IR 05000346/1988037

Insp Rept 50-346/88-37 on 881201-890210.Violations Noted. Major Areas Inspected:Licensee Action on Previous Insp Findings,Operational Safety,Maint,Surveillance,Lers,Licensee Events,Security & Mgt Meeting to Discuss 881218 Event

ML20245E070
Person / Time
Site:	Davis Besse
Issue date:	02/24/1989
From:	Defayette R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20245E055	List: IR 05000346/1988037 ML20245E051 ML20245E056 ML20245E061 ML20245E064
References
50-346-88-37, NUDOCS 8905020008
Download: ML20245E070 (26)

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U. S. NUCLEAR REG 1JLATORY COMMISSION

REGION III

Report No. 50-346/88037(DRP)

Docket No. 50-346 Operating License No. NPF-3 Licensee: Toledo Edison Company Edison Plaza, 300 Madison Avenue Toledo, OH 43652 Facility Name: Davis-Besse 1 Inspection At: Oak Harbor, Ohie Inspection Conducted: December 1, 1988 to February 10, 1989 Inspectors: P. M. Byron D. C. Kosloff C. H. Brown J. S. Stewart P. T. Burnett L. D. Wert Approved By: c7 Date '

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R.DeFayettQChief Reactor Projects Section 3A Inspection Summary Inspection on December 1, 1988 through February 10,1989 (Report No. 50-346/88037(DRP))

Areas Inspected: Routine, unannounced inspection by resident inspectors .

of licensee action on previous inspection findings; operational safety; maintenance; surveillance; licensee event reports; licensee events; security; and a management meeting to discuss a December 18, 1988 even Results: Of the seven areas inspected no violations or deviations were identified in four areas. One violation (failure to follow a maintenance  ;

procedure) was identified in the maintenance are One violation (failure to comply with Technical Specification 3.0.3.) was identified in the surveillance area, but a notice of violation was not issued for that violation. Four apparent violations (2 examples of inadequate log keeping; inadequate abnormal operating procedure; and failure to follow the approach to criticality procedure) were identified in the area of licensee events, as well as an apparent breakdown in the control of licensed activities in the control roo These apparent violations and the apparent breakdown of licensed activities, their causes and corrective actions, will be discussed in an enforcement conference in the NRC Region III office on March 3,198 e905o20008 890421 FDR ADOCK05oog6

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DETAILS i

1. Persons Contacted Toledo Edison Company (TED)

D. Shelton, Vice President, Nuclear

• L. Storz, Plant Manager W. Johnson, Plant Maintenance Manager

• R. Flood, Plant Operations Manager

• E. Salowitz, Planning and Support Director L. Ramsett, Quality Assurance Director

• A. Zarkesh, Independent Safety Engineering Supervisor G. Gibbs, Performance Engineering Manager

• P. Hildebrandt, Engineering Director J. Gates, Systems Engineering Manager

• M. Knaszak, Systems Engineering Supervisor J. Kasper, Operations Superintendent

• R. Rinderman, Quality Assurance Superintendent R. Schrauder, Nuclear Licensing Manager T. Haberland, Electrical. Superintendent G. Skeel, Nuclear Security Operations Manager

• G. Honma, Compliance Supervisor

• R. Gaston, Licensing Engineer

. USNRC

• P. Byron, Senior Resident Inspector

• D. Kosloff, Resident Inspector C. Brown, Resident Inspector, Callaway J. Stewart, Resident Inspector, Kewaunee M. Hunter, Co-op student P. Burnett, Reactor Inspector, Region II L. Wert, Resident Inspector, Oconee L. Valenti, EG&G Management meeting attendees on February 10, 1989, in Region III:

Toledo Edison Company L. Storz, Plant Manager R. Schrauder, Licensing Manager l G. Gibbs, Performance Engineering Manager NRC E. Greenman, Director, DRP ,

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R. Knop, Branch Chief l

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'.' R. DeFayette, Section' Chief P. Byron, Senior Resident Inspector E. Schweibinz, Assistant to Director, DRP T. Wambach, PM, NRR

• Denotes January 24, 1989, exit meeting attendee . Licensee Action on' Previous Inspection Findings (92701) (Closed) Open Item (346/84029-02(DRP)): Technical Specification is contrary.to the. Requirements of ANSI N45.4-1972. Interim review in.IR 50-346/86006. The inspectors verified that Technica Specification 4.6.1.2.C.3 was amended by Amendment No.120 issued on September 19, 1988 to be consistent with the requirements of 10 CFR Part 50, Appendix J to and ANSI N45.4-1972, Appendix .

This item is close (Closed) Violation (346/85009-03(DRP)):

Failure to perform Peiodic-Test (PT) 5131.02 when required. PT 5131;02, " Verification of Computer Calculations," a manual check of the computer heat balance, which was required to be performed monthly at the beginning of the_-

fuel cycle until the computer had been verified to_ consistently perform satisfactorily, was not performed during .the startup and initial run for Cycle 5 (January 15'through March 21,1985). The licensee revised PT 5131.02 (now Periodic Test Procedure 08-PF-04231)l so that the heat balance section is now done on.a weekly basis and a comparison of the data used.in the-computer heat balance calculation versus actual instrument readin0s is done weekly to increase confidence in the computer calculations. The licensee committed to I review all pts to determine if completion of the test is essential, terming the essential pts " Critical Periodic Tests." The inspectors verified that PT 5131.02 was revised to reflect the licensee's corrective action and also that it is classified as a " Critical PT."

The inspector also verified that the 11censee's revision _ of Administrative Procedure AD1838.02 (now DB-DP-0013), " Surveillance and Periodic Testing Program," incorporates the meaning and -

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significance of critical periodic tests. The corrective actions appear to be adequate; therefore, this violation is close (Closed) Open Item (346/85025-24(ORP)): Procedure designat' ions )

and approvals do not reflect past organizational change Interim reviews in IR 50-346/86005 and 8700 The licensee changed the l Nuclear Licensing and Nuclear Training procedures to reflect the organizational reporting changes. The licensee also revised the Nuclear Quality Assurance Manual (NQAM) to reflect these change The inspectors reviewed the changes and this item is close (Closed) Violations (346/85040-01a and Olb(DRP)): Failure to comply:

with Technical Specification (TS). From July 2, 1977, to August 4,

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1977, both Contre' Room Emergency Ventilation System (CREVS) trains were inoperable a, ath the water and air-cooled condensing units of each train were inoperable. The water-cooled condensing units were inoperable due tripping on electrical overload when operated with the air-cooled units. Also, for an indeterminate period of time until October 1985; both CREVS trains were inoperable as the refrigerant compressor motors of both trains would repeatedly trip on low refrigerant pressure when the outside air temperature was below 15 degrees ,

