IR 05000344/1992032

Insp Rept 50-344/92-32 on 921027-1207.Violations Noted.Major Areas Inspected:Maintenance,Surveillance,Event Followup & Followup of Previously Identified Items

ML20127E977
Person / Time
Site:	Trojan File:Portland General Electric icon.png
Issue date:	01/08/1993
From:	Johnson P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20127E920	List: IR 05000344/1992032 ML20127E918 ML20127E946
References
50-344-92-32, NUDOCS 9301200106
Download: ML20127E977 (23)

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i U. S. NUCLEAR REGULATORY COMMISSION REGION V i l

Report N /92-32 Docket N License N NPF-1 >

Licensee: Portland General Electric Company 121 S. W. Salmon Street Portland, Oregon 97204 Facility Name: Trojan Nuclear Plant Inspection At: Rainier, Oregon inspection Conducted: October 27 - December 7, 1992 Inspectors: R. C. Barr, Senior Resident inspector J. F. Melfi, Resident . inspector K. E. Johnston, Project inspector (November 16 - 19, 1992, Paragraph 10)

Approved By: MM P. Date Signed Reactu(Jphnson, Chief 1 Projects Section Summary:

Inspection on October 27 - December 7. 1992 (Inspection Report N /92-32)

Areas Inspectedi- Loutine inspection of operational safety verification, maintenance, surveillance, event followup, and followup of previously identified items, inspection procedures 61726, 62703, 71707, 92700, 92701, 92702 and 93702 were used as guidance during the conduct of the inspectio Results:

General Conclusions and Specific Findinas:

Strenoths:

The immediate response of Trojan operators to the November 9, 1992, steam generator (SG) tube leak was excellent. The operators correctly and rapidly responded to plant-indications and followed emergency procedure The operators' shutdown and depressurization of the reactor was very timely, allowing only a very minor release of radioactivit PDR .ADOCK 05000344 G PDR

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Weaknesses:

Based on the apparent violations of Paragraph 5.b. the inspector concluded that the licensee should strengthen their oversight of-  ;

contractor activities. The licensee should identify which of the -

-contractor activities can affect safety and assure that the contractor has established adequate procedures and administrative control .j Sionificant Safety Matters:

None Summary of Violations and Deviations:

Four cited violations (Paragraphs 3.b, 5.b, and 10) and three non-cited violations (Paragraph 3.a and 5.b) were identifie Open items Summary:

Two LERs (Paragraph 7), three followup items (Paragraph 8) and three-

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enforcement items (Paragraph 9) were close !

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! Portland General Electric t J. E. Cross, Vice President and Chief Nuclear Officer

• R. Robinson, Vice President, Nuclear '

• R. D. Nachon, Plant General Manager

• G. D. Hicks, General Manager, Plant Support

• C, K. Seaman, General Manager, Nuclear Plant Engineering D. L. Nordstrom, General Manager, Nuclear Oversight -

• T. D. Walt, General Manager, Technical function !

C. P. Yundt, Project Manager, Special Projects -

A. R. Ankrum, Hanager, Nuclear Training J. A. Benjamin, Manager, Quality Control R. D. Brandt, Acting Manager, Surveillance Procedures L. K. Houghtby, Manager, Nuclear Security '

H. K. Chernoff, Manager, Licensing H. B. Lackey, Manager, Planning and Control <

S. B. Nichols, Outage Manager W. O. Nicholson, Manager, Operations J. W. Patterson, Manager, Maintenance

5. H. Quennoz, Manager, Technical Services H. Singh, Manager, Plant Hodifications

• R. E. Susee, Acting General Handger, Nuclear Oversight -

G. P. Enterline, Branch Manager, Operations H. G. Cooksey, Maintenance Supervisor

• W. J. Williams, Manager, Nuclear Compliance J. W. Allison, Supervisor, Plant Hodifications A. C. Bielat Manager, Independent Safety Review Group C. H. Dieterle, Supervisor, Individual Plant Examination

• J. G. Frantz, Compliance Engineer

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• J. H. Pedro, Compliance Specialist E.-W. Ford, Compliance Specialist R. N. Sherman, Compliance Specialist D. Sparks Acting Supervisor, fire Protection H. R. Gandert, Supervisor, Nuclear Plant Engineering B. R. Wallis, independent Safety Review Group t Oreaon Department of Eneray

• A. Bless, Resident Safety Manager- ~

• V. Sarte, Resident Inspector

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-The inspectors also interviewed and talked with other licensee employees during the course of the inspection. These included shift supervisors, reactor and auxiliary operators, maintenance personnel,-plant technicians and engineers, and quality assurance personne * Denotes those attending the exit intervie ,

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-2- Plant Status The inspection period started with the reactor at 100% power. At 6:41 a.m. on November 9, 1992, with the reactor at 95% power, process and effluent radiation monitor (PERM) 26B, which monitors Nitrogen 16 (N-16)

gammas, alarmed, indicating a tube leak in the B Steam Generator (SG).

Operators immediately shutdown the reactor. The reactor remained shutdown the remainder of the inspection period for SG tube inspection and repair . Operational Safety Verification (71707)

During this inspection period, the inspectors observed and examined plant

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activities to verify the operational safety of the licensee's facilit Observations and examinations of those activities were conducted on a daily, weekly or biweekly basi 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 regulation 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 oncoming shift personne Each week the inspectors toured accessible areas of the facility to obsarve the following items:

• General plant and equipment conditions 4

• Maintenance requests and repairs e fire hazards and fire fighting equipment

• Ignition sources and flammable material control

• Conduct of activities in accordance with the licensee's administrative controls and approved procedures

• Interiors of electrical and control panels

• Implementation of the licensee's physical security plan

• Radiation protection controls

• Plant housekeeping and cleanliness-

• Radioactive waste systems

• Proper storage of compressed gas bottles

, Weekly, the inspectors examined the licensee's equipment clearance

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controls with respect to removal of equipment from service to determine that the licensee had complied with Technical Specifications limiting conditions for operation. Active clearances were spot-checked to ensure that their issuance was consistent with plant status-and maintenance evolutions. Logs of jumpers, bypasses, caution and test tags were i- examined by the inspectors.

