; and vacancies within NQAD technical J " , disciplines are being filled with degreed personnel whenever possible.
- . . Enforcement Item 50-344/89-19-05 (Closed), " Inadequate Corrective' Actions In Implementing the Design Basis Document Program." The licensee responded to the Notice of Violation via-letter dated November 6 J 1989.
.l The licensee attributed the violation,to lack of management .. accountability.
As corrective actions, the: licensee assignedlanew Branch Manager i SystemsEngineeringandrequiredthat-theManager,TechnicalServices ' complete a performance upgrade program. Also, a plan of action was t ' developed to complete a review of the DBD: Program.
Additional DBD Program guidance documents are being: developed to state - the content and level of detail, and;to' state the expectations of DBD < E system walkdowns. :The : inspectors ~also verified that the procedure for ' inspecting the containment and the-containment sump had been revised to-include specific inspection criteria.
The inspectors verified that the DBD: action plan and management reorganization were in place.
The new guidance documents for the DBD , -. Program are essentially complete.- , Enforcement * Item 50-344/89-09-09 (Closed),'" Inadequate Procedure -
Incorporation of Control Room Design Change." The licensee responded to .i the Notice of Violation via letter dated October 12 1989.L The licensee attributedtheviolationtopersonnelerrorinnotidentifyingthe required procedural-change, and failure to complete the required procedural change after the discrepancy was discovered by the internal Safety System Functional Inspection (SSFI) team.
As' corrective actions, the licensee revised ONI-46 (Loss of 120-VAC Instrument. Bus) and reemphasized individual responsibility in this area . a ,
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i5 . . H(di T to the Operations Support Staff.
The licensee is also in the process of-upgrading;its procedures onto a computer system that will have the ONI-46.. y to perform key word searches.
The inspectors have reviewed capabilit y 9.
Follow-up on Open Items (92701) Open Item-50-344/89-17-07 (0 pen), " Quality Hot Line (QHL) Formal -Tracking Mechanism.". The licensee has not yet responded to this item which was ' initially identified by QHL item number 89-04.
This item remains open - - -pending completion of corrective actions and actions to prevent-recurrence.
Open Item 50-344/89-17-08 (0 pen) " Time Frame for As-Built Plant Modifications Package." The licensee has not yet responded to this item, which was initially identified in Inspection Report 89-09.
This item remains open pending completion of corractive actions and actions to prevent recurrence.
Open Items 89-12-01 thru 89-12-05 (0 pen) "Non-Destructive Examination Open Items" 'The Inspector reviewed inspection report 89-12, conducted by Messrs.
Kerch, Harris, Oliveri, of the NRC, and five NRC. contractors, from May - 22,-1989 through June 1, 1989.
violations in the Inservice Inspection (ISI) area. port presented five This inspection re The licensee contested Violation A (Follow-up Open Item 89-12-05), which references that written examinations should be administered without access to reference material (closed book) except that necessary data, such as graphs, tables, specifications, procedures, and codes may be provided.
The inspector discussed the violation with the licensee,:and.the licensee agreed that the violation had occurred and agreed to rewrite the. reply to Violation A.
Violations B thru E (0 pen Items.89-12-01 thru 89-12-04) replies were reviewed by the inspector, however the corrective action steps taken to avoid further violations would not be completed until March 21, 1990.- 10.
Fitness for Duty (FFD): Inspection of Initial Training Programs (TI 2515/104) On June 7, 1989, the Commission published the final rule and statement of policy on fitness-for-duty programs for commercial nuclear power reactors, with an effective date for program implementation of January 3,1990.
To implement the rule, the licensee conducted training sessions to indoctrinate employees on the requirements of the rule prior to the rule's implementation.
The inspectors attended a policy awareness training session for general employees, a training session for managers / supervisors and a training session for those personnel who perform escort duties.
