IR 05000346/1987027

Insp Rept 50-346/87-27 on 871019-23 & 880105.Violations Noted.Major Areas Inspected:Licensee Action on Previous Insp Findings,Limited Scope Fire Protection Program Review & Fire Protection Sys Preventive Maint Program

ML20148R777
Person / Time
Site:	Davis Besse
Issue date:	01/28/1988
From:	Gardner R, Ulie J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20148R658	List: IR 05000346/1987027
References
50-346-87-27, NUDOCS 8802020277
Download: ML20148R777 (11)

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U. S. NUCLEAR REGULATORY COMMISSION

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REGION III l

i Report No. 50-346/87027(ORS)

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! Docket No. 50-346 License No. NPF-3 {

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J Licensee: Toledo Edison Company l Edison Plaza, 300 Madison Avenue

! Toledo, OH 43562  ;

i l Facility Name: Davis-Besse 1 l

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Inspection At: Oak Harbor, Ohio l Inspection Conducted: October 19-23, 1987 and January 5,198 f Inspector:

[d 'm . LAOk oseph M. Ulfe

//cy 5(Y

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Date Approved By:

Ah. khhh Ronald N. Gardner, Chief j

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) I Plant Systems Section Date Inspection Summary

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! Inspection on October 19-23, 1987 and January 5, 1988 (Report No. 50-346/87027(DRS))  !

Areas Inspected: Routine, unannounced inspection of licensee action on l j previous inspection findings, and a limited scope fire protection program ;

review including a selected review of the fire protection organization,

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administrative controls and fire protection system preventive maintenance i

! program (30703, 64704 and 92701). 4

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Results: Of the five areas inspected, no violations were identifieo in two ,

areas, three violations were identified in the remaining areas (Maintenance i 1 Procedure No MP 1405.07 did not require a design review for proposed l j modifications involving fire dampers - Paragraph 2; no Special Report was l 4 submitted for an out of service fire detection zone instrumentation - i

] Paragraph 5; and four deficiencies of the plant fire protection license l condition - Paragraph 6),

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DETAILS 1. Persons Contacted i I

! Toledo Edison Company / Contractor Personnel i  !

l *T. Almendinger, Fire Brigade Training Instructor I

• Bonner, Assistant Plant Manager, Maintenance P. A. Bowman, Radiological Controls Tester .

• R. Brandt, Operations Superintendent

"J. C. Buck, Auditor {

i l *R. Flood, Assistant Plant Manager, Operations  ;

• 0. L. Haiman, Engineering General Manager

• G. Honma, Licensing, Compliance Supervisor I

• C. Hildebrandt Engineering General Director l

1. • M. Lalor, Licensing Engineer / Fire Protection [

"J. Hagers, Licensing Associate l

. *J. E. Moyers, Qualification Verification Manager i

• H. Murtha, Fire Protection Engineer 6

) *T. J. Myers, Nuclear Licensing Director j *0. C. Shelton, Vice-President, Nuclear 1 0. Siferel, Technical Support Department >

"F. H. Sondgeroth, Senior Licensing Engineer / Fire Protection  !

! T. F. Steed, R=spiratory Protection Coordinator  !

j *L. Storz, Plant Manager {

j *J. Storz, Associate Nuclear Engineer  ;

• J. W. Strausser, Fire Protection Compliance Manager

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• Woolley, Supervisor Regulatory Programs [

j #*L. D. Young, Fire Protection Special Projects Supervisor j US NRC f

• P. Byron, Senior Resident Inspector

"D. Kosloff, Resident inspector The inspector also contacted other licensee personnel during the l inspection visi !

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• Denotes persons attending the exit interview on October 23, 1987, i I

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1. Denotes persons participating in telephone exit interview on January 5 j g 198 l 2, Action Taken on Previous Inspection Findings

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' (Closed) Open Item (346/86006-01(DRS)): During an NRC review it was

) determined that the licenseq did not administer written examinations i following fire brigade classroom training sessions and that records i of critiques of brigade member performance during drills were not

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i The licensee's staff previded the inspector records showing that E i exams following fire brigade classroom training sessions are being i

administered and that records of critiques of brigade member -

performance during drills are now being maintained. Therefore, i this item is considered close '

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I (Closed) Unresolved Item (346/85017-04): Maintenance Proc edure !'

i No. 1405.07, Fire Damper Maintenance, did not require a design review l prior to modifications occurring on fire dampers, This design review l j related to Step 7.2.4 which allowed field modification ("trimming") t

! of curtain type fire dampers which could result in voiding the i Underwriters Laboratories (UL) approval.

i t l The licensee is required to maintain the elements of the Fire i Protection Program in accordance with the NRC document entitled, !

