IR 05000346/1989011

Safety Insp Rept 50-346/89-11 on 890301-0423.Licensee Identified Violations Noted.Major Areas Inspected:Previous Insp Findings,Plant Operations,Radiological Controls, Maint/Surveillance,Emergency Preparedness & Security

ML20247D125
Person / Time
Site:	Davis Besse
Issue date:	05/11/1989
From:	Defayette R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20247D122	List: IR 05000346/1989011 ML20247D121
References
50-346-89-11, IEB-84-02, IEB-84-2, IEIN-88-046, IEIN-88-051, IEIN-88-055, IEIN-88-056, IEIN-88-067, IEIN-88-46, IEIN-88-51, IEIN-88-55, IEIN-88-56, IEIN-88-67, NUDOCS 8905250175
Download: ML20247D125 (23)

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s U.S.. NUCLEAR REGULATORY COMMISSION REGION III-

- Report No. 50-346/84011(DRP)

Docket No. 50-346 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, Ohio Inspection Conducted: March 1 to April 23, 1989 Inspectors: P. M. Byron E. R. Schweibinz D. C. Kosloff R. K. Walton Approved By:

h R. DeFayett , Chief ll .

Reactor Projects Section 3A Date Inspection Summary Inspection on March 1 through April 23, 1989 (Report No. 50-346/89011(DRP))

A routine unannounced safety inspection of previous inspection

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Areas Inspected:

findings, plant operations, radiological controls, maintenance / surveillance,-

emergency preparedness, security, engineering and technical support, and safety assessment / quality verification was performed. The following SIMS items were inspected: MPA-A-15 (closed) and MPA-B-45 (open). An Enforcement Conference relative to the December 18, 1988 rod pull event was held on March 3, 198 Results: Nine previous inspection findings heve been administrative 1y closed (Paragraph 2.c). Operating crews demonstrated excellent response to plant l

transients but made minor errors in control of plant equipment (Paragraph 3).

l The licensee has implemented a computer based program which allows " touring the plant" for work planning inside containment which should result in lower 1 exposures (Paragraph 4). There were weaknesses in the balance of plant PM program and in problem solving. The licensee needs to increase its efforts to reduce the maintenance backlog and a personnel error resulted in maintenance being performed on incorrect equipment. The licensee identified multiple examples of incorrect Appendix J testing intervals. Two violations were 8905250175 890512 PDR ADOCK 05000346 Q PDC

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identified which were of minor safety significance and meet the criteria of 10 CFR 2, Section V.G and therefore, no Notice of Violation will be issued (Paragraph 5). The licensee continues to have problems with the instrument air system (Paragraph 8). QA needs to direct more effort towards performance based reviews. Potential weaknesses in operability determination resulted in an unresolved item. The licensee took aggressive action in response to an increasing steam generator tube leak. The licensee was slow to recognize all safety issues related to equipment repair (Paragraph 9).

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' I DETAILS i

' Persons Contacted Toledo Edison Company (TED)

D. Shelton, Vice President, Nuclear

• L. Ramsett, Quality Assurance Director

• L. Storz, Plant Manager

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• W. Johnson, Plant' Maintenance Manager

• R. Flood, Plant Operations Manager '!'

• E. Salowitz, Planning and Support Director

• C. Ackerman, Independent Safety Engineering

• S. Jain, Engineering Director G. Grime, Industrial Security Director- .

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• J. Gates, Systems Engineering Manager V. Watson, Design Engineering Manager

• R. Coad, Radiological Protection Supervisor

• G. Honma, Compliance Supervisor R. Schrauder, Nuclear Licensing Manager

• G. Skeel, Nuclear Security Operations Manager

• R. Gaston, Licensing Engineer b '. 'U.S. Nuclear Regulatory Commission (USNRC)

• P. Byron, Senior Resident Inspector

• D. Kosloff, Resident Inspector E. Schweibinz, Reactor Inspector

• R. Walton, Resident Inspector in Training

• Denotes those personnel attending the April 28, 1989, exit meetin . Licensee Action on Previous Inspection Findings (92701)

The items identified below have been closed during this inspection period-based on a directive by the Division Director, Division of Reactor Safety, Region III. Our decision to close these items is based on the length of time the item has been in existence and the recognition of limited safety significanc (Closed) Unresolved Item 83016-14(DRS): Failure to properly design and install automatic sprinkler system (Closed) Open Item 83016-20(DRS): Review modifications made to automatic sprinkler and water spray systems to eliminate the possibility of cold soldering of sprinkler head (Closed) Open Item 84009-13(DRS): Significant backlog of design changes and jumper I