The licensee's corrective action was to replace the flow switch interlocks of the service water valves with high pressure switches, l which allowed the valves to open when the CREVS start and will only '

shut them on high refrigerant gas pressure. The damper control circuitry of the air-cooled condensing unit was also modified by 3 replacing temperature controllers with refrigerant head pressure l controllers. These modifications were completed by Facility Change 1 Request (FCR) 85-0265, and successfully tested to demonstrate l operability with test procedure TP 850.75, " Control Room Emergency l Ventilation System Acceptance Test." Surveillance Test (ST)

Procedure ST5076.01 (DB-SS-03041 and 03042), "CREVS Monthly Test," l was revised to include verification that the service water supply l valves open automatically when CREVS is started. Both check and stop valves were added per FCR 85-222 to the interface of the water and air-cooled condensers to prevent refrigerant migration, the cause of the compressor tripping. Also, procedure 08-S5-03710 (03711), "CREVS Train 1 (2) 18 Month Surveillance Test," was implemented, which verifies the CREVS operability. All corrective actions appear adequate. This violation is close Failure to provide adet, sate (Closed) Violation (346/85040-02(DRP)J:

design control for design changes which increased heat loads in the area cooled by the Control Room Emergency Ventilation System (CREVS). !

Added heat loads were not evaluated relative to the cooling capability of the CREVS and were not included in the Updated Safety Analysis Report Table 9.4-2, "CREVS Heat Loads." Also, the roof mounted ,

air-cooled condensing unit piping was not adequately protected from l tornado missiles as described in the USA l l

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The licensee completed a new heat load study for the control )

room. The results are described in Toledo Edison Calculation j No. C-ME-28.01-003 and show that the total cooling load is approximately 106,570 BTU /hr, with certain non-essential loads

shed. This load is less than the cooling capacity of the CREVS, which was upgraded from 66,750 BTV/hr to 120,000 BTU /hr by l Facility Change Request (FCR)85-274. Table 9.4 of the USAR was The updated to reflect the actual design basis for the CREV licensee completed FCR 85-222, which installed solenoid, check and stop valves in the refrigerant system. Check and stop

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1. ~ valves at the interface of the water-cooled and air-cooled, "

condensers now isolate.the air-cooled condensing unit piping 1 on:the roof'so that a tornado missile would not affect the water-cooled subsystem of- the' CREVS. Because of this and an j earthquake, which is the only design basis' accident that could ~

render the water-cooled condenser inoperable, and a tornado are'

not postulated in the design basis _ to occur simultaneously, the air-cooled subsystem coolant lines on the roof do not need to be protected. All. corrective actions appear complete. This violation is close .

l Failure to

. . (Closed) Violations (346/85040-3a and 3b(DRP)):

establish a procedure for the elimination of nonessential heat'-

loads in the control rooni area if the control room temperature reached ~its upper limit while being cooled by the CREVS. Also,-

a procedure had not been established to inform personnel that )

removing either the CREVS air or water-cooled condensing units j frnm service would degrade the operability of the CREV a Heat load testing of the CREVS as part of the CREVS Acceptance l Test (TP850.75) indicated that load shedding beyond the station i computer is not required. -The' licensee implemented Abnorma l Procedure AB 1203.42 (08-OP-02533), "CREVS Load Shedding," which ,

.j prioritizes the equipment to be- shed as temperature increase ]"

The Updated Safety Analysis Report (USAR) was revised to reflect-the true design basis of the CREVS. All corrective actions were completed and appear adequate to prevent recurrence.. The violation is close (Closed) Violations-(346/85040-4a and 4b(ORP)): Failure to adequately test the CREVS. The CREVS monthly test did not ..

q require testing to demonstrate the operability of either Service Water (SW) supply valve nor did it test the cooling capacity o l the CREVS. Also, the licensee failed to identify that  !

post-maintenance testing was necessary to verify. the required leak tightness of door No. 509, a control room airtight door, after replacemen * i The licensee's corrective actions for these violations included various Facility Change Requests (FCRs) as the licensee believes the root cause to be inadequate design and incomplete design verification testin FCRs85-265, 85-299; and 85-308 have been completed and door No.: 509 is adequately leak tight and several of the CREVS design deficiencies were corrected. System Procedure SP 1104.69 (DB-0P-06505), " Control Room Emergency Ventilation System Procedure," was revised to require energizing- ~

of the air-cooled condensing unit damper actuators for. subzero temperatures. Sluggish damper operation at these temperatures would degrade the air-cooled condensing unit's performance which

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should have been identified earlier. Administrative Procedure AD1844.11 (DB-MN-00008), "Premaintenance and Post / Maintenanc i

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Testing Requirements," now requires testing to ensure maintenance / modification work was completed correctly and the equipment will function correctly when. returned to servic l TP850.75, "CREVS Acceptance Test," verifies the operability of l CREVS, including the maintenance of the required control room i leak tightness. Surveillance Procedures 0B-55-03710 and DB-SS-03711, "CREVS Train 1 (2) 18 Month Surveillance Test,"

were implemented, which adequately verify the CREVS operabilit j

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This violation is close Failure to promptly IClosed) Violations (346/85040-5a and 5b(DRP)): 3

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identify and. correct conditions adverse to quality of the control room emergency ventilation system (CREVS). Corrective action was i not taken when a Facility Change Request (FCR 84-0054) identified that the CREVS compressors would not start in winter when outside temperatures dropped below 15 to 20 degrees F. due to refrigerant migration to the air-cooled condensing unit, thus making both CREVS trains inoperable. Also, corrective action was not taken when a Bechtel employee noted that door No. 509 did not have the gaskets required to make it airtigh .

The licensee's corrective action was completion of three FCR' FCRs85-222 and 85-265 installed check and stop valves at the interface of the water-cooled and air-cooled condensers to eliminate refrigerant migration. FCR 85-308 installed the l I

required gaskets on door No. 509. TP850.75, "CREVS Acceptance Test," verified both the operability of the CREVS and the leak i tightness of door No. 50 j i Failure to report the

[ Closed) Violation (346/85040-6(DRP)J:

Control Room Emergency Ventilation System (CREVS) condition as outside the design basis, as required by 10 CFR 50.72(b)(ii)(B). l The licensee issued Licensee Event Report (LER)85-108, "CREVS - 1 '

Inoperable Cooling" to describe the even This violation is close J. { Closed) Violation (346/86012-01a(ORp)): Emergency diesel generator (EDG) returned to service following an FCR completion prior to operator training. After work was completed on the EDG governor in accordance with FCR 84-189, the EDG was declared j operable prior to the training of operators on the completed j work. Immediate corrective actions included the completion of the training on the FCR 84-189 change The Modification Coordinators were instructed to contact Training to verify that any required training has been completed, and the Shift Supervisors were instructed not to return any affected equipment or systems to service prior to reviewing documentation that