. Each week the inspectors conversed with operators in the control room, l

and with other plant personnel. The discussions centered on pertinent j topics relating to general plant conditions, procedures,-security, L training and other topics related to in-progress work activitie l i-

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The inspectors examined selected Corrective Action Requests (CARS)

within the licensee's Corrective Action Program (CAP) to confirm that deficiencies were identified and tracked by the system. Identified nonconformances were being tracked through completion of the corrective

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actio Routine inspections of the licensee's physical security program were performed in the areas of access control, organization and staffing, and detection and assessment system The inspectors observed the access control measures used at the entrance to the protected area, 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 obstruction 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 sit 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 information. 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 signifi-cant plant activities were assessed through conversations and review of RWP sign-in record 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 applicabl Compliance with Radiation Protection Procedures (1) Operator Entry into a Posted Hiah Radiation Area Without Required coveraae At 2:10 a.m. on November 12, 1992, while touring the 45 foot level of containment in the accompaniment of a Radiation Protection Technician (RP1), an Oregon Department of Energy (0 DOE) inspector observed an Auxiliary Operator in a high radiation area near the entrance to the recirculation sum Both the ODOE inspector and the-RPT noted that the auxiliary operator did not have a survey meter and was not accompanied by an RPT. To both the inspector and the RPT, this appeared to be-a violation of Trojan Plant Procedure (TPP) 20-12, " Access Control for High Radiation Areas," step 4.1.5, that states:

"All entries to high radiation areas require the use of an

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Instrument which continuously indicates the dose rate in the area."

The RPT accompanying the ODOE inspector stopped the operator and pointed out that he had been in a high radiation area without proper coverage. The RPT surveyed the area where the operator had been and found the highest radiation level to be approximately six millirem per hour (mr/hr). The RPT also verified that the operator's digital alarming dosimeter (DAD)

indicated acceptable dos The operator explained that he had entered the area briefly to perform a surveillance test, P0T 3-3DE, " Containment Penetration Valve Inservice Test," and that completion of this surveillance was required prior to reduced inventory operation. The auxiliary operator exited containment in response to a call from the control roo The RPT promptly notified the Radiation Protection shift coordinator and the shift supervisor in the control room. Upon completing the tour and exiting containment, the RPT's supervisor promptly documented his observation in Corrective Action Request (CAR) 92-0545. The CAR evaluation concluded that the operator's entry into the area was not in compliance with TPP 20-12 and characterized the worker's action as an apparent noncompliance with Radiation Work Permit (RWP) 92-4005, the Trojan Radiation Protection Manual, and with Technical Specification 6.12. The 000E inspector discussed this observation with PGE radiation protection management and the NRC resident inspecto The NRC inspector verified the accuracy of the RPT and the ODOE inspector's observation, discussed the apparent violation with PGE management and reviewed the CA The NRC resident inspector found the CAR determination of root cause, complacency on p rt of the operator and poor communications, and the CAR corrective actions, counseling of the operator and improved radiation area posting, adequate. This apparent violation is not being cited because the criteria specified in Section VII.B.(1) of the Enforcement Policy were satisfied (NCY 50-344/92-32-01).

(2) RPT Containment Entry Without Reouired Protective Clothina On November 13, 1992 at approximately 10:00 a.m., an ODOE inspector entered the containment airlock to observe Instrumentation and Control (I&C) technicians calibrating level transmitter LT-1040. As the inspector entered the containment airlock, he was joined by an RPT. The ODOE inspector observed that the RPT was dressed in anti-contamination clothing,- but was carrying his cloth hood in one hand. The RPT's entry into-the airlock appeared to be in violation of Trojan Plant Procedure (TPP) 14-12, " Radiation Work Permits," which states that the worker " reviews and complies with all requirements outlined in the RWP." The RPT donned the hood while standing

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-5-in the airlock. The inspector asked the RPT if PGE procedures allowed entry into the airlock without wearing the hood. The RPT replied that he was in a hurry and had to get to the jo After leaving containment, the ODOE inspector discussed his observation of the RPT with Radiation Protection (RP)

management and the NRC resident inspecto RP management stated that the RPT's entry into the airlock without wearing his hood would only be acceptable if the RWP on which the RPT was assigned permitted an unhooded entry. RP management committed to follow up the ODOE inspector's observation, and concluded that the RPT had in fact violated TPP 14-12 by not complying with the requirements of RWP 92-4004. As corrective action, RP management took disciplinary action with the RPT and discussed the event within the RP departmen The NRC inspector verified the accuracy of the ODOE inspector's observation and discussed the apparent violation with PGE management. The corrective action implemented by PGE management appeared appropriat This apparent violation is not being cited because the criteria specified in Section VII.B.(1) of the Enforcement Policy were satisfied (NCV 50-344/92-32-02). Warehouse-Access Not Controlled by Authorized Personnel On November 12, 1992, an ODOE inspector entered the Trojan issue warehouse during a routine plant tour. He found the door open,-the access point unattended, and the gate to the parts storage area open. He entered the parts storage area and walked through the area without seeing any PGE staff. The inspector notified the Control Room that access to the storage facility appeared not to be controlled as required by TPP 16-12 "Haterial-Storage and In Storage Inspection and Checks," that states:

"The Materials Manager shall ensure access to Material Services storage facilities .... is controlled." and "As a minimum, the following controls shall be applied: a. All access doors to storage facilities shall be locked or controlled by authorized personnel."