< "Nuclear Plant Fire Protection Functional Responsibilities, i l Administrative Controls and Quality Assurance." Paragraph 1.0.c j of Attachment No. 6 of this NRC document requires that plant l t modifications involving fire protection systems be reviewed by  ;

qualified personnel to assure inclusion of appropriate fire  !

protection requirements including design reviews for room  ;

isolation (i.e., fire dampers).  ;

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j The inspector determined that the Fire Damper Maintenance Procedure i j No. MP 1405.07 Revision 0, dated F:bruary 24, 1984, did not require [

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a design review of proposed modifications involving fire damper l j This is considered a violation of the Facility Operating License as '

j described in the Notice of Violation (346/87027-01).

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The licensee's staff provided the inspector with a copy of the  !

! Temporary Modification Request sheet approved October 25, 1986 i j modifying Procedure No. MP 1405.07 such that a design review is  ;

now required by Facility Engineering prior to performing field J modifications. The inspector considers the licensee's corrective i action to be adequate and this item is therefore considered closed.

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j 3, Fire Protection Organization f

i t The inspector examined a selected number of fire brigade training records i l and witnessed an unannounced fire brigade dril t i

, As requested by the inspector, the licensee provided fire brigade  !

l training records demonstrating the following: (1) that shift three had j performed the required fire drill during the first quarter of 1987; l (2) that five individual fire brigade members had performed the required {

fire brigade classroom instruction training during the second quarter of !

1986; and (3) that the 1985, 1986, and 1987 annual practice training I sessions for five individual fire brigade members had occurred as required.

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!. As part of the fire protection organization review, tha inspector I j requested an unannounced fire drill be conducted utilizing the on-duty j operations shift personnel. As committed to by the licensee, Attachment  !

No. 2 of the NRC document entitled, "Nuclear Plant Fire Protection i

! Functional Responsibilities, Administrative Controls and Quality l Assurance " dated June 14, 1977, indicated that fire brigade drills should i

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be performed in the plant so that the fire brigade can practice as a tea !

! This document further entailed other drill parameter The licensee  ;

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j commitment to the NRC document is described in the SE dated July 26, 197 The inspector requested a fire scenario which would involve the fire j brigade demonstrating firefighting techniques (including fire hose  ;

handling) and which also would demonstrate the adequacy of communication (

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interface between the fire brigade and Health Phy:ics technician  !

j personnel during fire emergency conditions having radiation hazard  !

involvemen *

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{ The fire drill postulated an ordinary combustible type fire in the Boric Acid Addition Tank (8AAT) Room (Room 240). This room is located in a

! Radiologically Controlled Area (RACA) of the plant, thereby, involving a -

i potential contamination hazard. The inspector reviewed the fire drill scenario and pre-fire plan which included a walkthrough of the "fire" area prior to the dril j

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In preparing to witness the fire drill, the inspector also reviewed l j appropriate portions of licensee procedures which relate to fire discovery and subsequent fire extinguishmen These procedures included

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l Abnormal Procedure No. AB 1203.37, Fire Procedure, Revision 3, l approved November 27, 1985 Abncrmal Procedure No. AB 1203.02, Serious Station Fire, Revision 3, l

) approved December 9, 1986; l Fire Pre-Plan No. FP 9240.00, Room 240 - BAAT Room Revision 1

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approved April 4, 1983; and Emergency Plan Drill Procedure No. EP AD-0200, Emergency Plan Drill and Exercise Program, Revision 1, approved February 20, 198 This unannounced fire drill was initiated on October 21, 1987, at i approximately 1935 hour0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.362675e-4 months <br /> The inspector was stationed initially in the

control room to observe the actions taken by the ontrol room operators i upon receipt of the fire alar The inspector '. hen proceeded to the fire i brigade station and followed the fire brigade to the "fire" area observing j the brigade including certain support personnel actions until the fire

drill was terminated.