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/ verifies that the corresponding training has been complete Administrative Procedure AD 1845.03 (DB-PN-00011) was revised to require.the Modification Coordinator to ensure that any training required has been completed prior to the equipment's return to 1

service. The inspectors reviewed the procedure revision, which includes'a training verification check 11st'which .the Modification Coordinator completes. This. checklist appears to be'more than adequate to verify that training is. complete, and all other corrective actions appear _ satisfactory to prevent- q recurrence. This part of this violation is close i 1 (0 pen) Violation (346/8_6012-Olb(ORP)): . Potential for break of nonseismically supported water lines over safety-related. control j

panels. This part of this violation remains open pending.further

.. revi e .) (Closed)'Open Item (50-346/86012-08(DRP)): Maintenance activities ]

on all equipment should be prioritized. The'inspec. tors reviewed the licensee's Priority' Assignment Instructions and Processing Requirements, " Attachment 9 to Administrative Procedure A01844.02 (DB-PN-00007), " Control of Work." Either the Planning. Operations Specialist' or the Operations Coordinator establish the priority of a task, from which there are six to choose. The priorities-appear adequate to assure that. corrective' maintenance' activities on all equipment providing a protective function are prioritized satisfactorily. This item is closed, Failure to document i (Closed) Unresolved Item (346/86014-01(DRP)): i loss of reactor coolant system (RCS) inventory as a Potential Condition Adverse to Quality (PCAQ). The licensee initiated PCAQ report 86-0217 subsequent to the inspection report identifying the event so that a thorough review of the subject RCS inventory loss

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would be conducted. The root cause of the RCS inventory loss was a lack of communication among control room operators, tne assistant  :

shift supervisor, and the shif t supervisor. :The operators stroke '

tested valve DH1518, but the DH Pump 1-2 vent and drain valves were not closed prior to the test as no'one had verified that the tagging log and temporary valve lineups had been properly reviewe RCS inventory was lost through the vent and drain valves. This Unresolved Item is closed based on the issuance of the PCAQ and the:

subsequent revie { Closed) Open Item (50-346/86014-04(ORP)): Emergency Plan l

Supporting Procedures need to be reviewed to determine if events (other than a tornado) that require anticipatory actions could occur-before the licensee receives notification of the even The licensee reviewed the Emergency Plan Supporting Procedures and determined that no other procedures are affected. 'This item

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, (Closed) Violation (346/86016-06(DRP)): Violation of Technical .

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l Specification 6.2.3., overtime hours. During a strike by Toledo - l Edison's bargaining unit employees,.a group of ~ individuals not-normally considered " key maintenance personnel" conducted plant

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maintenance activities. In numerous cases some of these individuals working substantial amounts of overtime.without the plant manager's.or his designee's authorization. The licensee reviewed the work performed by individuals who had exceeded the maximum allowable hours to identify any _ errors or discrepant.ies, .

and none were identified._ Procedure AD 1800.01 (DB-OP-00900),

which includes.the overtime limits set in TS 6.2.3, was subsequently issued, and Maintenance Department management personnel received formal training on the procedure. .The licensee's corrective action appears to be satisfactory and this-violation is close (Closed) Open Item (346/86032-06(DRP)): Proficiency Watch changes to correspond with 10 CFR 55. changes. The licensee now requires all its non-shift licensed operators to' schedule time on shift for Proficiency Watch Standing,' limiting the watches to one person per day on the day or' afternoon shift. The Shift Supervisor,is' required to ensure that valid productive work is obtained while personnel are-standing Proficiency Watches. The inspectors have observed that 3 proficiency watch standers are participants and not observer I This item is close l (Closed) Open Item (346/87004-03(DRP)): Lack of available on-shift SR0 licensed operator There is no longer a shortage of on-shift SRO licensed operator The licensee has increased the number of available SRO licenses and now has a six shift i rotation. This item is close ! (Closed) Open Item (346/87004-05(DRP)): Deficiencies in Licensee Event Report (LER) evaluations and reviews. It was recommended to the licensee to provide additional' training to LER evaluators and to provide an additional level of review to LER evaluations due to a concern regarding the quality of LER safety / engineering evaluation The licensee responded by instituting a root cause determination training course (QETC-030), which all engineering personnel are required to attend, and having the Independent Safety Engineering-Director review the analysis of occurrence section of each LER to verify the event has been analyzed properly and technica11y' supports the final root cause determination. The inspectors reviewed the training course outline, . schedule, and. syllabus, in addition t attending the course. The course appears to be more than ,

satisfactory in that it includes workshops in which the attendees l participate in the actual determination of root causes. This item :

is close .

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o. (Closed) Violation (346/86016-06(DRP)): Violation of Technical Specification 6.2.3., overtime hours. During a strike by Toledo Edison's bargaining unit employees, a group of individuals not

normally considered " key maintenance personnel" conducted plant I maintenance activities. In numerous cases some of these individuals working substantial amounts of overtime without the plant manager's or his designee's authorization. The licensee reviewed the work performed by individuals who had exceeded the q

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maximum allowable hours to identify any errors or discrepancies, and none were identified. Procedure AD 1800.01(DB-OP-00900),

which includes the overtime limits set in TS 6.2.3, was '

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subsequently issued, and Maintenance Department management personnel received formal training on the procedure. The licensee's corrective action appears to be satisfactory and this violation is close p. (Closed) Open Item (346/86032-06(DRP)): Proficiency Watch changes to correspond with 10 CFR 55. changes. The licensee now requires all its non-shift licensed operators to schedule time on shift for Proficiency Watch Standing, limiting the watches to one person per day on the day or afternoon shift. The Shift Supervisor is required l to ensure that valid productive work is obtained while personnel are standing Proficiency Watches. The inspectors have observed that proficiency watch standers are participants and not observer This item is close q. (Closed) O_ pen Item (346/87004-03(DRP)): Lack of available ,

on-shift SR0 licensed operator There is no longer a shortage I of on-shift SRO licensed operators. The licensee has increased l

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the number of available SR0 licenses and now has a six shift rotation. This item is close r. (Closed) Open Item (346/87004-05(DRP)): Deficiencies in Licensee Event Report (LET(Evaluations and reviews. It was recommended to the licensee to provide additional training to LER evaluators and to provide an additional level of review to LER evaluations due to a concern regarding the quality of LER safety / engineering evaluation The licensee responded by instituting a root cause determination training course (QETC-030), which all engineering personnel are 1 required to attend, and having the Independent Safety Engineering i Director review the analysis of occurrence section of each LER to {

verify the event has been analyzed properly and technically supports l the final root cause determination. The inspectors reviewed the i training course outline, schedule, and syllabus, in addition to l attending the course. The course appears to be more than i satisfactory in that it includes workshops in which the attendees i participate in the actual determination of root causes. This item '

is closed.