The Control Room operator paged the warehouse person on duty, who appeared shortly thereafte On November 15, 1992, the ODOE inspector entered the issue warehouse again during a routine plant tour. The access point to the parts storage area was again unattended, and the inspector entered the parts storage area and waited until the attendant appeared. The-000E inspector notified Operations shift management that he had found the issue warehouse unattended. The 000E inspector requested that a concern form be generated to document his observation. The 000E inspector discussed his observation and concern about warehouse access control with the NRC resident inspector.

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-6-The licensee initiated CAR 92-0557 to evaluate the 000E inspector's observations. The CAR evaluation concluded that more restrictive measures were required to control access to the Trojan warehouse The CAR corrective action required the warehouse attendants to lock the warehouse exterior door when not at the issue counter and to wear a pager at all time The NRC inspector verified the accuracy of the ODOE inspector's observations, reviewed the CAR data base for previous concerns about

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warehouse access and then discussed the apparent violation with PGE management. The NRC resident inspector found that CAR 91-0269 had also identified that warehouse access control required strengthen-ing. The lic.ensee implemented the following corrective actions for CAR 91-0269: revised material services procedures, restricted ware-house access to approved personnel, revised their unescorted access list, and held documented training sessions for warehouse personnel regarding access control. The licensee closed CAR 91-0269 on July 9, 1991, based on completion of these corrective actions. Licensee followup of these corrective actions appeared insufficient to identify chat the corrective actions did not fully resolve warehouse access control concerns. The corrective action that PGE management implemented for CAR 92-0557 appeared appropriate for full resolution of warehouse access control concerns. This is an apparent violation of 10 CFR 50, Appendix B, Criterion XVI (50-344/92-32-03).

One cited violation and two non-cited violations were identified, as discussed abov . Maintenance (627031 The inspector observed the licensee rebuild the reactor coolant pump (RCP) seals for the C RC The pump seals had shown erratic behavior before plant shutdown, and the licensee replaced the seals pursuant to Maintenance Request (HR) 92-4127. MR 92-4127 used the guidance contained in Maintenance Procedure (HP) 5-5, " Removal and Replacement of Reactor Coolant Pump Seals." The inspector compared this procedure with the RCP vendor manual, and HP 5-5 generally followed the disassembly / reassembly _

instructions contained in the vendor manua Qualified vendor (Westinghouse) personnel, under the licensee's supervision, did the work using calibrated equipment. Inspection of the old seal did not reveal apparent conditions that would have caused the erratic behavior observe During the observation of the work, the inspector observed no conditions that would adversely affect the operability of the seals, but observed some activities which involved poor maintenance practices or conflicted with PGE policies. These were: (1) the ladder going up the RCP platform could have been improved to pose less of a safety hazard, and (2) the contract maintenance personnel noticeably displaced the number 2 and number 3 leakoff lines, moving them down about 12 inche The inspector and a Radiation Protection (RP) technician noted several items that did not appear to be in accordance with Occupational Safety-

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and llealth Administration (OSHA) standards for a ladder. The ladder to the platform was longer than 20 feet, the end of the ladder was tiewrapped to the platform and did not extend past the platform surface, and the slope was greater than 4:1. This was the only access to the platform, due to RP concerns. Once a worker reached the top of the ladder, he also had to climb over rails to reach the slatform. After the inspector mentioned this situation to the licensee, 11ey agreed it could be improved and built another scaffold platform about five feet down from '

the platform surface, attaching another ladder to permit access to the

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platform. The inspector reviewed Plant Safety (PS) procedure 8-5,

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" Ladders," and found that the original ladder did conform to procedure requirements and to Oregon OSHA standard During the work observation, the inspector noticed that contract personnel had bent down the free ends of the number 2 and number 3 leakoff lines. These leakoff line ends protrude into the _RCP motor stand, where the workers were removing and replacing the seals. Due to -

the tight space inside the motor stand, the workers occasionally pulled these leakoff lines out of position to permit access for seal remova After the inspector mentioned this to PGE supervision, maintenance personnel secured the ends of these lines. Nuclear Plant Engineering (NPE) personnel, in discussions with the inspector, stated that the lines "

had not exceeded code allowable stresses. The inspector noticed that the leakoff lines returned to their original positions when released, indicating no plastic deformation.

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While these observations did not result in a safety concern, they indicated a need to more closely monitor vendors for implementation of good work practice ,

No violations or deviations were identifie . Event Followun (62703. 93702)

B Steam Generator (SG) Tube leak. Inspection and Repairs B SG Tube leak At 6:41 a.m. on November 9, 1992, with the reactor at 95% power, process and effluent radiation monitor (PERM) 26B, which monitors Nitrogen 16 (N-16) gammas, alarmed, indicating a tube leak in the B S The shift manager immediately dispatched an operator to evaluate the alarm. The operator concluded this alarm was valid, ,

indicating a leak of about 140 gallons per day (gpd). . The operator remained stationed at PERM 268 to monitor the leak rate. At 6:43 a.m., condenser off gas radiation monitor PERM 6A alarmed, also indicating a leaking steam generator tube. At 6:44 a.m., the operator dispatched to PERM-26B reported a reading of approximately 200 gpd. Licensed operators began a rapid reactor shutdown at 6:45 a.m., and at 7:00 a.m. the Shift Manager declared an unusual event (UE). The operators manually tripped the reactor from 5% power at 7:30 a.m. and licensed operators isolated the B SG at 7:44 a.m.,