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The inspector observed six fire brigade members assemble and don protective clothing includir.g self-contained breathing apparatus at a fire brigade station (fire equipment room). The inspector evaluated the fire brigade and support personnel actions in determining and observing the following: (1) fire brigade members' conformance with established plant firefighting procedures; (2) an assessment of the fire brigade leader's direction of the firefighting ef ferts; (3) actual donning and use of the self-contained breathing apparatus (SCBA); (4) actual donning of protective clothing; (5) simulated use of an 1\" fire hose station; (6) use of portable radio communication equipment; (7) brigade timeliness in response and numbers of personnel responding with proper firefighting equipment; and (8) brigade leader interaction with the Radiation Control Technician (RCT) and other support personne The inspector participated in the post-drill critique and provided the following comments regarding his observations: Positive Observations i * The number of fire brigade members responding exceeded NRC minimum requirement * Fire brigade personnel safety taken during the drill relative to proper wearing of the protective clothing and SCBA, and the utilization of the portable radios and hand held lights was beneficia ;

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• A representative from Health Physics accompanied the fire i brigade daring the fire drill exercise and simulated the taking of radiation surveys, Deficiencies

• The control room operator verbal instructions given to the

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plant operator appeared to express the need for only a l

non-emergency type response to the alarmed are ;

. * The chosen method of comunications (portable radios) did j not appear to f unction properly, which resulted in the brigade l

, leaoer's use of the Gai-tronics syste Due to a previously j j raised NRC concern discussed in Inspection Report (34E/83016-09)

i regarding the comunications system, the licensee has a planned task to resolve the overall communications system problem * Throughout the fire drill exercise, an overall lack of brigade leeder direction was noted.

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• The length of the ifre hose from the hose station chosen was l inadequate to effectively reach the inside of the room l

announced as the alarmed "fire" are * Charging of the pulled fire hose occurred, contrary to the established Emergency Plan Orill Procedure No. EP-AD-0200.

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l As a result of the deficiencies identified above, the fire drill l i participants overall meeting of the standards described in t

{ Emergency Plan Orill Procedure No. EP-AO-0200 was determined ;

to be unsatisfactor '

At the exit interview of October 23, 1987 l the licensen's senior management present acknowledged that a fire [

j drill utilizing the same shift witnessed by the inspector had {

been scheduled to be conducted on or about October 28, 198 }

l This action is in accordance with the Emergency Plan Orill '

j Procedure. Consequently, the deficiencies of the drill are being

categorized as an open item (346/87027-02) pending further NRC witnessing of licensee fire drill activities.

Also at the exit interview of October 23, 1987, the inspector i emphasized a point made by a licensee evaluator during the post l

)' drill critique regarding the need of drill participants to verbalize !

j their mental process so that drill evaluators ;an more fully l

understand the actions being considered by drill participant [

This mental process would also reinforce the drill participant's i

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knowledge of the subject matte l I

l During the critique following the fire drill, several plant I

operators voiced a need to reduce the number of nuisance and/or !

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inadvertent type fire alarms believed to be being caused primarily by l maintenance work activities. According to Step 6.2 of Administrative !

Procedure No. AD 1844.07, entitled, "Open Flame, Welding, Cutting and l Grinding Permits," Revision 3, approved on March 14, 1986, before [

j issuing a permit, the Foreman, respective Group Leader or Craft Supervisor shall physically survey the work area and determine that l an unwarranted actuation of the fire detection system will not l occu The procedure further requires that if an unwarranted i

actuation cannot be assured then the Instrumentation and Control i

(I&C) Depart.9ent shall be contacted to remove the fire detector from j service prior to the work commencing. The inspector, after

discussiors with the Mechanical and I&C Superintendents, was unable ,

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to determine the specific cause of the nuisance and/or inadvertent

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l fire alarms actuations. Consequently, the inspector requested the ,

licensee's staff to perform a review to determine the cause of the j l nuisance and/or inadvertent fire alarm actuations. This is i considered an unresolved item (346/87027-03) pending NRC evaluation !

of the licensee's revie !