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(Closed) Violation 84009-17(DRS): Reduce backlog of older nonconformance report (Closed) Unresolved Item 85025-06(DRS): Identification of required test (Closed) Open Item 8tiOO6-04(DRS): Review containment building fire'

detection syste (Closed) Unresolved Item t ,12-04(DRS): Verify that problems ..rith service water pump.1-3 were not a symptom of an ineffective maintenance program for the service water pump (Closed) Open Item 86030-01(DRS): Complete Phase 2 of Technical Specification verification progra (Closed) Open' Item 87022-02(DRS): Draft ANS 3.1-1977 was not appropriately reference No violations or deviations were identified in this are . Plant Operations (71707, 71710, 64704, 93702) _perational Safety Verification Inspections were routinely performed to ensure that the licensee conducts activities at the facility safely and in conformance with regulatory requirements. The inspections focused on the implementation and overall effectiveness of the licensee's control of operating activities, and on the performance of licensed and non-licensed operators and shift manager The inspections included direct observation of activities, tours of the facility, interviews-and discussions with licensee personnel, independent verification of safety system status and limiting conditions of operation (LCO), and reviews of-facility procedures, records, and reports. The following items were considered during these inspections:

• Adequacy of plant staffing and supervisio * Control room professionalism, including procedure adherence, operator attentiveness, and response to alarns. events, and off-normal condition * Operability of selected safety-related systems, including attendant alarms, instrumentation, and control * Maintenance of quality records and report The inspectors observed that control room shift supervisors, shift managers, and operators were attentive to plant conditions, performed frequent panel walk-downs and were responsive to off-normal alarms and conditions. The licensee has established the new position of

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k L* Shift Manager. Shift Managers are qualified as Shift Technical a Advisors (STA) and hold SR0 licenses. They work 12-hour shifts,  !

L perform STA duties and assist the shift supervisor in managing plant  ;

activities, primarily those that occur outside the control room and  !

involve departments other than operations.

l The' operating crew was cognizant'of ongoing work activitie Surveillance and testing activities were appropriately authorized and logge Licensed operators were generally cognizant of entry into and compliance with-LC0 action requirement On. March 3 the operators manually recovered the plant from a reduction

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in instrument air pressure. Quick and appropriate action by the

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operators prevented air pressure from dropping low enough to induce a plant transient. However, appropriate communications among' licensee i personnel and better control of air compressor maintenance activity

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by the operations department could have minimized the reduction in air pressur On March 10 the licensee performed a loss of main feedwater pump test in accordance with procedure DB-PF-10008. A main feedwater pump was tripped while the plant was at 85% power. The rapid feedwater reduction (RFR) and plant runback circuits functioned as designed. The plant stabilized at 62% and all systems operated as l expected. The inspectors observed the test and noted that operating crews did not attempt to override the automatic control The licensee then continued to reduce power in preparath,n for a short maintenance outag On March 11, while inserting group 5 control rods during plant shutdown, control rod 5-2 dropped into the core. The inspectors review of the rod drop indicated that operator response was correct and appropriate procedures were followe On March 13 the licensee began starting up the plant, and on March 14 the inspectors observed two attempts by the operators to increase plant power high enough to raise steam generator level above the low level limit During both attempts feedwater oscillations forced the operators to take manual control of various systems'to stabilize the plant. The operators performance was excellent. On March 15, following maintenance of feedwater regulating valve SP6B, plant power was successfully increase On March 17 the licensee observed that the Reactor Coolant System (RCS) to secondary leak rate increased from approximately 0.006 gpm to 0.038 gpm as determined by tritium analysis. The operators followed the requirements of abnormal procedure DB-0P-02531, " Steam Generator Tube Leak" to assess the leak. This procedure requires a plant shutdown if leakage exceeds 0.5 gallon per minute (gpm).  ;

Technical Specification 3.4.6.2 requires a plant thutdown if leakage exceeds I gp The leak received appropriate management attention

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and an initial action level of .07 gpm (100 gallons per day) was established to require another management decision on continued plant operatio On March 20, at 9:35 pm, the licensee removed containment atmosphere radiation monitor RE 4597 AA from service for testing. This placed the plant in the Action Statement for TS 3.4.6.1 because containment atmosphere radiation monitor RE 4597 BA had been taken out of service earlier for maintenance. Operating personnel did not recognize that they had entered this action statement until 1:55 am on March 21 when the shift supervisor was told that problems had been encountered returning RE 4597 AA to service. At this point the shift supervisor recognized that the plant was in the Action Statement for TS 3.4. and ensured that RE 4597 AA was returned to service at 2:30 am. The Action Statement was not violated. This event revealed a weakness in the licensee's control of the containment atmosphere radiation monitors similar to weaknesses previously observed in controls for radioactive effluent monitor Late on April 17 the licensee experienced a feedwater transient with the unit at 100% power when feedwater regulating valve SP6B began oscillatin The operators immediately took manual control of the valve and stabilized the plant at 95% power. Repairing SP6B at 95%