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Y Actuation System (SFAS) radiation monitors. :The licensee completed-its analysis'ofzthe detector failures and.the documented results in

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Memorandum NES-88-00347, dated Ap"ril 19, 1988; The failures were determined to probably be doe to vibration or. shock from handling of the detectors during calibration. replacement _ and transfer of the detector's between the annulus and containment. Maintenance procedures which concern the movement, replacement, or' calibration of.these radiation detectors wereLincorporated with' caution statements that read, "Use extreme ' care when handling detector to '

avoid physical shock .or ' damage to. detector may occur." This. item '

is close ,

t. (Closed) Violation (346/87008-09(DRP)): : Poor maintenanc j housekeeping practices. Emergency Diesel Generator (EDG) .1-2-was declared inoperable after " packages of cleaning cloths and; i l

plastic bags fell from high in the room, pieces of cloth blew out of ,the duct work," as the. diesel was started for the performance of ST5081.01'(08-5C-03071) "EDG 12 Monthly Operation Test." The licensee attributed this incident to personnel error j)

instead of poor housekeeping in that the personnel who left th i cloths and plastic bags did not adhere to Administrative I Procedures AD1844.05 (DB-MN-00005), " Housekeeping Control,"  ;

AD1844.02 (DB-PN-00007),~" Control of Work," and AD1835.00 (DB-MN-00015), " Plant Cleanliness and Material Readiness ,

Inspection Program." j

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The licensee's inspection of the duct work and fans determined that there were no indications of damage, and the. fans were  ;~

tested satisfactorily. A Potential Condition Adverse to Quality Report (PCAQR 87-0222) was issued, with' corrective-action to i prevent recurrence being a discussion / training. session- for .l

'i maintenance foremea. PCAQR 87-0222, AD1844.02, and AD1835.00 were discussed at the meeting, and the foremen were instructed to relay the information to their men. This violation is close ] (Closed) Violation (346/87008-10(DRP)): System Engineer' Performed ,

Maintenance on Component Cooling Water (CCW) Ventilation System . i

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without a Maintenance Work Order (MWO).. The violation was caused by personnel error, as the system engineer thought that TP 850.59,

"CCW Pump Room Ventilation Test," could.be used as a guideline.to verify the operation of the temperature switch that automatically starts the CCW pump room ventilation. The inspectors reviewed-the l

licensee's written response to the violation, which explains'that _ .i

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potentially rendering safety-related equipment inoperable without the use of the required approval tracking required in A01844.00 and AD1844.02." ]

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This event and the control of maintenance were s'bsequently u  !

f:" discussed with all System Engineering personnel. An MWO was I also created to repair the CCW temperature switch. This violation is close Verbal changes in (Closed) Violation (346/87014-02B(ORP)):

i procedurally defined responsibilities of the Operations j i

Superintendent. Interim review in IR 50-346/87002. The licensee's corrective ' actions, as stated in the October 9,1987, Response to <

Inspection. Report No. 50-346/87014, were to have the Assistant Plant Manager, Operations assume the responsibilities of the Operations .l Superintendent (05) until the 05 designee rccsised an NRC SR0 licens The inspectors verified that a Toledo Edison intra-company memorandum issued on September 3,1987, which delineated that the Assistant Plant Manager Operations assume the responsibilities of the OS until the OS designee received an NRC SRO license, had been implemented. In June 1988, the 05 designee receiveci an NRC SR0 license and assumed the responsibilities of the 0 Violation 346/87014-02a(0RP) required no response. This violation is close w. (Closed) Open Item 346/87018-02(DRP)): Verification that Senior Reactor Operator R(I_(0fTrainees are under the direct supervision of an SR0 who is performing the duties of an SRO. The Nuclear Training Director is responsible for providing Senior Reactor Operator Training which meets the requirements of the references listed in Section 3.0 of Administrative Procedure AD 1828.0 NUREG 1021, which in 1.3-d, states that the SR0 trainee should be an extra person on shift, directly under the supervision of a licensed SRO performing the duties of licensed SRO on an operating shift. The licensee includes the SRO trainee positions on the weekly schedule change notices, thus verifying that the trainees are extras and do not perform any other function while on shift. This item is close (Closed) Open Item (346/88007-05(DRP)): Deficiencies in administrative procedure. Administrative Procedure AD 1838.00, l Revision 16, " Surveillance and Periodic Test Program," Attachment 1, ,

I listed no implementing procedures for Technical Specification (TS)

Surveillance Requirements 4.8.1.1.2.c.6, 4.8.1.1.3.c.7, and f 4.8.1.1.2.d. The current " Surveillance and Per' odic Test Program,"

procedure (DB-0P-00013) no longer contains the referenced attachment, as the licensee now maintains a computerized data base (DBMMS) which serves as a controlled current matrix between the TS surveillance requirements and implementing procedures. This item is close (

No other violations or deviations were identified in this are .__-__- - a

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• (Closed) Violation (346/88007-06(DRP)): Failure to implement procedure PP1102.10. The licensee was filling both Steam Generators (SGs) to place them in wet layup while the reactor was in cold shutdown, by following the applicable procedures:

PP1102.10, Revision 16, and SP1306.08, Revision 12. " Steam Generator Secondary Side Fill, Drain and Layup." Note 1 of PP1102.10, Step 6.2.25 instructed the operators to vent the SGs to prevent pressurization during fill if the MSIVs are closed. The MSIVs were closed and the SGs were not vented, thus causing the pressurization of SG2. The corrective action taken by the licensee was to revise SP1106.08 so that it clearly requires the Atmospheric Vent Valves (AVV) to be opened to vent the SGs during fill to wet layup if the HSIVs are closed. The i inspectors reviewed SP1106.08 (DB-OP-06230), verifying that the l revision was incorporated and that it directly precedes the wet layup steps procedures. The licensee also revised PP 1102.10, which was superseded by DB-0P-06903,~so that the note to vent the SGs if the MSIVs are closed precedes the step that directs  !

the operator to SP1106.08. All corrective actions were I satisfactorily completed. This violation is close . Operational Safety Verification (71707)