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The licenbee's staff indicated that the actions exhibited by the

, control room operator during the fire drill exercise may have been a result of the numerous fire alarm actuations discussed

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l An additional discrepancy was identified regarding a Plant Policy as i

described in "Fire Procedure" No. AB 1203.37. When an unplanned 1 fire alarm activa *. ion is received on the Control Room annunciator panel an cperator is dispatched to the fire alarmed area to investigate whether an actual fire is present, The procedure

did not prescribe the need for brigade assistance upon receipt

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of an alarm in the control room.

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I The fire detection system was installed to provide early [

l notification of a fire condition, however, the licensee was unable '

to provide justification for not relying on this indication and,  ;

upon initial receipt, assembling the fire brigad [

l The present Plant Policy appears to create the potential for a delay 1' in alerting and assembling the fire brigade after an unplanned i actuation of a fire alarm has occurred and may allow the potential j i fire to spread unsuppressed, i

l l As dcscribed in the SER, the licensee committed to the NRC "Nuclear Plant Fire Protection Functional Responsibilities, Administrative {

i Controls and Quality Assurance" documen Attac hent No. 5 of this !

document identifies that the firefighting procedures should identify }

actions to be taken by the control room operator and the need for  :

j fire brigade assistance upon receipt of a fire alarm on the control [

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room annunciator pane As previously mentioned, the licensee's i

"Fire Procedure," did not prescribe the need for fire brigade  !

assistance upon receipt of an alarm in the control roo l

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The above fire procedure deficiency regarding the need for [

brigade assistance upon receipt of an alarm in the control room i l is considered an unresolved item (346/87027-04) pending further i

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internal NRC revie i Administrative Controls (

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The inspector examined, in part, the licensee's fire protection j administrative control procedures and the implementation of these j

, procedures while performing plant tours on October 19, 20 and 21,1987.

1 Those procedures reviewed included: (1) Administrative Procedure j No. AD 1835.00, Plant Cleanliness Inspection Program, Revision 7,  ;

approved on June 30,1%7; (2) Administrative Drocedure No. AD 1810.01,  !

Control of Combustibles and Ignition Sources, Revision 7, approved on l September 17, 1985; (3) Maintenance Procedure No. MP 1410.76, Control '

and Regulation of Transient Combustibles, Revision 1, approved on March 23, 1985; and (4) Administrative Procedure No. AD 1844.07 entitle Open Flame, Welding, Cutting and Grinding Permits, Revision 3, approved j on March 14, 1986. The four procedures were determined to be generally i j well written, i r j During plant tours conducted on October 19, 20, 21 and 22, 1987, l

{ implementation of the Plant Cleanliness Progran was determined to be i i satisfactory. However, the inspector did observe an approved five gallon j flammable / combustible liquid container in Diesel Generator Room 1- I This was contrary to Administrative Procedure AD 1810.01.5, which  !

irdicates that storage locations for combustible fuels shall be prohibited

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in safety-related area The inspector considered the finding to be an l

isolated occurrence. In addition, fourteen (14) scaffolding assemblies with fire retardant treated wooden planking were observed in safety-related !

safe shutdown areas of the plant which had tags showing installation j

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dating oack to August 7, 1987. The inspector also identifi9d a mislabeled tag in the Diesel Fire Pump Room. The inspector expressed a concern that wooden planking used in scaffolding could create a potential sprinkler head spray pattern obstruction. This planking could also be a combustible hazard. These concerns are strengthened due to the scaffolding being ,

left in place for extended period Eight of the 14 areas had sprinkler :

systems installed in which certain sprinkler head spray patterns appeared to be obstructed. The licensee's staff indic3ted that a new procedure has recently been written which will provide guidelines as to scaffolding being left in place for extended period i The above mentioned concerns are considered an cpen item (346/87027-05)

pending inspector followup of the licensee's implementation of the new scaffelding procedure and the determination of this procedure's effectivenes . Fire Protection System Inspection, Maintenance and Test Program The inspector reviewed, in part, tha licensee's fire protectio') system surveillance inspection, maintenance and test program as required by ,

plant Technical Specifications (TS) and other licensee commitments. This review consisted of an examinstion of completed surveillance packages, in progress surveillance tests, a talk-through of a fire hose station

! surveillance inspection, and inspector discussions with other licensee personnel, This revi w included the following:

• The semi-annus1 fire detection instrumentation surveillance checks of the fire detector circuitry (TS 4.3.3.8.2) was performed using Surveillance Test (ST) No. 5016.04.07. The inspector witnessed the satisfactory performance of two fire detectors being tested in Battery Room A (Room 4298) on October 20, 1997.