Additionally, the inspectors reviewed applicable licensee Nuclear Department Procedures (NDP 900 series) prior to attending the trainin, . - - - - - - - - - - - a q, < [q[y
, [ ,7 4a f ' The inspectors concluded the Policy Awareness Training for the general > employees generally addressed the new rule by discussi_ng the following: Licensee policy and procedures, including the methods used to - , implement-the policy; Personal and public health and safety; hazards associated with - drug abuse and misuse of. alcohol; - , The affect of prescription drugs on the testing and the role of - the Medical Officer; .The' employee assistance program (EAP); and - _ _ What is expecte'd'of' employees and the consequences that may- - result from lack of adherence-to the policy.
The inspectors' concluded the'FFD training for supervisory and management personnel generally addressed the new rule with respect to managers / supervisor responsibilities.by discussing the following: Management and supervisors role and responsibility.-in - implementing the program; . The roles and responsibilities of others such as the personnel, - medical, and employee assistance program staffs; Techniques =for recognizing drugs and indications of the use, '" - sale or possession of drugs; Behavioral observation techniques for detecting. degradation in - performance, impairment or change-in employee behavior; and Procedures for initiating aparopriate corrective action, - including referral to.the EAP.. Since the licensee does n'ot have employees whose sole function is to serve as an escort separate escort training sessions were not conducted; howeverescorttralningwasincludedinboththePolicyAwareness ~ Training-for general employees, and the FFD training for general employees and the FFD training for managers / supervisors, since any PGE employee may escort visitors.
The training generally addressed the responsibilities of an escort by addressing the following:. Their responsibilities when escorting; - Techniques for recognizing drugs and indications of use, sale, - or possession of drugs; Behavior observation techniques for detecting use of drugs; - and, Actions to be taken if a visitor is suspected of being under - the influence of drugs.
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l After the training sessions, the inspectors discussed with licensee management potential FFD training improvements.
Specifically for-managers / supervisors'more detailed explanatio ' drugs and- < - behavioral observation techniques were recommended.
Additiona in the . . _ managers / supervisors training, the definition of their responsibil ' ~ e
- as escorts could have been more detailed.
The licensee made changes to- , the training based on the inspectors observations.
' 11.
Licensee Safety System Functional Inspection 5This inspection was to assess the' licensee's performance in several areas of technical work during their performance of a Safety System Functional: Ins Document (DBD)pection(SSFI).
The areas to be reviewed were Design Basis ! reconstruction effort, the system engineer involvement in
inormal and off-normal-plant events, and licensee management involvement in the SSFI inspection.
H Trojan, with assistance from an engineering contract firm, United Energy-Services Corporation (UESC), conducted a SSFI to assess the design of the service water system.
In addition any deficiencies identified in the designofthesystemweretobefollowedintoothersystemswherejudged , appropriate.z l The SSFI objectives were to assess the operational readiness of a selected safety system through determination of the following: a.
Capability of the system to perform all safety functions.
I b.
Whether the system has been adequately tested to perform all H-safety functions, i c.
Whether the system's components have been maintained to ensure i operability under all postulated conditions.
- l d.
Whether the system's initiating and control functions were effective.
I e.
Whether operator training, plant procedures, and equipment accessibility were adequate to ensure proper operations under
accident conditions.
.The inspector reviewed the SSFI team Design Basis Document (DBD) inspection effort on the service water system.
The team discovered that .after the replacement of the service water pumps' impellers with larger impelle'rs the pump curves were not replaced with new curves.
In addition, the.DBD did not reflect this fact or that the pump manual was not updated.
The team also discovered that the booster pumps lead / lag logic operated per the design-schematics, however the DBD was incomplete in the description of'how it operated.
The team discovered that Maintenance Request (MR) 89-4971 was initiated to determine how the booster pump's control logic performed their lead / lag functions.
(A particular interesting aspect of this discovery was that the simulator training staff was the initiating organization for determining the booster pumps lead / lag functions.) The team found that the MR was
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- 3g_ , h w *d sl p , - presented to.the operations deiartment, and the engineering department ' was not presented with the pro)1em to-determine functionality or correctness of the lead / lag circuit during the entire investigation.
. _ . Finally, the SSFI team discovered that DBD open items were not resolved n 'in a timely manner.
The inspector concluded that the SSFI's-DBD - inspection effort ap) eared to acceptably uncover discrepancies.or . deficiencies in the )BD.: The team discovered the incorrect use of an MR< 'to' conduct a. design review on.the booster pumps lead / lag functions.