terminating the roble gas releas ,

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-8-The licensee calculated that approximately 0.2 curies of radioactive noble gas was released during the event. At 7:51 a.m., the operators began a reactor cooldown. At 9:11 a.m., with the reactor coolant system (RCS) at 513 F, operators began RCS depressurization to :ninimite the leakage of reactor coolant into the B SG. At 9:30 a.m., RCS and SG pressure were about equal, essentially stopping the leakage of RCS water into the B SG. The licensee terminated the unusual event at 10:40 a.m. and continued with reactor cooldow The plant reached Mode 4, Hot Shutdown, at 2:22 p.m., and Mode 5, Cold Shutdown, on November 10 at 5:09 The inspector observed the licensee respond to the SG tube leak event from the control room. The inspector concluded that the licensee's response was timely, thorough and in accordance with Trojan procedures. The inspector observed that communications in the control room were clear and concise. The control room staff also displayed good teamwork in monitoring the numerous coincident activities during the event. SG Tube Inspection and Repairs From November 16, 1992 to the end of the inspection period, PGE, employing Babcock and Wilcox (B&W) and Allen Nuclear Associates (ANA) as contractors, inspected the B, C and D SG tubes. Inspection of the B SG found that the tube located in row 25, column 17, had failed at the lower weld of the sleeve located at the first tube support plate. The licensee had installed the sleeve during the 1991 Refueling Outag PGE concluded from review of 1991 SG repair records and 1992 eddy current examination that the weld failed because the sleeve had not been stress relieved (because the heater had not been fully inserted into the sleeve). Based on this finding, PGE performed eddy current inspections in November 1992 of all SG tubes that had been sleeved. These examinations confirmed that all the remaining 1095 sleeves were properly stress relieve At the conclusion of the inspection period, the licensee was evalua-ting the SG tube eddy current examination results and considering whether to perform additional tube inspections to support a license amendment change that would justify continued operatio The licensee convened an event review team (ERT) to evaluate the event and determine a root cause of the SG tube failure. The ERT's review of the data identified that the tube failure had progressed in three steps. For the first seven minutes of the event the leak rate was about .5 pints per minute (100 gpd); for the second seven-minute period, the leak rate increased to about one pint per minute (200 gpd); for the remainder of the event the leak increased t about five gallons per minute. The ERT concluded that between 300 to 800 gallons of RCS water had leaked into the B SG. The ERT concluded that the increase in leak rate was expected due to the tensile stresses experienced by the SG tubes during a rapid power reduction. The-ERT concluded that the root cause of the tube failure was failure to stress-relieve one tube, due to a combination of operator error and an inadequate stress relieving procedur _ _ _ _ _ _ _ _ . _ _ . _ _ _ . _ . ___ __ _ _ _ . - _ __

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4 The inspector reviewed the ERT report and historical data, spoke with m a agers and supervisors, observed selected portions of B, C, ar.d D SG tube inspections, and attended selected management meetings at which the tube failure was discussed. The inspector concurred with the licensee's determination of root caus The inspector reviewed B&W procedure 10876A2-1, dated January 1990,

" Field Procedure for Recirculating Steam Generator Tube Sleeving."

Section 9.0 established steps for stress relief heater operatio The procedure required the operator to remotely insert the heater in the sleeve and, during the insertion, to monitor the hardstop pressure signal on the computer (changes in the hardstop pressure indicate when the heater is properly positioned within the sleeve).

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At the completion of heater insertion, the procedure required the operator to verify that the hardstop signal was adequate. However, the procedure contained no guidance to the_ operator on the criteria for acceptability of the hardstop pressure. In discussion with the licensee and B&W personnel, the inspector learned that the heater operators had been trained on observing the hardstop pressures, but that a clear acceptance criterion had not been established to assure the heater had been properly inserted into the sleeve. This is an apparent violation of T.S. 6.8.1.a. which requires adequate proce--

dures for repair of steam generator tubes (NCV 50-344/92-32-04).

This apparent violation was not cited because the criteria of Section Vll.B.2 of the Enforcement Policy were me The inspector reviewed the work history of the individuals who performed the heat annealing of the failed tube, which is a safety related function. The inspector found that the-individual had been working seven days a week, 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> per day, and that management authorization to exceed the established overtime limitations had not been obtained. This exceeded the work hour limitations of .2.2.g. and Administrative Order A0 3-24, " Fitness for Duty and Work Hours." This is an apparent violation (50-344/92-32-05).

The above apparent violations indicated a need for the licensee to strengthen their oversight of contractor activitie . Surveillante (61726)

B Train Auxiliary Feedwater (AFW) Pumn Speed Oscillations During the normal surveillance test on the B train AFW pump (November 15, 1992), operators noticed speed oscillations on the diesel engine driver for this pump. With the pump in manual, the licensee observed:

• Incorrect speed (low) versus the pump demand speed;

• A speed drop from 1200 rpm (100% flow) to 800 rpm without operator action;

• A speed increase from 600 rpm (less that 0% flow).without operator l action; l * A speed drop from 600 rpm to 100 rpm, resulting in a low lube oil I pressure trip.

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The licensee investigated to find the cause for these pump speed swing They concluded that two problems contributed to these speed swings and also identified an annunciator problem during their investigation. The contributing problems were (1) fuel starvation of the injectors due to the manual priming pump suction check valve sticking open and (2) high contact resistance in the diesel speed control circui The annunciator problem identified was that it was possible to trip the diesel engine and not receive annunciation on a computer that it had trippe The licensee replaced the check valve that was sticking with an equiva-lent spare part. The manual priming pump is installed in parallel with the normal engine driven supply pump. With the suction check valve sticking open on the manual priming pump, fuel oil was being diverted from the injectors, starving the engine. Af ter replacement of the check valve, adequate flow and pressure were maintained to the injector _