The inspectors observed control room operations, reviewed applicable logs and conducted discussions with control room operators during the months of December and January. The plant remained in hot standby (mode 3) until December 5, 1988, when the reactor was taken critical (mode 2). On December 8, 1988, the licensee shut down the reactor because a normally open instrument isolation valve was found partially open and the next day began a plant cooldown to cold shutdown (mode 5)

to determine if this condition existed on other' valves. The plant remained shut down until December 15, when the reactor was taken critical and power operation (mode 1) began. On December 17, 1988, the reactor tripped and was restarted. On December 18, 1988, the reactor shut down when a group of safety rods dropped into the core. The reactor was taken critical later that day and returned to mode 1. Power was slowly increased until the plant reached full power on December 3 The licensee conducted reactor physics testing during the initial startup and as power was being increased. The plant remained at full power until the end of the inspection period. The inspectors verified the operability of selected emergency systems, reviewed tagout records and verified proper return to service of affected components. Extended inspection coverage was provided from November 28 through December 12, 1988, to observe the licensee's restart activities. Resident inspectors from other sites and a reactor inspector from Region II assisted the resident inspectors in this activit The licensee's reactor physics testing activities were inspected by the Region II reactor inspector

! and a Region III reactor inspector. The reactor physics inspection l activities were documented in Inspection Report No. 50-346/89003, t

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'. Tours of the auxiliary, reactor, turbine, water treatment and service water buildings were conducted to observe plant equipment conditions, including potential fire hazards, fluid leaks, and excessive vibrations and to verify that maintenance requests had been initiated for equipment in need of maintenance. The inspectors by observation and direct

' interview verified that the physical security plan was being implemented in accordance with the station security pla The inspectors observed plant housekeeping and cleanliness conditions and verified implementation of radiation protection controls. During the month of December and January, the inspectors walked down the accessible portions of the Service Water, Emergency Diesel Generator, Essential 120 Volt AC, Essential 4160 Volt AC, Essential 480 Volt AC, Essential 125 Volt DC, and Component Cooling Water Systems to verify operability. These reviews and observations were conducted to verify that facility operations were in conformance with the requirements established under technical specifications, 10 CFR, and administrative procedure Updated Safety Analysis Report (USAR) subsection 3.6.2.7.1.13, " Hot Water Heating System," states that "A high flow switch on the pump discharge has been provided to prevent the system makeup water supply valve from opening." The high flow switch is FIS 5222 which receives a flow signal from flow transmitter FT 5222. The non-safety related Hot Water Heating System is referred to in licensee procedures as the Station Heating (SH) System. The USAR further states that the makeup water supply valve is prevented from opening to protect essential equipment in Rooms 500, 501 and 515 from flooding. On January 9, 1989, the inspectors observed that the sensing lines for FT 5222 were disconnected with the isolation valves (SH 5222A and SH 52228) close In this condition the indicator for FIS 5222 indicates no flow, the switch cannot sense high flow and the switch function described in the USAR does not exist. Valves SH 5222A and 5H 5222B are also shown on USAR figure 9.4-7 as open. The inspectors discussed the condition with various licensee personne The inspectors later observed that valves SH 501 and SH 502 were closed and that on January 13, 1989, the licensee had placed operations information tags on valves SH 501 and SH 502 indicating that they should be kept closed except when filling the Heating System Compression Tank because FT 5222 was out of service. With SH 501 and SH 502 closed, makeup water is isolated from the SH system, protecting equipment in Rooms 500, 501 and 515 from SH system flooding. USAR figure 9.4-7 shows SH 501 open. Maintenance information tags near FT 5222 indicate that it failed some time before October 2, 1987. The inspectors learned from licensee personnel that FT L222 had not been repaired or replaced because it is no longer made and parts are not available. A plant modification to replace FT 5222 was scheduled for the seventh refueling outage in 199 However, licensee personnel told the inspectors that, as a result of the discussions with the inspectors, the schedule for the replacement modification would be reconsidere _ - _ _ _ _ _

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Because closing valves SH 5222A and SH 5222B and temporarily eliminating the function of FIS 5222 are changes to the facility as described in the

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USAR, it appears the licensee was required by 10 CFR 50.59 (b)(1) and (2)

I to maintain records of the above changes and submit a.brief written report of these changes to the NRC with it annual report. The inspectors reviewed the licensee's August 25, 1988, letter (Serial No.1569) to the NRC, titled "1987 Annual 10 CFR 50.59 Report of Facility Changes, Tests and Experiments." The letter did not describe the changes to the Station Heating System described above. This is an Unresolved Item (346/88037-01(DRP)).

USAR Subsection 9.2.1.2,." System Description" for the Service Water (SW)

System, states that " Additionally, the dilution pump,.P-180, can supply water to the Service Water System from the intake structure in the event:

of a fire disabling the Service Water Pumps." On about October 31, 1988, the licensee removed.the dilution pump from service for repairs.. By the end of the inspection period the pump was not restored to service. For part of this period, the pump was removed from.its norma 11y' installed location. Although 10 CFR 50.59 requires that a licensee must maintain a written safety evaluation of changes to the facility as described in the USAR, it does not discuss long duration maintenance activities. -The licensee did not write a safety evaluation of the dilution pump repair This item will be evaluated in conjunction with unresolved Item (346/88037-01(DRP)) abov USAR Subsection 10.4.4.1, " Turbine Bypass System," describes the main steam system associated with the Turbine Bypass Valves (TBV),

including piping and controls. In December,1988, the licensee added a temporary electric heating system for piping associated with the TBV. The heating system is not described in the USAR. The heating system was installed in accordance with administrative procedure DB-0P-00020, " Temporary Modifications" (TM). As part of the TM process a safety review was performed in accordance with nuclear group procedure NG-NE-304, " Safety Review and Evaluation." The safety review is a screening process to determine if a 10 CFR 50.59 safety evaluation is required. The licensee determined that because the addition of the electric heat'ing system did "not alter the form or function of any USAR described equipment" it was not a change to the facility as described in the USAR and a safety evaluation was not performed. However, to the inspectors, the addition of the heating system appears to be a change to the facility as described in the USAR and as c ch would require a written safety evaluation. The inspectors also observed weaknesses in the written operator. aids, post maintenance testing and procedural controls associated with the installation. This item will be evaluated in conjunction with unresolved Item (346/88037-01(DRP)) abov No violations or deviations were identified in this are _ _ __ ______ ___ _ _ _ __J

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' Monthly Maintenance Observation (62703)

Station maintenance activities of safety related systems and components listed below were observed or reviewed to ascertain that they were conducted in accordance with approved procedures, regulatory guides an industry codes or standards and in conformance with technical specification The following items were considered during this review:. the limiting-conditions for operation were met while components or systems were removed from service; approvals were obtained prior to initiating the work; activities were accomplished using approved procedures and were inspected as applicable; functional testing or, calibrations were performed prior to returning components or systems to service; quality control records were maintained; activities were accomplished by qualified personnel; parts and materials used were properly certified; radiological controls were implemented; and fire prevention controls were implemente Work requests were reviewed to determine status of outstanding jobs and to assure that priority is assigned to safety related equipment maintenance which may affect system performanc The inspectors reviewed the licensee's progress in its program to improve availability of spare parts. On December 18, 1987, the licensee had stated in a letter (Serial No. 1454) to the NRC that the spare parts evaluation portion of its Spare Parts Project would be completed by March 31, 1990. The spare parts evaluation includes identification of spare parts and preparation of the necessary specifications for procurement. The licensee also stated that the stocked spare parts inventory was being augmented in parallel with the spare parts evaluation but did not project a completion date because completion is contingent on other ongoing activitie Discussion with licensee personnel reyt led that the scheduled completion of the Spare Parts Project is September, 1990, based on the contract the licensee has with its Spare Parts Project contracto The following maintenance activities were observed or reviewed:

' Troubleshooting of Control Rod Drive Syste * Replacement of carbon steel nuts on makeup system valve MU 2 * Leak isolation in fire protection water syste * Troubleshooting and repair of annunciator trouble' alarm.