power would have rendered the valve inoperable and it would not have i been able to respond to a Steam and Feedwater Line Rupture Control l System (SFRCS) signal within the time specified in the technical specification and therefore would have placed the plant in Technical Specification .,.0.3. Reducing power to reduce steam generator level to low level limits to repair the valve would have transferred feedwater control to the startup feedwater (SUFW) control valve During a discussion by the lir,ensee on the repair, there was strong sentiment by some personnel to repair SP68 at 95% power in order nat to maneuver the plant. However, the decision was made to reduce power to make the repair. The licensee's lack of discussion regarding the effects of an SFRCS initiation and the apparent willingness by some personnel to operate the positioner without calibrating it after installing the new pilot valve concerned the inspectors. The inspectors discussed their concerns with the license The licensee then began reducing power to replace the suspect pilot valve at about 4:30 p.m. on April 18. While reducing power the turbine became unstable with the reactor at about 60% power. The output of the generator was swinging approximately 20 MW. The operators immediately recognized the condition and placed the turbine in manual control and stabilized its operation thus preventing a unit tri The pilot valve was replaced with the reactor at low power and the licensee determined during its calibration that the calibration procedure was inadequate and had to be revise The licensee observed that the operation of SP6B again became erratic after the plant was taken off low level limit Power again was reduced and additional trouble shooting took place. Instrument air tubing was tightened and finally it was determined that a lockout valve was leaking ai ,

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When the lockout valve was disassembled its o rings were found to be deteriorated. The o-rings were replaced in the discrepant lockout valve but a second lockout valve in the control circuit was not ,

internally inspected. About 6:00 a.m. on April 20, 1989, the l

. licensee began to increase power and approximately 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> later 100% power was. achieved. No perturbations were observed during the power. increase. .The inspectors provided almost continuous coverage from power reduction until reactor power was at approximately 50L On April 18 and 19,1989, the inspectors observed multiple false fire alarm activations. If the number of alarms observed by.the inspectcrs is-typical, the licensee is responding to a large number

.of false alarms. A large number of unnecessary alarms may lead to-

. lackadaisical alarm responses and increased incidence of inadequate compensatory measures. This is an area the licensee should addres During the last refueling outage the *;:ensee installed a Smart Analog Signal Selector (SASS) System which is an interface between the non-nuclear instrumentation (NNI) and the integrated control system (ICS). The. SASS automatically' switches ICS input signals when the SASS computer senses failure. When the operating range level transmitter (LT-SP981) for steam generator (SG) 1-1 failed high the SASS automatically transferred to the alternate transmitte Discussion with plant operators revealed that there was only a'small'

perturbation of the main feedwater system. The licensee believes that the SASS prevented a significant plant transient and that the system demonstrated it, worth. The licensee plans a containment entry to repair the level transmitter, Olf-shift Inspection of Control Rooms-The inspectors performed routine inspections of the control room-during off-shift and weekend periods; these included inspections between the hours of 10:00 p.m. and 5:00 a.m. The inspections were conducted to assess overall crew performance and, specifically, i control room operator attentiveness during night shift l The inspectors determined that both licensed and non-licensed operators were alert and attentive to their duties, and that the administrative controls relating to the conduct of operation were being anered t ESF System Walkdown The operability of selected engineered safety features was confirmed by the inspectors during walkoowns of the accessible portions of several systems. The following items were included: verification that procedures match the plant drawings, that equipment, instrumentation, valve and electrical breaker line-up status is in j agreement with procedure checklists, and verification that locks, ';

1 tags, jumpers, etc., are properly attached and identifiable. The following systems were walked down during this inspection period:

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• - Service Water System e.- Component Cooling Water System )

• Emergency Diesel-Generator System . Plant Material Conditions / Housekeeping )

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The inspectors performed routine plant tours to assess materia conditions-within the plant, ongoing quality activities and plant-wide housekeepin Plant deficiencies were appropriately tagged for deficiency l

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correctio No violations or deviations were identifie . Radiological Controls (83524)

The licensee's radiological controls and practices were routinely observed by the inspectors during plant tours and during the inspection of selected work activities. The inspection included direct observations of health physics (HP) activities relating to radiological surveys and monitoring, maintenance of radiological control signs and barriers, contamination, and rt.dioactive. waste controls. The inspection also included a routine review of the licensee's radiological and water chemistry control records and report !

Health physics controls and practices were satisfactory. The housekeeping in the radiological controlled areas was noted to have been maintained at .,

a high level. Knowledge and training of personnel were satisfactor l The inspectors have routinely observed boron buildup on the outboard seal end of both makeup pumps. The licensee cleaned the boron deposits when the inspectors discussed their observation. The licensee did not have a program to routinely remove the deposits. The inspectors also observed a similar condition in the Boric Acid Addition Tank (BAAT) room and discussed their observations with the plant manager. The plant manager directed that a program to remove boron buildup be initiate The inspectors will follow the licensee's corrective action The licensee implemented a computer based program " surrogate tour" which enables it to tour the plant by the use of a cathode ray tube (CRT).