During post-maintenance testing of the diesel engine, the engine unex-pectedly shut down after the engine was reduced to idle speed (about 644 rpm). The computer did not show that the diesel had shut down. The licensee investigated the control circuit and found a high resistance contact on an Agastat relay. The licensee determined that it was a misapplication of the relay, since the relay design is for 125 volts DC and 10 amps. This Agastat relay energizes a transistor in the starting circuit that uses 0.002 amps at 0.6 volts. The resistance changes (24 to 294 micro-ohms) observed at the contact affected the operation of the transistor. The licensee verified that there were no other misapplied Agastats in the AFW circuitry. The licensee replaced this Agastat with an identical part, and was considering a long term fix to this proble The licensee began a preventive maintenance replacement cycle for this Agastat relay, pending completion of a possible design chang The annunciation problem was found to be a design oversight, in that it is possible to get a momentary trip of the diesel without receiving an alarm on the compute The licensee is initiating a plant modification _

request (PMR) to install a-seal-in feature in-the trip-software circuitr There were other indications of_ a problem with the pump, including AFW flow indication and other alarms (e.g., loss of oil soakback pump) on the AFW diesel engin Following completion of corrective actions, the licensee tested the AFW pump and observed the engine during operation, with satisfactory result No violations or deviations were identifie . f_ollowun of licensee Event Reports (92700)

The inspector closed the following LERs based on in-office review. This review determined-that the licensee had adequately described the event, determined the root cause, and implemented or identified appropriate corrective action LER 90-46. Revisions 0 and 1 (Closed). " Inadvertent Actuation of Cable Spreadina Room Deluae System"

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• l WL92-20. Revision 1 (Closed). "Rfutetor Trio Caused by failure of the Controller on Main feedwater Pumo B Due to Electronic Component failures."

Initial inspector followup of this event was documented in NRC inspection report 50-344/92-2 No violations or deviations were identifie l followuo of Goen and Unresoly-d items (927011 l l

Followuo item 92-21-03 (Closed). " Class 1E/Non IE Interaction" This item was initiated to determine if the main feedwater (MFW) and auxiliary feedwater (AFW) power supplies were consistent with applicable design requirements. The licensee concluded in LER 92-20, Revision 1, that the power supply designs met the applicable design requirements at the time of system design. The inspectors reviewed LER 92-20, Revision 1, and its supporting documentation and concurred with the licensee's determination. This item is closed based on LER 92-20, Revision Followuo item 92-21-05 (Closed). "Temocrary Modifications" During a review of temporary modifications (TMs), the inspector had raised two issues on temporary modifications. These were:

• The oldest TM did not meet the intent of a temporary modification, since it was installed for a long time and apparently would continue to be be installed for a further period of time. Specifically, TM 85-003, " Solenoid valve on A Waste Gas Compressor," was installed in January 1985 and was scheduled to be removed in February 199 * The other issue concerned administrative controls for TMs for disabled annunciators and whether the licensee met the requirements ,

of Regulatory Guide (RG) 1.33. The inspector noticed that the licensee removed TM 85-086 employing the requirements of another procedur The licensee used a non-quality-related lower tier procedure, OM 4-14, " Annunciator System," to disable annunciator During subsequent discussions the licensee indicated an intent to make TM 85-003 a permanent design change by the end of 199 When-TM 85-086 was issued, disabled annunciators were required to be TM With Temporary Change Notice (TCN)91-596 (initiated November 25,1991),

disabled annunciators could be excluded as a TM. The licensee closed this TM on November 25,:1991 after TCN 91-956 was initiate RG 1.33 requires that all TMs be logged, independently verified and periodically reviewe Disabled annunciators are logged per OH 4-14 and reviewed before each startup, to verify that no technical specification annunciators are disable The Operations Department reviews the disabled annunciator ~ log weekl _

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Since the licensee is meeting the requirements of RG 1,33 with OH 4-14, and since TH 85-003 will be incorporated into the permanent design of the facility, this item is closed, followuo item 92-24-02 (Closed). " Actuator Snrino Settina IJ1 correct and Sprina Comoression Drift" During observation of several air-to-open, spring-to-close containment isolation valves, the inspectors noticed that the initial spring setting was incorrect, and the valve spring force appeared to drift. The inspectors opened this item to understand why this happene The

" spring" used to close this valve is a series of Belleville washers. The force required to open the valve was measured by air pressure, since the ,

surface area on the disk is constant. The force to open the valve was about one-half to two-thirds of the specified value on the drawings. The vendor supplied the valves with the specified setting. After the licensee reset the valves, the inspectors and the licensee noticed that the force declined about 5% within one hou ,

In response to this item, the licensee formed an Event Review Team (ERT).

The licensee tested a similar series of Belleville washers to approxi-mately the same force. After 44 hours5.092593e-4 days <br />0.0122 hours <br />7.275132e-5 weeks <br />1.6742e-5 months <br /> of this test, they did not see any compression set or drift except for some minor diurnal variatio During discussions with the inspector, the Technical Services Manager said it was not possible to determine conclusively what had happened. He also said it was likely that the valve spring settings.were not left at the initial factory settings during installation. After review of the design installation package, the licensee found that the actual

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installation did not meet the specifications of the )ackage (i.e., the valve is installed different from the design). Furtaer, the maintenance shop inspected and adjusted these valves before installation and the work done was not documented, and the licensee did not verify the required spring force during post-maintenance testin The licensee attributed some of the observed differences to initial installation set up. The licensee also questioned the point where the force to lift the valve was determined. These valves travel less than 1/8 of an inch between full open and full closed, and a small measurement error could result in an apparent force change on the valve. During observations by the inspector, the workers took care to observe the point of determination and the air aressure. The only other explanation offered by the licensee was t1at backpressure from the process sampling system could affect the force measure As corrective action, the licensee intends to monitor the valves during the next refueling outages, to see_if there is any observed force chang Based on the licensee's actions, this item is close No violations or deviations were identified.