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- On December 18, 1988, an I&C technician was troubleshooting a problem with the control rod drive (CRD) system. The work was being performed in accordance with maintenance work order (MWO) 1-88-3031-00. The technician had narrowed the source of the problem to be in the Groups 3 and 4 Programmer drawer. tamp sensor boards were removed from the drawer which resulted in Group 3 control rods being dropped into the cor The maintenance part of the event was documented in PCAQR No.88-108 The ,

I event resulted in reactivity changes which were documented in PCAQR No. 88-1089 and is described in more detail in Paragraph Administrative Procedure DB-PN-0007, " Control of Work," Section 6. requires the planner to perform appropriate walkdowns, review the j P&ID's, drawings, precedures and vendor manuals to identify corrective actions and necessary documentation for the maintenance task. The planner discussed the task with the technician to determine if any precautions were required. The technician checked one drawing (M-515-220-3) which appeared to indicate that the '

programmer lamps were powered directly by the power supply. However, the drawing also referenced another drawing which gave greater detail l of the power supply and which contains a note which states that a jumper must be installed when a programmer lamp sensor module is removed so that power to the programmer lamp is not disrupted. The planner failed to review t.he referenced drawing which would have identified the necessary precaut ons. This is a violation (346/88037-02(DRP)) of technical spt:ciffeation 6.8.1, in that the licensee failed to implement a written procedu~ No other violations or deviations were identified in this are . Monthly Surveillance Observation (61726)

The inspectors observed technical specifications required surveillance testing on the Reactor Coolant System (RCS), DB-SP-03358, "RCS Flow i Rate Test," and verified that testing was performed in accordance with adequate procedures, that test instrumentation was calibrated, that limiting conditions for operation were raet, that removal and restoration of the affected components were accomplished, that test results conformed with technical specifications and procedure requirements and were reviewed by personnel other than the individual directing the test, and that any l

deficiencies identified during the testing were properly reviewed and resolved by appropriate management personne DB-SP-03358 is performed to meet TS surveillance requirement 4.2. which is required to be performed every eighteen months. On January 5, 1989, with the plant operating at full power, the licensee realized that the test was required to have been completed on November 3, 1988. Failure to perform the test on time caused the plant to be in TS 3.0.3. which requires thct a plant shutdown begin within one hour. Because the test takes longer than one hour to perform and evaluate, the licensee requested l

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.- permission from the NRC to continue operating'the plant at power until the test could be. performed and evaluated. The licensee was granted discretionary; enforcement'and allowed.to continue operation untti the test'

wasevaluated(letter.datedJanuary 27,.1989, to Toledo Edison from-Region III Regional Administrator). The test results indicated that RC flow was within TS limits. For purposes of. enforcement, the plant i considered to have entered TS 3.0.3 on November 3,1988. Since the plan was not shut down to' hot standby within'seven hours as required by.TS 3.0.3, this'is a violation (346/88037-03(DRP)) of TS 3.0.3. .The licensee-identified delay in performing the surveillance test was of minor safet significance and therefore, in accordance with 10 CFR 2., Appendix 2,Section V.G.1 (Dttober 13,1988) a notice of violation will .not be issued and no licensee resporde is required. An LER is required to be-issued fo this even The inspectors also' witnessed or reviewed portions of the following test activities:

• DB-PF-03001,-"Seven Day Fire Pump. Test"

• DB-PF-03212, "Zero Power Physics Testing"

• DB-PF-04277, " Core Power Distribution"

• DB-SC-03111, " Safety Features Actuation System Channel 2 Functional Test."

• DB-SC-03114 " Safety Features Ast"

• DB-SC-03271, " Control Rod Drive Program-Verification"

• DB-SP-03357, " Reactor Coolant System Water Inventory Balance."

The inspectors observed that this surveillance' test was complete at 9:30 p.m. on December 3,1988, and was. not completed again until 9:35 p.m. on December 7, 198 The period between. tests:was 96 hours0.00111 days <br />0.0267 hours <br />1.587302e-4 weeks <br />3.6528e-5 months <br /> and 5 minutes. Technical Specification Surveillance Requirement 4.4.6.2.1.d has a . required frequency of 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> (90 hours0.00104 days <br />0.025 hours <br />1.488095e-4 weeks <br />3.4245e-5 months <br /> including the 25% extension allowed by Technical Specification 4.0.2) during steady state operation. 'The inspectors discussed this situation with the Shift Supervisor on December During the discussion,.the December 7 surveillance test was in progress. The shift / supervisor stated that he did not consider the-plant to have been in steady state operation between the two tests and that he had ordered the test started'as soon as the plant was in steady stat No other violations or deviations were identified in'this area.

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. 6. Licensee Event Reports Followup (92700) Through direct observations, discussions with licensee personnel, ( and review of records, the following event reports were reviewed

, to determine that deportability requirements were fulfilled, immediate corrective action was accomplished, and corrective action to prevent recurrence had been accomplished in accordance with technical specification .

{ Closed) LER 82-028: Swing Check Valve SW44 in Service Water (SW)

System stuck open. Part of the licensee's corrective actions for this LER were documented in Inspection Reports No. 50-346/84018 and No. 50-346/87008. The licensee had not corrected the root cause of the valve failure at the time of the previous inspection The root cause of the valve failure was an inadequate valve design which utilized dissimilar metals that allowed a galvanic effect to produce corrosion products at the valve body and disk arm pivot points, thus causing the disk assembly to stick in the open positio Facility Change Request (FCR) 83-0151, which replaced SW44 and four other SW swing check valves with manual actuated butterfly valves, was completed. The butterfly valves can be closed even with some l corrosion presant. Twelve other SW check valves similar to SW44 l that were determined to be unnecessary for system operation were I

modified by removal of internals. All corrective actions appear i to have been satisfactorily completed.