Approximately 50,000 photographs of the piant were recorded on a computer ,

disk. The program allows an individual to choose a starting point and an end point and visually go through the plant by viewing the CRT. The program allows for work and routes to be planned to minimize exposure. It also allows personnel to visually plan their endeavor by noting " landmarks" or evacuation routes. The licensee utilized this tool to plan the successful repair of a core flood tank level transmitter while at powe )

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The maintenance effort for Steam Generator 1-1 level transmitter described in paragraph 5 is being planned using the surrogate tour. The inspectors consider the surrogate tour to be an effective tool for minimizing exposure ,

and work planning in containmen l On March 22 inadequate control of the containment atmosphere radiation )

monitors was identified by the shift supervisor. This was similar to previous weaknesses identified in control of radioactive effluent monitor On March 22 a licensee maintenance worker crossed a radiation control boundary in the main steam room after he had been direct ' by both his supervisor and a health physics foreman not to cross the boundary. The worker was immediately suspended and later terminated. The licensee issued PCAQR No. 89-0160 to document this even No violations or deviations were identifie . Maintenance / Surveillance (25584, 61725, 61726, 62703, 92701, 92702, 93001, 93702, MPA-B-45)

Selected portions of plant surveillance, test and maintenance activities on systems and components important to safety were observed or reviewed to ascertain that the activities were performed in accordance with approved procedures, regulatory guides, industry codes and standards, and the Technical Specifications. The following items were considered during 4 these inspections: limiting conditions for operation were met while {

components or systems were removed from service; approvals were obtained prior to initiating work; activities were accomplished using approved procedures and were inspected as applicable; functional testing or calibration was performed prior to returning the components or systems to service; parts and materials used were properly certified; and appropriate fire prevention, radiological, and housekeeping conditions were maintaine Maintenance The reviewed maintenance activities included:

• Repair of motor operated service water valv * Repair of Main Feedwater Regulating Valve SP6 The regulating function of SP6B is not a safety related functio The safety function of SP6B is to close on loss of air. On March 14, the inspectors noted that the positioner for SP6B was blowing air from the positioner cover and there was no maintenance tag on the valve. The inspectors discussed this condition with the licensee and

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was informed that the air flow was the result of a close command to the positioner with the valve already fully closed. Continued air flow with the valve in operation would be an indication of a lea . _ _ _ _ _ _

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On March 23, with the valve in normal operation the inspectors again

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noted air flow from the positione The inspectors again discussed this condition with the licensee and was informed that the positioner l was leaking air but that it was not a large enough leak to prevent l the valve from operating properly. On April 17, SP68 caused a feedwater transient which was discussed in the operations sectio As noted earlier, the inspectors observed that the diagnosis of the problems associated with SP6B appeared to be focused on the pilot i valve and did not consider other possible cause Discussion with licensee personnel revealed that there are weaknesses  !

in the licensee's preventative maintenance (PM) program for {

replacement of aging elastomeric components in the feedwater control valves. Licensee personnel stated that the PM program for elastomeric 3 products that serve a safety function is effective, but agreed that I the program for non safety functions needs improvement. The licensee l is developing an action plant to correct the weakness. The inspectors will review this action plan when implementation has begu * Repair of Spent Fuel Pool (SFP) to Cask Pit Gate seal. On March 6 the maintenance crew assigned to this job removed the SFP to Fuel Transfer Pool Gate instead of the SFP to C6sk Fit Gate. Because the water level was the same on both sides of the gate, there was no effect on plant operation. Licensee personnel identified the error, corrected the situation and documented the error with Potential Condition Adverse to Quality Report (PCAQR)

89-0143. This error occurred even though a pre-job briefing was hel The inspectors reviewed the Maintenance Work Order (MWO)

for this jo The " Description of Problem / Malfunction / Work to be Performed" section of the MWO states that the "Inflatible seal for the Cask Pit /SFP Gate . . . needs replacing." The inspectors reviewed the licensees corrective actions proposed in response to the PCAQR 89-0143. The licensee plans to label both SFP gates; clarify procedure MP 1700.33 (DB-MM-09557.03), " Spent Fuel Pool Gate Inflatable Boot-Replacement"; and perform a Human Performance Evaluation of the error. The inspectors reviewed MP 1700.33 and determined that the error had minor safety significance because MP-1700.33 includes prerequisite step 6. which requires the water level to be the same on both sides of the gate to be repaired. Procedure DB-MN-00001, " Conduct of Maintenance" required that Maintenance Supervisors ensure that work is performed in accordance with the latest MWO revisio Failure to comply with this procedure is a violation (346/89011-01) of TS 6.8.1 which requires that maintenance activities be controlled by procedure This violation meets the criteria of 10 CFR 2, Appendix C, section V.G.1 (October 13, 1988) and therefore a notice of violation will not be issue The inspectors will review the licensee's corrective actions (described above) in a future inspectio * Installation of grout in wall of station battery room

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Troubleshooting and repair of cause of_ dropped control rod on

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March 1 Diligent troubleshooting of the control circuits for control rod 5-2 identified a loose wire in the transfer switch for the rod which caused an intermittent open circuit. The ,

loose wire, which had been installed during plant construction, 1 was repaired and several other transfer switches were randomly i inspecte The inspection revealed no other problem !