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9. Followun of Enforcement items (92702)

Enforcement item 92-17-01 (Closed). "Inadeauate Procedure for Emeraency Diesel Generator (EDG) Jackina Device" During observation of work on an EDG, an inspector observed that Maintenance Procedure (MP) 12-7, " Emergency Diesel Generator Mechanical Maintenance," did not include instructions for removal or installation of the EDG jacking device. The inspector further verified that there was no procedure or maintenance request (MR) instruction documenting this activit Since the proper reinstallation of the jacking device could affect the diesel's operability, the inspector concluded that this activity should be controlled by procedure. As another concern, the inspector noticed that some mounting bolts for the air start motors had washers, but others did not. Since the vendor drawings did not have washers, configuration control was questione The licensee admitted the violation, concluding that the root cause was that management expectations had not been adequately transmitted regarding the technical content of procedures. The licensee fixed the procedure to provide more detailed instructions, and did an operability

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determination to assess the configuration of the starting motor To more clearly convey management expectations regarding procedures and improving the technical content of procedures, the Maintenance Manager wrote a memo stating these expectations. Further, the licensee has a maintenance procedure improvement program and is making progress in these procedures. Based on the licensee's actions, this item is close Enforcement item 92-17-02 (Closed). "inadeauate Procedure for Auxiliary Feedwater (AFW) Flow Transmitter (FI) 30430 Calibration" The inspector observed problems with a calibration check of FT-3043D, a Foxboro N-E-13-DM flow transmitter. This flow transmitter calibration procedure was not appropriate in that: The calibration procedure used was for a Barton transmitter (a separate transmitter which was being calibrated at the same time), The generic procedure, not present at the work site, was not specific enough for the Foxboro transmitte The procedure used did not require that the system piping and test apparatus be free from leak The inspector also questioned some licensee work practices, in that .some exposed, untaped electrical leads posed a potential hazar The licensee admitted the violation, concluding that the root cause was that management expectations had not been adequately transmitted regarding the technical content of maintenance requests (MRs). The licensee fixed the specific procedure problems with this maintenance activit .

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To correct some of the programmatic issues surrounding this observation, -

the maintenance manager issued a memo regarding the licensee's expecta-tions. To better reflect these expectations, the licensee improved and updated their planning information guide to state the expectations of HR technical content. The licensee is improving their maintenance instructions. Based on the licensee's actions, this item is close Enforcement Item 92-17-05 (Closed). "Feedwater Isolation Valve (fWlV)

Couplina failure" On June 5 and June 9, 1992, the licensee broke the B FWlV coupling and the A TWlV coupling respectively. These couplings broke after the licensee tried to open them many times. During these attempts, the coupling yielded before breaking, and then broke. This coupling connects a hydraulic ram to the valve dis The licensee's guidance contained in Operations Manual (OH) 1-3, " Shift Operating Responsibilities," would have them investigate why a valve / pump would not open or close before attempting to operate it a second tim The NRC cited a violation on this issue since not following this guidance led to the failur The-licensee acknowledged the violation, attributing it to personnel error with a contributing cause that the intent of the OM l-3 wording was not fully understood by the personnel involve The licensee briefed the maintenance and operations personnel about the operation of equipment with problems. The licensee fixed the couplings involved and intends to look at the other couplings during the 1993 outag Based on the licensee's actions, this item is close No violations or deviations were identifie . Containment Airlock Door Eaualizino Valves '

During an fr.spection conducted from November 16 through November 19, 1992, the inspector reviewed the resolution of concerns identified with the design, maintenance, and testing of the equalizing valves for the containment airlock doors. in April 1932, the NRC became concerned that the licensee had not taken comprehensive actions to address several identified problems with the-design, maintenance, and testing of the equalizing valves in late 1989 and early 1990. The concerns were forwarded to the licensee for review and comment in a May 29, 1992 NRC letter. The licensee responded in letters dated June 29 and August 31, 1992 and indicated that some remaining issues were being addressed In summary, some of the concerns were validated and subsequently addressed by the licensee. The inspector also identified-some issues which had not been fully addresse This report addresses the following:

• The inspector's findings of weaknesses in maintenance and testing procedures for the equalizing valve . - ~ _ .

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• The inspector's finding that a licensee-identified design deficiency had not been evaluated or corrected in a timely manne * A summary of the weaknesses identified by the licensee in their evaluation requested by the May 29, 1992 14RC letter, Backaround Airlock Eaualizina Valve Desian Trojan has two containment personnel airlock doors, one at the 45'

elevation and a second at the 93' elevation. Both airlocks have double doors. Each door has equalizing valves to allow operation of the doors with a differential pressure between the containment and ;

outside atmospher An equalizing valve is installed on the inside of each door. The equalizing valves consist of a spring-loaded disk which closes on an open pipe end flange. it is sealed with two concentric 0-rings mounted in grooves in the upper disk. As the airlock door handwheel is operated, the handwheel linkage lifts the equalizing valve upper disk approximately three inches to equalize pressure across the airlock door. Continued handwheel operation undogs the airlock door, allowing it to swing free on its hinge ,

Chronoloav

The following is a brief chronology of the containment airlock equalizing valve issue /26/89 The 45-foot airlock did not pass the six-month local leak rate test (LLRT) because of excessive leakage of the outer door equalizing valve. The test was discontinued without determining the as-found condition. It was discovered that the wrong nut, one which was not self-locking, had been used on the equalizing valve actuator, and had backed off during plant operation. The control room was not promptly notified. These issues were documented in Event Review (ER)89-274, 12/27/89 The 45-foot airlock was repaired without pre- or post-maintenance testin Some of the work was performed without instructions. The airlock was declared operable and returned to servic /8/90 The licensee discovered that the airlock inner door equalizing valves had never been tested-in accordance with the LLRT requirements of 10 CFR-50 Appendix J and declared the inner doors inoperable. This was documented in ER 90-00 /7/90 The licensee submitted LER 90-01, which documented the failure to test the inner doors. Although the LER mentioned the 12/26/89 event, it did not address the