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{ Closed) LER 83-036: Multiple failures of Safety Features Actuation System (SFAS) Containment Radiation Monitor. Interim review in IR 50-346/84020. The licensee's immediate corrective action was replacement of the detectors. The licensee committed to a continuing investigation of the cause of the failures because specific reason for the detector failure had been determine The licensee completed an analysis which indicates that the failures are probably due to " vibration or shock from handling of the detectors for calibration, replacement and transfer of the detectors between the annulus and containment." This determination is supported by the facts that no other plants have identified similar problems with Victoreen detectors and that the number of detector failures decreased after several modifications to reduce vibration were completed. The inspectors reviewed Memorandum NES-88-00347, dated April 19, 1988, which documented the results and conclusions of the failure analysis, and the surveillance procedures for the four SFAS channel radiation monitors. Each ST (DB-MI-03121 through 03124) now ,

contains five caution statements throughout which read, "Use extreme care when handling detector to avoid physical shock or damage to detector may occur." ~

(Closed)LER85-018: Control Room Emergency Ventilation System . ~

(CREVS) - Inoperable Cooling. The conditions reported by this

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- LER were the subject of-Inspection Report 50-346/85040 which identified several violations'. The licensee's corrective actions for the violations included the corrective actions for the LE Paragraph 2 above discussed the licensees corrective actions for the violations. The LER is closed by the corrective actions for the violation Modification Degrading Shield Building l(Closed)

ntegrit Interim review LER 86-033: in..IR 50-346/87018.. During an engineering review of Facility Change. Request (FCR)86-107, which'

would have lowered the setpoint pressure of shield building wall'

blowout panels, the licensee determined that the panels.would no longer withstand the differential pressure'during a loss of coolant accident.(LOCA). The setpoint value listed.in'the Updated Safet Analysis' Report (USAR) was 0.5 psid, a:value which should have been-updated in'1977 when the blowout panels setpoint was upgraded to 1.0 psid in order to withstand a LOCA. During a LOCA, the calculated differential pressure across the panels is 0.8 psid;' th.erefore, if the setpoint were 0.5 psid, the panels would not withstand 'the -

differential pressure during a LOCA. A high energy line break (HELB)

analysis 4 was performed for equipment qualification of the' panels using the 0.5 psid setpoint from the USAR. .FCR'86-107.was initiated

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to reduce the differential pressure to 0.5 psid.: The licensee immediately revised FCR 86-107 to return the blowout; pressure L setpoint to 1.0 psid to withstand a LOCA. The USAR was updated s that the blowout pressure is now specified at 1.0 psid. A revised HELB analysis using the 1.0 psid setpoint was performed which resulted

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in only minor differences in the equipment qualification ^ analysi The inspectors reviewed Inipell Calculation / Problem No. 1040-054-002,:

" Justification of Environments with 0.50 psi Blow-out panel in Room~

314," which contained comparisons of. various' HELB analyses using both- j

the 0.5 and 1.0 psi setpoints. The results:showed that.the differences l were negligible. The licensee's safety evaluation for the' FCR to change the setpoint to 1.0 psid concluded that no' equipment in the- i affected rooms would have its qualification affected and also that j the compartment pressurization loads due to the new~1.0 psid analysis; ,

on the structural adequacy of Room 314 and the adjoining rooms were j determined to be acceptable as demonstrated in Bechtel civil 1 calculation No. 44, Volume F14, Revision 2. The licensee has -l implemented Nuclear Group Procedure NG-NL-0806, " Preparation and 1 Control of USAR Changes," which requires the Nuclear Group ensure ;j the USAR is reviewed and updated annually in accordance with i 10 CFR 50.71. The Design Criteria Manual, which catalogs.the' design criteria and design basis used in the development of Davis-Besse,:

has been approved. All corrective actions appear to be' satisfactor '

This action closes the LE Inoperable Seismic Monitoring System Due to ;

.{Deficient Closed)LER86-035:

Surveillance Test (ST) program. The licensee determined' :

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that ST5034.03 (DB-MI-03300.03), " Strong Motion Accelerometer ,

Channel Calibration Test," did not adequately meet Technical Specification (TS) 4.3.3.1 requirements because the functional test ;

did not check the strong motion triaxial accelerometers and the i

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calibration' test did not test the calibration of the accelerometer As immediate corrective action the licensee removed the strong motion accelerometers for calibration. The calibration showed that the l recorded accelerations during an earthquake would have been  !

conservative. The accelerometers were reinstalled, and the system J was declared operable after system loop and control panel testin Both ST 5034.02 and ST 5034.03 were revised to include the functional test and channel calibration, respectively, required by TS 4.3.3. ,

Long-term corrective action was to prepare and review all procedures under Administrative Procedure AD 1805.00 (DB-DP-00003) " Procedure l Preparation and Maintenance." This procedure should eliminate l occurrences of this type by providing specific guidance for i

performance of reviews and validation of procedure l

{ Closed) LER 87-012:

Inadverten't, Inconsequential Trip of Control l Rod Drive (CRD) Breakers in Hot Shutdown. While the Unit was in Mode 4 (Hot Shutdown) with all control rods inserted, an inadvertent-Anticipatory Reactor Trip System (ARTS) trip of the CRD breakers was experienced due to an inadequate Surveillance Test (ST) procedur Procedure ST 5030.16, " Reactor Protection System Functional Test in i j

Shutdown Bypass," did not include the additional steps to be taken to prevent an ARTS trip due to the existing plant conditions. The licensee's corrective action was to change ST 5030.16 to include the appropriate step { Closed) LER 88-023: Design Deficiency in the ITT Hammel Dahl l Conoflow, 16 Inch Butterfly Valve i i

{ Closed)LER88-025: Inadvertent Actuation of Steam.and Feedwater Rupture Control Syste { Closed) LER 88-26: Inadvertent Initiation of Steam and Feedwater Rupture Control System, The following LER's were reviewed during the~ inspection period but could not be close {0jen) LER 88-022: Failure to Test Automatic Actuation of Fire Sprinkler System. This event is being evaluated by Region III fire protection specialists in conjunction with other fire protection issue {0 pen) LER 88-024: Missed Fire Watch for Fire Detection Zone 23 This event is being evaluated by Region III fire protection specialists in conjunction with other fire protection issue ,

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- (0 pen) LER 88-027: Missed Surveillance Test for Inoperable Asymmetric Rod Fault Circuitr No violations or deviations were identified in this are . Onsite_ Followup of Events (62702), (82201), (82206) and (93702)

During the inspection period, the licensee experienced several events, some of which required prompt notification of the NRC pursuant to 10 CFR 50.72. The inspectors pursued the events onsite with licensee personnel. In each case, the inspectors verified that the notification was correct and timely, if appropriate, that the licensee was taking prompt and appropriate actions, that activities were conducted within regulatory requirements and that corrective actions would prevent future recurre...<. The specific events are as follows:

• December 16, 1988 On December 16, 1988, the licensee completed the modification and refueling outage which had commenced on March 12, 198 The reactor was in Mode 2 on December 6,1988, at which time low power physics testing was performed. The licensee discovered an instrument line valve out of position on December 8, 1988, shut the reactor down, and initiated a program to walk down all instrument lines to verify valve positions. The licensee restarted the reactor and entered Mode 1 on December 15, 198 December 16, 1988 Main turbine tripped from high vibratio * December 17, 1988 On December 17,1988 at 7:43 a.m. , the reactor tripped from high flux while at 37% power as indicated by nuclear instrumentatio The operators were attempting to raise steam generator level above the low level stops and feedwater oscillations resulted. The

! increased feedwater flew lowered Tave causing the rods to withdraw, which increased reactor power above the reduced trip point. The reactor was restarted approximately 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> later.