During the inspection period the inspectors observed that the backlog of open'non-outaga corrective maintenance work orders increased slightly, contrary to the goal of the license The instrument and control (I&C) area had the most difficulty managing its workload. The plant maintenance manager has been attentive to this problem but so far .i J

has not found a solution. ' Continued licensee management attention to this area is require OSHA received worker complaints related to working conditions in the-main steam room, containment during plant operations, and on the roofs of i the auxiliary and turbine building An inspection was performed by OSHA on April 4, as a result of the complaint The inspection did not include the area inside containment. The OSHA inspector had several findings and issued violations. OSHA determined that the complaint regarding work in- i

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containment was under the jurisdiction of the NRC and sent the complaint to Region III for resolutio Surveillance The reviewed surveillance included:

Procedure N Activity

• 08-55-03091 Motor Drive Feedwater Pump Quarterly Test

• DB-SC-03112 Safety Features Actuation System Channel 3 Monthly Test

• DB-SP-03152 Auxiliary Feedwater Train 1 Level Control, l Interlock and Flow Transmitter Test l l

• DB-SP-03357 RCS Water Inventory Balance  :

f During its review of the TS as part of its TS Verification Program the licensee discovered that it had been testing the containment airlocks in accordance with TS 4.6.1.3.b which allow the provisions !

of TS 4.0.2 to be applied. TS 4.0.2 allows test frequency variations l of up to 25 per cent. Therefore eleven test intervals of greater l than six months were identified. Each case was an example of a .

violation (346/89011-02) of 10 CFR 50, Appendix J, III.D.2.b which !

does not allow testing at greater than a six month interval. The i I licensee has changed its computer program for test scheduling so that the test schedule will indicate that future tests must be completed within six-month intervals. This violation had minor safety

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. significance and meets the criteria of 10 CFR 2, Appendix C, Section V.G.1 (October 13,1988) and therefore a notice of violation

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(0 pen) Temporary Instruction (TI) 2515/84 SIMS Item MPA-B-45:

Verification of Compliance with Order for Modification of License:

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Primary Coolant System Pressure Isolation (Event V) Valve The '

inspectors verified that the Technical Specifications (TS) had been modified as required by the Order dated April 20, 1981. The Order affected test requirements for four valves, CF 30, CF 31, DH 76, and DH 77, which isolate the Reactor Coolant' System (RCS) from a low pressure system. The inspectors reviewed surveillance test procedure DB-SP-03300, revision 00, Change C-1, "RCS Isolation Check Valve Leak l Test (CF 30, CF 31, DH 76, DH 77). The test method used is acceptable, l obtains leakage rates for individual valves, the test acceptance- .

criteria are in accordance with the TS, and corrective action is l identified for unacceptable test result The tests are conducted a pressures less than the rnmimum potential pressure differential across the valves and the procedure includes appropriate adjustment of results for DH 76 and DH 77. However, the procedure does not require any adjustment to the results for CF 30 and CF 31. This apparent deficiency was brought to the attention of the licensee and the inspectors will discuss this item with the licensee as the inspection of this TI continues. The inspectors verified that.the licensee had a copy of the Order and the original SER available. The inspectors reviewed Inspection Report 50-346/86030(DRS) and the records of test procedure TP 850.85, " Reactor Coolant System Isolation Check Valve Test" and determined that TP 850.85 had been witnessed and reviewed by NRC inspectors. TP 850.85 tested the same' valves as DB-SP-03300, although it used the acoustic emission test method-instead of ti,e volumetric methods used by DB-SP-03300. Personnel

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performing maintenance or surveillance used correct procedures and  ;

proper work control documents. Work authorization had been obtained 1 for the jobs performed. Prerequisites for performing the job, such 1 as worker protection and tagging had been performed. Surveillance continues to be an area where only an occasional minor problem arise No other violations or deviations were identifie . Emergency Preparedness (71707)

The inspectors met with the licensee during the inspection period to discuss the emergency preparedness program, the upcoming drills, training, and the Citizens Advisory Council on Nuclear Safety Report to Governor i Celeste. The annual exercise is scheduled to be held August 8 and 9, 1989, which will include state and local governmental agency participatio An inspection of emergency preparedness activities was performed to assess the licensee's implementation of the emergency plan and implementing procedures. The inspection included monthly observation of emergency facilities and equipment, interviews with licensee staff, and a review of selected emergency implementing procedure . _ _ _ _ - _ . _ _ _ - _ - _ _ - _ - - -

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? The equipment'and facilities were noted to be. satisfactory. The licensee performed routine emergency. equipment functional verifications. The emergency procedures reviewed were of-current revision.