The next concern reviewed was the system engineer involvement.in normal . and off-normal plant events.
Several bronze valves were replaced 4 . commencing in 1987 with heavier replacement valves which caused a1 seismic-j
as well as a desigry pressure concern.
The bronze valves were 600 psi l design pressure being installed into a 150 psi design area.
Normally there would not have been a pressure concern except that the replacement H . valves had threaded connections and machining was performed for the-q socket' connections.
Other aspects of the valve replacement problem.
, y' -occurred, such as hanger supports, valve throttle settings, and seismic ' category II/I concerns.
The system engineer appeared to solve the short term-problem i. e.
the particular valve being replaced at the time; but was not makin,g_a ge,neric case for future replacements.
Eventually all . p ' . . valve replacement concerns were addressed after several valves were replaced.
The SSFI team found that system engineer involvement with replacement valves could have been more systematic and concise.
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The:SSFI team discovered another issue during the walkdown of Emergency
Operating Procedures (EOPs) for service water system fire protection ! . considerations.
It was concluded that the' system engineer and operations -{ L personnel were not using the emergency lighting, but were using normal
u
- 11ghting'for thq E0P walkdowns.
Har less than normal light was available j 1.
to see and direct valve and pump operations using only tie emergency ? lighting.
The team determined that valve and pump operations would have ! y been difficult without flashlights while using emergency lighting.
i- -. - . -l - A' final issue in:this area determined by the SSFI team was a potential d conflict between Final Safety Analysis Report (FSAR) and Operating i Instruction temperature limits. The FSAR service water temperature limit j is 75 degrees F., and in 1985 Trojan contracted Bechtel to evaluate
whether a service water temperature of 77 degrees F. was permissible.
The tvaluation was conducted because the Columbia River was approaching a l L , temperature of 74 degrees F. that summer.
Bechtel responded with an j evaluation that 77 degrees F. would not affect system caeration.
E H Consequentl Operation,"y, Operating Instruction (0IT 4-3, " Service Water System. limits s ~;
- direct conflict with the FSAR's temperature limit.
01.4-3 is adequate to i
o)erate the service water system but this conflict in limits indicated tlat the review of the OI and the FSAR by the system engineer or j engineering management may have been inadequate.
-.The-last area. reviewed was management involvement in the SSFI inspection.
! .During the SSFI of'the service water system, plant management was i involved in the SSFI by having representatives from maintenance,
operations, and engineering interacting with the SSFI team members.
In g addition,'at each briefing in the morning and at the end of;the_ day, o . i l , s , _ - ,
g.
, gin pJ l '; i
.. .y plant management and. supervisors were present to receive the details of ~ , the SSFI team-findings.
The SSFI cteam used a Request for Information - e , t (RI) form.to obtain further details of 3 articular problems or design requests.
These RIs were answers could be obtained.provided to tie organization from which the a .. Generally; the answers were provided with - . sufficient detail by the cognizant engineer or personnel.
,- lit. appears that the management involvement in the SSFI team inspection was acceptable for the problems uncovered.
The-RIs were answered either ' the day they were requested or the next da observed by the inspector from all levels,y. -Management attention wasinclud e h Th'e inspector made the following observations concerning the SSFI team inspection: -The team members appeared knowledgeable and experienced in - their respective areas; licensee management' appeared to be very responsive to the-identified issues or discreaancies as they appeared'or as requested by the RIs: the~SSFI team's dept 1 of review appeared.to be l sufficient to uncover discrepancies or design deficiencies; the J licensee's engineering support of the SSFI team findings was responsive 'andtheSSFIteamobjectiveswerebeingmet.
, J 12.
Exit Interview (30703 and 30702) .The inspectors met with.the licenseo representatives denoted in para'raph , L 1 on December 1 1989 and January 11, 1990, and with licensee management
throughouttheInspectionperiod.
In these meetings the inspectors , l summarized the scope and findings of the inspection-activities.
The ' ' ' inspectors emphasized the~ continuing instances of procedural noncompliance, personnel error and inadequate supervision of routine and off-normal activities.
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