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• The last two 18 month surveillance checks of the sprinkler systems !

heads which verify no blockage (TS 4.7.9.2.b.2) were provided to the j inspector. These surveillances were satisfactorily performed du y May 1985, and during September and November, 1986 using ST's 5016..:

and 5016.07. The inspector reviewed the completed ST packages and j determined that the surveillances were performed as required, i i

i * A monthly surveillance inspection of the plant fire hose stations '

1 (TS 4.7.9.3) was conducted on October 19, 1987. This inspection was conducted using ST No. 5016.03, Revision 00, dated August 19, 198 ;

The individual performing this surveillance inspection talked-through certain of the procedural step requirement The surveillance procedural steps were being met with the exception of exercising the l j nozzle on/off lever. This was pointed out to the individual performing the surveillance inspection. This individual indicated t'13t he does not routinely perform this surveillance procedur Based on the inspector's review, it appeared that prior to the licensee's staff conducting fire protection surveillances, the '

licensee should assure that individuals performing the surveillance j understand all steps of the procedur i l

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• Quarterly Periodic Test (PT) No. 5199.14, Respiratory Protection i

Equipment, Revision 15, approved on October 21, 1987 was performed

on Self-Contained Breathing Apparatus (SCEA) during the week of this inspection. The inspector witnessed in part the satisfactory

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performance of this PT on October 21, 1987. Certain of these SCBA are used by the fire brigede for firefighting bs During the inspector's review of the fire protection program, the j licensee provided Potential Crndition Adverse to Quality (PCAQ)

Report No. 87-0555 dated October 7, 1987. This report indicated that on July 18, 1987, at 0700, Fire Detection Zone (F0Z) A208 '

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(Annulus area) went into alarm resulting in Health Physics personnel

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teing dispatched to verify the area statu According to the

report, no fire was present and a work request was originated

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causing FDZ A208 to be declared inoperable. This resulted in less than the minimum number of detectors being operable as required by ,

Technical Specifications for this fire zone. A plant tour of the l

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fire alarm local annunicator panel on October 23, 1987, identified that this zone was still in an alarmed condition. Technical l

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Specification 3.3.3.8 allows 14 days to return inoperable fire '

detection instrumentation to operable status or, submit a Special i j Report to the Commission pursuant to Specification 6.9.2 -cithin the j aext 30 days. As of October 23, 1987. F0Z-A208 had not been restored

, to an operable status, nor had a Special Report been submitted. Thiv

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is considered a v41ation (346/87027-06) of Technical Specifications as described in the Notice of "folatio ,

i a By letter cated November 6, 1987, the li ensee submitted a Special Report regarding the inoperablo fire detection instrumentatio The licensee indicated that the Special Report was not submitted within the required time limit due to a personnel error in failing to

! follow Procedure Number NG-QA-702. As corrective action for the '

late Special Report, all Shift Supervisors were being required to I review this incident to improve their understanding of tne proper mechanism for ensuring that such incidents are reviewed and reported appropriately. This review was scheduled to be completed by November 20, 1987. Regarding the late Special Report, the inspector i (.onsiders that the licensee's corrective action was adequate and i this item is corsidered close I 6. Fire Protection License Condition I' ,

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The inspector evaluated five potential fire protection license condition I violations which were discovered by the licensee's staf These five

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potential violations relate to Paragraph 2.c(4) of the facility Operating i Licens l

J Three of these deficiencies were formally identified to the NRC by l Special Report No.86-030 dated August 18, 198 I l i