, No violations or deviations were identifie . Security (71707)

The licensee's security activities were observed by the inspectors during routine facility tours and during the inspectors' site arrivals and departure Observations included the security personnel's performance associated with access control, security checks, and surveillance activities, and focused on the adequacy of security staffing, the security response (compensatory measures), and the security staff's attentiveness and thoroughnes .

.The security personnel were observed to be alert at their post Appropriate compensatory measures were established when necessary l in a timely manner. Vehicles entering the protected area were thoroughly searche The licensee has installed handles on those fire / security doors with flush panic hardware in areas of high differential air pressure. The inspectors have operated the doors and consider the fix to be acceptabl There are a few doors which are difficult to open because of the.high differential pressure and the licensee is considering different' striker

mechanism The inspectors observed that some vital area doors could be exited without alarming if a key card had not been used. This observation was discussed with the licensee. The licensee concurs with the observation and is in the process of adjusting door alarm timers. The licensee plans to continue its investigation of this area and the inspectors will. follow its action No violations or deviations were identifie . Engineering and Technical Support (62703, 64704, 71707, 92701, 93702) An inspection of engineering and technical support activities was performed to assess the adequacy of support functions associated with operations, maintenance / modifications, surveillance and testing activitie The inspection focused on routine engineering involvement in plant operations and response to plant problems. The inspection included direct observation of engineering support activities and discussions with engineering, operations, quality control and maintenance personne The inspectors have observed a continuing engineering presence in the plant relating to maintenance work and in response to plant problem Engineering efforts to reduce the backlog of temporary modifications (TMs) have been effective, although the number TMs remaining in the plant is excessiv ,- _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ._

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On March 3,1989, the licensee appointed a new director of engineering to replace the previous director who resigned to accept other 1 employment. The engineering division has several areas to which )

attention must be focused. These include timely preparations of j engineering packages to support the next refueling outage; i" implementation of the configuration management program; and timely implementation of fire protection corrective actions to support .

completion of the program to meet the requirements of 10 CFR 50, Appendix R. The inspectors have discussed their concerns with the  !

license The licensee named a Toledo Edison employee to head the fire protection program. The inspectors consider that having licensee personnel control the program and its implementation rather than ,

contractor direction should be beneficial to the program directio l The inspectors will follow this change to determine its effectivenes The non-safety grade instrument air system was improved during the recent maintenance and refueling outage. Engineering effort on those improvements was not fully successful. This was demonstrated by the March 3 air pressure reduction and by numerous spurious air pressure '

l alarms. The spurious alarm problem has been resolved, however additional engineering effort is in progress to improve the reliability of the syste The licensee has applied appropriate management attention to this issue and an action plan has been developed with a schedule for short and long term corrective action The inspectors will observe the progress of the action pla There was ample management and engineering involvement in preparation for and conduct of the March 10 loss of main feedwater. pump test, b. Information Notices IN No. 88-46: (Supplement 1) (Closed) Defective Refurbished Circuit Breakers. The inspectors reviewed the supplement and determined that neither Toledo Edison (Davis-Besse) nor Centerior Energy Corporation were listed as customers of any of the five suppliers. The licensee determined that this information notice does not appl IN No. 88-51: (Closed) Failures of Main Steam Isolation Valves (MSIVs). The licensee performed extensive testing of MSIVs as part of the System Review and Test Program (SRTP) which occurred during the 18 month outage of 1985 and 1986. The MSIVs were tested with instrument air and nitrogen isolated as part of TP851.11, "MSIV Response Time Test." The inspectors observed the performance of this tes The inspectors reviewed licensee surveillance procedures, DB-SP-03442 and DB-SP-03443, MSIV Test and DB-SP-03444 and DB-SP-03445, SFP.CS Test of MSIV All four surveillance have requirements to isolate instrument air and nitrogen to the activators prior to the timing test _ _ -

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l IN No. 88-55: (Closed) Potential Problems Caused by Single Failure

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l of an Engineered Safety Features (ESF) Swing Bus. The licensee's review determined that the notice did not apply because Davis-Besse j has two 100% capacity high pressure injection (HPI) pumps. Each is l powered and controlled by separate and independent busses. The l

licensee determined that single failure will not render the HPI l inoperable.

l IN No. 88-67: (Closed) PWR Auxiliary Feedwater (AFW) Pump Turbine j Overspeed Trip Failure. The licensee uses Terry Turbines as prime j movers for the AFW pumps. The licensee determined that the notice is -

not applicable as the overspeed trip device used on the AFW turbines utilizes a tappet spring mechanism rather than the tappet ball mechanism described in the information notice. The toppet spring mechanism is not subject to the same type of failure as the toppet ball mechanis Bulletins (Closed) Bulletin 84-02 Failures of General Electric Type HFA Relays in Use in Class 1E Safety Systems The inspectors reviewed the licensees response to this Bulletin and determined that the licensee had identified four relays that required replacement within two years at the date of the Bulletin (March 12, 1984). The inspectors reviewed Facility Change Request 84-142 and Maintenance Work Orders 2-84-0142-01, -02, -03, and -04 and determined that the relays were replaced in January and April of 1985. This Bulletin is close . Safety Assessment / Quality Verification (25593, 255100, 35502, 35702, 40500, 90712, 93702, MPA-A-15)