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failure of the outer door to pass the LLRT, nor did it *

address the safety significance of both doors being inoperable at the same tim /28/90 The Plant Review Board (PRB) reviewed ER 90-003 and found it to be acceptabl /18/90 The licensee requested a 10 CFR 50, Appendix J exemption from full pressure testing of the inboard equalizing valve The licensee had determined that the inner valves could not be tested at full pressure without a design chang PGE proposed to use a test which pressurized the annulus between the two concentric 0-rings to 5 to 10 psi /21/90 An 0-ring was found missing from the 93' airlock outer door equalizing valve. Corrective Action Report (CAR) 90-3101 was initiated to document this proble /2/90 A containment integrated leak rate test (ILRT) was successfully conducte /8/90 The NRC granted the April 18, 1990, Appendix J exemption reques /13/90 Testing was performed on the 45' airlock inner equalizing valve. However, corrective maintenance was performed on the inner door equalizing valves before as-found data were take /90 The Excellence Response Program (ERP) received concerns regarding the testing, maintenance, and design of the airlock equalizing valves. ERP 90-053 was initiate /12/90 1he PRB met to review ER 89-27 The PRB did not recog-nize that the event had not been adequately reporte /23/91 A memorandum was issued by the sponsors of the ERP program stating that they had found the concerns regarding the design and testing of the equalizing valves to be vali No response was received. The resolution was not tracke /92 The NRC became concerned regarding the resolution of containment airlock equalizing valve design, maintenance and testin /29/92 An NRC letter to PGE requested evaluation of airlock equalizing valve concern /29/92 PGE provide a response to the 5/29/92 NRC lette /10/92 LER 90-01, Revision I was issued. The LER reported the 12/26/89 LLRT failure of the 45' airlock in detai . - - - , -

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8/31/92 PGE provided an additional response to the 5/29/92 HRC letter, 11/19/92 The inspector discussed his findings with PGE. Testino and Maintenance Procedures The inspector reviewed the current revisions of maintenance and testing procedures as well as recently performed maintenanc Several revisions to testing and maintenance procedures had been made in response to the equalizing valve issues. However, the inspector found that the some of the procedures did not appear to provide adequate guidance to prevent a repeat of maintenance and testing problem * Testina Procedures The airlock leakage test procedure did not provide adequate instructions to ensure that the valve was properly maintained during testing. Periodic Engineering Test (PET) 5-2, revision 24, " Containment Local Leak Rate Testing," covers the LLRT of containment penetrations, including the airlock. The first step of the section governing the airlock test required that the linkage for the inner door be disconnected. This allows the inner valve to be clamped closed for the test. Step 7. stated:

" Disconnect the equalizing valve operating linkage on the inner door of the personnel airlock being tested."

The restoration step (7.7.13.h) stated:

" Connect the equalizing valve operating linkage."

These steps did not provide instructions on what specifically needed to be disconnected, did not reference the applicable maintenance procedure, and did not reference applicable design drawings. The inspector determined that there were several ways to disconnect the linkage. The preferred way would be to remove the self-locking nut on the valve actuator. However, reinstallation of the nut is critical for proper operation of the valv * Maintenance Procedure The maintenance procedure lacked specificity, which could contribute to the failure to set up the valve correctl Maintenance Procedure - Mechanical-(HPM) 28-2, Revision 0,

" Personnel Airlock," provided the procedure to verify the proper seating of the equalizing valve disc. The procedure provided non-specific instructions such as "nearly," " slight,"

and "just." The proper verification of seating is necessary to ensure that, with the door closed, the spring force holding the equalizing valve closed is equal to an opposing force of

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between 10 and 15 psig, as specified in the licensee's April 18, 1990 Appendix J exemption reques * Maintenance Reauest Weaknesses in the testing procedure were demonstrated during the performance of maintenance in February 1992. The inspector reviewed the maintenance request which covered performance of the airlock LLRT, as described in PET 5-2 (HR 91-1866). MR 91-1866 was performed on February 15, 1992 prior to plant startup from an extended outage. The inspector observed the following:

• Several pen and ink changes had been made to the MR (originally drafted in March 1991), making the instructions difficult to follow. The changes included substantive scope changes such as gluing the equalizing valve 0-rings in place. A complete revision of the instructions appeared to have been appropriat * The MR did not require a pre-maintenance LLRT of the inboard equalizing valve, a good practice to which the licensee had committed in their procedure * The MR did not include design drawings or maintenance procedures for the work performed on the equalizing valve The inspector concluded that the procedures used to test and maintain the equalizing valves had not received appropriate attention during the licensee's followup review. The inspector discussed these findings with the licensee during a November 20, 1992 exit meeting. The licensee committed to review and revise HPM 28-2 and PET 5-2 as appropriate. The General Manager stated that since February 1992, action had been taken to limit the extent to which pen and ink changes can be made to an MR without a complete revision of the M Eaualizina Valve 0-rina Displacement The inspector reviewed the resolution of the Corrective Action Report (CAR 90-3101) which addressed the displacement of equalizing valve 0-rings. CAR 90-3101 was initiated on May 21, 1990 to document the discovery that an 0-ring had fallen out of the 93' '

airlock outer door equalizing valve. The inspector for d several issues, discussed further below:

• The Operability Determination was inadequat >

• The root cause of the failure was not addressed before plant startu * The corrective action to prevent recurrence, when finally implemented over a year after the initiation of the CAR, was not effectiv _ .