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The first deficiency was identified during a July 12, 1986, Quality Control (QC) inspection of Kaowool fire wraps in the CCW Pump Room (Room 328) and the SW Valve Room (Room 53). During the QC inspection thirty-seven of sixty-three circuits requiring fire wraps were considered unsatisfactory due to missing Kaowool, damaged Kaowool or missing band Section B.13 of Table 1 of tne Safety Evaluation requires Kaowool to be installed around conduits in the CCW Pump Room and SW Valve Room to protect equipment needed for cold shutdow The second deficiency regarded 5 missing eight hour emergency lighting unit required to be installed in the Room 241 passage. Section 8.12 of Table 1 of the Facility Fire Protection License Condition Paragraph 2.C(4)

requires the emergency lighting unit to be installe The *.hlrd deficiency identified two areas where area wide type fire detection wts required but was not present. These two areas were the Demireralizer Room No. 233 and Fuel Handling Area Room No. 30 Section 8.10 of Table 1 of the Saf9ty Evaluation requires additional area type fire detectors be installed in Rooms 233 and 30 According to the licensee, the required fire detectors had not been installe A fourth deficiency identified by the licensee regarded Section of Table 1 of Amendment 18 to the Facility Operating Licens Section B.9 requires the application of spray-on type fire proofing on structural steel identified as supports for the four horizontal cable trays penetrating the three hour fire barrier at column line Q-F on elevation 602'-0". According to the licensee's review of correspondence regarding this license condition, this location does not exist and the correct reference should have been to apply spray-on fire proofing to the cable tray supports at Column Line 9-F above elevation 603'-0" (Turbine Bldg. - Numbered 422). However, according to the licensee's PCAQ Report, the cable tray supports at Column Line 9-F above elevation 603' 0" did not have the required fire proofing. While the licensee stated that a fire suppression sprinkler system was located near the supports of concern, NRR will address the adequacy of this sprinkler system in a future SE NRR approval does not alleviate the failun of the licensee to meet the license condition as originally require The fif th deficiency was formally identified to the NRC in a letter dated August 21, 198 The deficiency regarded Section B 9 of Table 1 of the SER dated July 26, 1979 which was incorporated into a condition of the plant licens Section B.9 requires the application of spray-on type fire proofing to the supporting structural steel in the mechanical and electrical penetration room On May 15, 1980 Revision 6 to the licensee's Fire Hazard Analysis Report (FHAR) was submitted to NRR for review. The revision resulted from design and construction activities which identified areas without the required ? ire proofing installe According to the licensee's letter, subsequent attempts to install fire proofing proved impossible. Subsequently, according to the licensee, the structural steel in Room 314 was then effectively protected by a sprinkler system. Justification for the automatic suppression

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system in lieu of the structural steel fire proofing was provided in FHAR, Revision By letter dated July 17, 1980, NRR accepted the alternative protection for specific rooms in lieu of the fire proofin However, Room 314 (No. 4 Mechanical Penetration Room), according to the licensee, wa- inadvertently omitted by NRR. NRR has yet to formally respond to the licensee regarding this matter, however, during an October 29, 1987, meeting between the licensee and NRC in Bethesda, Maryland, the NRC Fire Protection Reviewer acknowledged the licensee's explanation as being plausible. NRR is planning to address this matter in a future SE The licensee is maintaining compensatory measures until the necessary deficiencies have been resolved which includes various analyses to satisfy in place configuration The first four deficiencies are considered four examples of one violation (346/87027-07) of the licensee's fire protection license conditica as described in the Notice of Violatio . Open Item Open items are matters which have been discussed with the licensee, which will be reviewed further by the inspector, or which involve some action on the part of the NRC or licensee or bot Open items disclosed during the inspection are discussed in Paragraphs 3 and 4 of this repor . Unresolved Item An unresolved item is a matter about which more information is required in order to ascertain whether it is an acceptable item, a violation, a failure to meet a licensee comnitment, or a deviatio Two unresolved items disclosed during the inspection are discussed in Paragraph 3 of the repor . Exit Interview The inspector met with licensee representatives (denoted in Paragraph 1)

at the conclusion of the inspection on October 23, 1987, and summarized the scope and findings of the inspection. The inspector also discussed the likely informational content of the inspection report with regard to documents reviewed by the inspector during the inspection. The licensee did not identify any of the documents as proprietar On January 5, 1988, additional discussions relating to the inspection were held between members of the licensee's staff and the inspecto l

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