An inspection of the licensee's quality programs was performed to assess the implementation and effectiveness of programs associated with management control, verification, and oversight activities. The inspectors considered areas indicative of overall management involvement in quality matters, self-improvement programs, response to regulatory and industry initiatives, the frequency of management plant tours and control room observations, and management personnel's participation in technical and planning meeting The inspectors reviewed Potential Condition Adverse to Quality Reports (PCAQR), Station Review Board (SRB) and Company Nuclear Review Board meeting minutes, event critiques, and related documents, focusing on the licensee's root cause determinations and corrective actions. The inspection also included a review of quality records and selected quality assurance audit and surveillance activitie Performance in this area included the following major items: Quality Assurance Activities All Quality Assurance onsite audits and surveillance are reviewed by the inspectors. They concluded after reviewing them for over a year that audits were heavily biased toward compliance rather than

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performanc Early in the-inspection period the inspectors discussed- l their conclusions with QA management. The discussion'also inc1Lded 1 several advantages of performance-based audits, including the increased likelihood of early identification of significant problem ,

~The licensee stated that it would implement more performance-based j audits. The inspectors will continue to review and evaluate QA  !

audit l Eauipment Operability Determinations On March 14, licensee engineering personnel gave the shift supervisor j

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PCAQR 89-0149 which stated that high pressure injection flow indicating switch FIS-HP04A'(Barton model 288A) was mounted with a bracket that had not been seismically qualified by the manufacture l The shift supervisor noted on the PCAQR that the affected equipment 1 was operable, that engineering was performing a calculation to verify

. seismic qualification and that the condition could become reportable under 10 CFR 21. The inspectors reviewed Safety Evaluation (SE)

89-0065 which concluded that the bracket and any similar brackets used to mount Barton Model 288A switches did not affect plant safety because engineering Calculation No. C-CSS-100.0-072 showed that the brackets would maintain the seismic qualification of any Barton model 288A switches flow switches that the brackets supported. SE 89-0065 was considered a generic safety evaluation because ITT-Barton may have supplied the wrong bracket with other Model 288A switche The inspectors review of the SRB minutes of March 31 indicate that SE 89-0065 was recommended for approval on that dat The inspectors discussed the PCAQR 89-0149 with the shift supervisor who had reviewed it. He did not recall being told that there was a potential for more than one switch having the incorrect bracke He and two other SR0s stated that the concept used.to determine operability of equipment in such situations was that equipment was to be considered operable until proven inoperable. The inspectors '

l reviewed Procedure NG-QA-00702, R1, effective March 1, 1989,

" Potential Condition Adverse to Quality Reporting". Step 6.3.2.c. of NG-QA-00702 states, "If the Shift Supervisor cannot determine if the condition identified in Part IJ affects operability, mark Part 2E YE The Part 5 evaluation will determine if the system can perform its specified function." Part IJ of'a PCAQR is the description of the PCAQ, Part 2E is the shift supervisors operability determination, and Part 5 is the Remedial Action sectio Part 5 was' completed for PCAQR 89-0149 on March 28; the operability determination was made fourteen days after the shift supervisor was notified of the condition. This will remain an Unresolved Item (346/89011-03(DRP))

until the inspectors can verify whether the licensee process for determining operability is adequat Steam Generator Tube Leak Action Plan Because of the steam generator tube leak identified on March 17, 1989, the licensee developed a detailed action plan. The multi-level action plan, issued March 22, uses a matrix of RCS to secondary leakage and RCS iodine 131 levels to direct specific actions at defined action level _ _ _ _ - . __ - l

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Steady state RCS Iodine 131 has been measured at 0.004 microcuries per gram which correlates to two leaking fuel pins. The licensee recognized that repair of the steam generator tubes will require reduced RCS inventory and the actions and requirements of Generic Letter 88-17 will apply. Tube leakage rates are calculated twice dail The calculated leakage values but has been fairly consistent at about 0.04 gpm. The inspectors will continue to follow this issue closel d. Management Response to Feedwater Transient On April 17 feedwater regulating valve SP6B caused a plent transien Repairing SP6B at 95% power would have rendered the valve inoperable and it would not have been able to respond to a Steam and Feedwater Line Rupture Control System (SFRCS) signal within the time specified in the technical specification which would have placed the plant in Technical Specification 3.0.3. Reducing power tn reduce steam generator level to low level limits would have transferred feedwater control to the startup feedwater (SUFW) control valves. There was