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• December 18, 1988 On December 18, 1988, the reactor was operating at approximately two percent power when a constant "IN" command existed in the control rod drive (CRD) system. The licensee initiated a maintenance work order to trouble shoot the problem and as a result of an error during this troubleshooting, control rod Group 3 safety rods dropped

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, into the core (see Section 4 of this inspection report for more

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discussion on the cause of the dropped rods).

The shift supervisor's log book has an entry at 0358 which states,

" Group 3 safety rods dropped - Plant entered Mode 3." Another entry at 0359 indicates he contacted the I&C technicians working on the CRD problem and determined they had pulled a wrong card, causing the rods to drop. At 0401, the log book indicates that the duty operations manager was notified; at 0404, the Group ' rods were  ;

being withdrawn; and at 0405, the Group 3 rods were being inserted

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with an entry that also states the reactor was subcritical. The log book further indicates that at 0406, the regulating rods were being inserted and the reactor coolant temperature was less than 525' The NRC is concerned about these series of events because they may indicate a breakdown in the control of licensed activities in the cuntrol room or a potentially significant lack of attention toward licensed activitie This is corroborated by the following discussion which is quoted ll directly from a licensee report to the Vice President describing ll the recovery of the Group 3 rods:

"The first indications in the Control Room that Group 3 rods

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had dropped were the "CRD SAFETY RODS NOT WITHDRAWN" annunciator alarm and Group 3 rod bottom lights. The Primary ll

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RO noted that reactor power was decreasing on the Intermediate ,

Range nuclear instrumentation and that a constant negative startup rate existe The STA contacted the Duty Operations I Manager who then immediately reported to the Control Roo The Assistant Shift Supervisor and the STA checked DB-0P-02516,

CRD Malfunctions, and DB-PF-02000, RPS, SFAS, SFRCS Trip or SG  !

Tube Rupture, but found no guidance covering actions for an entire group of rods being droppe ..

The Shift Supervisor positioned himself at the front panel .'

between the Primary and Secondary R0s to direct their action '

The Secondary RO concerned himself mainly with feedwater flow  !

and Deaerator 1-2 level (Deaerator 1-2 level control had been placed in manual due to swinging), while the Primary RO was directed by the Shift Supervisor to latch Control Rod Group 3 -

in preparation for withdrawa At no time throughout this event was the return or approach to criticality discussed by the shif Although an uncomfortable feeling about withdrawal of Group 3 pervaded the shift, no i recommendations by shift personnel concerning this were voiced it i l to the Shift Supervisor except by the STA. The STA suggested s'

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. standard operating procedures. Those which were not incorporated

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were listed in the memorandum with a statement that they would be implemente One of the listed controls was that, "during high activity periods, SRO qualified operations management will be available on shift for consultation and advisement for the shift supervisor." As noted earlier, a duty operations manager was on shift but did not advise the shift superviso In addition to the four potential violations and apparent failure of the duty operations manager to follow internal guidance, of greater concern to the NRC is the apparent lack of dialogue among licensed personnel before the initial rod pull, and the rapidity with which it was don No one appears to have evaluated the " big picture" with the result that reactivity was being added in an uncontrolled manner from the cooling of the reactor coolant and from withdrawal of the Group 3 rod Furthermore, the minimum required temperature for criticality is 525 F and at the time the rods were initially being pulled, the temperature was between 526'

and 528' and decreasing but no one appears to have recognized i Adding to the NRC's concern is that on July 25, 1988, INPO issued a letter to the CEO of Centerior Energy Corporation on the issue of reactivity contro In that letter it states, "During startups and certain other infrequent situations it is a concern, and it is vitally important that all operating personnel understand the possible consequences of improper reactivity control, and that their attitudes and actions reflect this understanding." The letter further states that a significant operating experience report in 1984 on this subject " emphasized strict compliance with procedures."

The letter concludes by recommending and requesting that the operating line organization be informed that " conservative action is required whenever an unexpected situation arises with respect to reactivity, criticality, power level, or any anomalous behavior of the reactor core. This conservative action should include rod insertion to reduce power, or a reactor scram without hesitation, whenever such unanticipated or anomalous behavior is encountered."

The licensee stated that these actions do receive proper emphasis

, in both operator training and procedures and should have been sufficient to preclude the inappropriate Group 3 withdrawa Collectively, all of the above events appear to indicate a breakdown in control of licensed activities or a potentially significant lack of attention or carelessness toward licensed activities. These issues will be discussed in an enforcement conference with the i licensee on March 3, 198 _ _ - _ _ _ - _ _ . _ .__

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. Security The licensee installed many new fire doors during the fifth refueling outage (RFO). Several of these doors are dual purpose, in-that they are alarmed and are part of the security program. The doors are equipped with flush panic hardwar The inspectors have observed that in those areas with high differential pressure (d/p) the door closures do not provide sufficient force to close the doors against the high d/p. The flush panic hardware does not provide a sufficient surface to pull the door closed. This could allow the door remain open far enough to initiate an alarm. The inspectors have discussed this concern with the licensee and will follow the licensee's corrective actio No violations or deviations were identified in this are . Unresolved Items Unresol'v ed items are matters about which more information is required in order to ascertain whether they are acceptable items, violations, or deviations. One unresolved item disclosed during the inspection is discussed in three areas in Paragraph 3 and one item in Paragraph . Exit Interview (30703)

The inspectors met with licensee representatives (denoted in Paragraph 1) throughout the inspection period and at the conclusion of the inspection and summarized the scope and findings of the ',

inspection activitie The licensee acknowledged the finding After discussions with the licensee, the inspectors have determined there is no proprietary data contained in this inspection repor . Management Meeting On February 10, 1989, the NRC met with Toledo Edison management in Glen Ellyn to discuss events surrounding the rod pull incident of December 18, 1988 (see Section 7 of this report).

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