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Doerability Determination The Operability Determination _ concluded that the equalizing valve was not inoperable while the plant was in Mode 6 (refueling) because the function of the inner 0-ring was to allow the testing of the valve sea Testing of the equalizing valves was not required for Mode The reviewer concluded that the valve was operable because it still had its outer 0-ring in plac Since no instance was identified when both 0-rings were missing from o valve, the inspector recognized that no period of valve inoperabi-lity had been identifie The inspector expressed concern regarding a,surance of future operability, however, since a review of mainte-

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naore history indicated that the 0-rings had been dislodged several times. This concern was especially valid for an outage, when there would be increased traffic through the airlocks. The CAR root cause determined correctly tha', this indicated a design fla Root Cause The dislodged 0-ring was replaced in the equalizing valve prior to startu However, the design deficiency, determined to be the root cause, was not addressed prior to plant startup. The design deficiency was that the 0-rings were not well captured in the square cut grove of 'he upper disc. The forces of gravity and the differential pressure across the 0-rim seat as the valve is opened tend to pull the 0-ring from the gre in the upper disc. There was no assurance that a repeat even'. ~vuld not occur without resolution of the root caus Corrective Action The corrective action to address the design deficiency was to glue the 0-rings in place. The CAR included a 10 CFR 50.59 evaluation for Qis design change. The design change was implemented during the 1991 refueliag outage and the valves were in service during the February 1992 start up. The inspector found that, before the February startup, an 0-ring was found dislodged is one instance and an 0-ring was not completely captured in its groove in another. The licensee should have re-evaluated the adequacy of gluing the 0-rings

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as a viable corrective action to prevent recurrence.

l l Following the NRC's May 1992 request for information, the licensee reevaluated the corrective actions and discovered that the airlock l door vendor had an upper disc design which used dovetailed 0-ring i grooves to positively capture the 0-ring. - The licensee replaced the

discs in the 93' airlock door during the maintenance outage in 1992 l and the discs in the 45' airlock during the outage following the l November 9, 1992 steam generator tebe lea The failure to take l timely corrective actions to address a condition adverse to quality, l as discussed above, is an apparent violation (92-32-06). However,

! in view of the corrective actions taken by the licensee, and l Verified by the inspector, a written response is not required.

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At the November 20, 1992 exit meeting, the licensee committed to review-the CAR to determine if there were lessons to be learned from i The reevaluation of the CAR was completed on December 23, 199 The evaluation supported the licensee's initial conclusions that the equalizing valve had been operable. The inspector reiterated his concern regarding future assurance of valve operability, Issues Resolved in Response to the May 29. 1992 NRC Letter The licensee's letters dated June 29, 1992 and August 31, 1952, indicated that several actions had been taken in response to the May 29, 1992 NRC letter. The licensee found that there were several issues which had been inadequately addressed during the resolution of ER 90-003, ER 89-274, and ERP-90-053. The specific issues included:

• The failure to appropriately report the failure of the 93'

outer airlock door in LER 90-0 * The failure of the PRB to adequately review ER 90-003, ER 89-274, and LER 90-01. The PRB was tasked with reviewing all reportable event * The failure to initiate a CAR to assess the concerns of ERP-90-05 Adeouacy of LER 90-01 The LLRT failure of the 93' outer airlock door was not reported in accordance with the requirements of 10 CFR 50.7 LER 90-01 covered the January 8, 1990 discovery that the inboard equalizing valves had not been subjected to an LLRT. Although the LER did mention the December 26, 1989 failure of the outer door LLRT and in one sentence described the cause, it did not include specific information-required by 10 CFR 50.73, such as an assessment of the safety consequences and implications-of the event and a description of any planned corrective action The licensee's June 29, 1992 letter recognized these weaknesses. On August 10, 1992, the licensee submitted a revision to LER 90-0 The inspector reviewed the LER and found it to be acceptabl The licensee's failure to properly report tha LLRT failure of the 93' outer airleci door is an apparent violation (92-32-07). In view of the corrective actions taken by the licensee, and verified by the inspector, a written response is not required, Plant Review Board Review of LER 90-01 The licensee's Technical Specifications required that the PRB review all reportable events. The inspector found that the PRB had reviewed both the December 26, 1989 and January 8, 1990 events after LER 90-01 was issued. In addition, the PRB concluded that the

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December 26, 1989 had been adequately reported in LER 90-0 This conclusion, for reasons discussed above, was in erro The inspector reviewed the licensee's programs and current practices for PRB review of LERs. The inspector found that reportable events were routinely reviewed by the PRB before an LER was issued to the NR ERP Did Not Resolvdgnsnni The inspector reviewed ERP 90-053 regarding the equalizing valv The inspector found that the ERP review had been comprehensive and that the program's conclusions regarding equalizing valve design were consistent with the inspector's. The inspector did not concur with the conclusion of the ERP, however, that the equalizing valves r should be considered part of the airlock door seal, requiring -

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testing following every containment entry. The inspector's conclusions regarding testing were supported by the NRR project

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The sponsors of the ERP issued a January 21, 1991 memo regarding their finding The itcensee discovered during their review in response to the May 29, 1992 NRC letter that the memo had received no response and the ERP was closed with no documented justificatio The licensee determined that the ERP evaluators should have initiated a CAR to provide proper resolution of the concerns they had validated. The ERP procedure in place in 1990, which included instructions to initiate a CAR if appropriate, was not followe The licensee initiated CAR 92-0306 to address this issue and reviewed all past ERP reviews to determine whether CARS would be appropriat The failure to initiate appropriate corrective action as recomended by ERP 90-053 is an apparent violation (with 92-32-06, above). In view of the corrective actions taken by the licensee, and verified by the inspector, a written response is not require Although the licensee had not addressed the specific issues described above prior to the NRC's involvement, the programmatic issues regarding the weaknesses of the corrective action process, the Excellence Response Program, and the LER process had already been-addressed. These areas had been the subject of several other PGE and NRC findings and had undergone extensive revision, 11. Exit Interview (30703)

The inspectors met with licensee representatives (denoted in paragraph 1)

on December 28, 1992, and with licensee management throughout the inspection period. During these meetings the inspectors summarized the scope and findings of the inspection activitie The licensee did not identify as proprietary any of the materials reviewed by or discussed with the inspectors during this inspectio w - - ____ _ - _ - _ _ - _ - _ __ ___ m