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strong sentiment to repair SP6B at 95% power in order not to maneuver the plant. The licensee's lack of discussion regarding the effects of an SFRCS initiation and the willingness to operate the positioner without calibrating it after installing the new pilot valve concerned the inspector The inspectors discussed their concerns with the license e. (Closed) LER 86-021, Inadequacies in Raychem Installations (Closed) Information Notice IN 86-53, Improper Installation of Heat Shrinkable Tubing (Closed) Temporary Instructi on (TI) 2500/17. Inspection Guidance for Heat Shrinkable Tubing On May 9, 1986, tho licensee discovered, during a training session, that due to past practices improper splices and terminations existed in the field and issued Licensee Event Report (LER) No. 86-21. The licensee inspected all class 1E connections, both Raychem and tape Approximately 1100 connections were identified as having to meet EQ requirement The licensee either corrected all identified deficiencies or qualified them by testing before the plant restarted on December 22, 1986. The inspectors followed the licensee's progress, examined terminations and splices and quality record In addition the Raychem issues were reviewed during the EQ team inspection of August, 1986. The team determined that the licensee's actions were adequat The results of the various inspections are documented in Inspection i Reports No. 50-346/86014, 50-346/86016, 50-346/86024, and 50-346/8602 j The licensee has completed all the required actions and this item is closed.

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(Closed) TI 2515/93, Recuest for Verification of Quality

' Assurance Request Regarcing Diesel Generator Fuel Oil Multi Plant Action Item A-15, SIMS Item MPA-A-15 l

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The inspectors verified that diesel generator fuel oil is included in the licensee's quality assurance program and this item is close (Closed) TI 2515/100, Proper Receipt, Storage and Handling of Emergency Diesel Generator (EDG) Fuel Oil The inspectors reviewed the Technical Specifications (TS), Updated Safety Anc. lysis Report (USAR) and the Nuclear Quality Assurance Manual (NOAM) and determined that the NQAM does not list any commitments to diesel fuel oil standard Section 9.5.4.4 of the USAR states that fuel quality will be verified at regular intervals in accordtnce with the TS. TS 4.8.1.1.2.b requires that at least once every 92 days a sample of fuel from the fuel storage tank is within acceptable limits as specified in ASTM D975-68 when checked for viscos ity, water, and sediment. The inspectors reviewed seven of eleven licensee procedures relating to EDG fuel oil sampling, including DB-CH-00008, " Diesel Fuel Oil Program". The procedures adequately control safety related fuel oil activities and complete with TS requirements. The procedures are sufficiently detailed to perform tre required activities. This item is close . Enforcement Coriference On December 18, 1968 an improper reactor startup event occurred at Davis-Besse. This was documented in NRC Inspection Report N /88037(DRP) issued on February 24, 1989. On February 10, 1989, L. F. Storz, Plant Manager and E. G. Greenman, Director, Division of Reactor Projects and their respective staffs met in Region III to discuss this event. On March 3, 1989, Region III held an enforcement conference with Mr. D. Shelton, Vice President Nuclear, and staff to discuss the violations, root causes, and corrective actions. A handout provided by the licensee at this enforcement conference is enclosed with this report. On April 21, 1989, a Notice of Violation and Proposed Imposition of Civil Penalty was issued to the license . Unresolved Items Unresolved itens are matters about which more information is required in order to ascertain whether they are acceptable items, violations, or deviations and unresolved item disclosed during the inspection is discussed 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 activities. The licensee acknowledged the findings. After discussions with the licensee, the inspectors have determined there is no proprietary data contained in this inspection repor _ _ _ - _ - _ - _ _ _ .

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t NRC/ TOLEDO EDISON i DECEMBER 18,1988 EVENT l SAFETY CONTROL ROD GROUP INSERTION Agenda Event Overview I Event issues 111. Post Event issues IV. Corrective Actions

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EVENT OVERVIEW 4

- Dropped Group of Rods Due to Maintenance Error

- After Discussion Among Shift Members Decision Made to Pull Dropped Group and Resume Startup

- Group' Recovery Stopped When Failed to Meet Temperature Conditions For Criticality

- Terminated Startup and inserted All Rod Groups

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POST EVENT ISSUES

- Reactivity Event Recognition

- Authorized Startup Without Requiring -

Specific Dropped Rod Direction l

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CORRECTIVE ACTIONS i

- Develop Maintenance Troubleshooting Procedure l

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- Shift Supervisor Removed From Shift Activities For Evaluation l

- Duty Operations Manager Counseled {

- Standing Order issued to Control Room Personnel to Define Actions For Dropped Rod Events

- Lessons Learned /What Happened Has Been Communicated to Each Shift Supervisor

- Shift Managers' Will Have Responsibilities Emphasized During Selection interviews j t

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Communication / Teamwork cf Shifts Will Be Evaluated by Management During Training and Simulator Exercises i j

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EVENTISSUES

- Violated Conservative Action Policy ,

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STA Advice I

- Log Keeping

- Duty Operations Manager Leadership

- Shift Supervisor Erred in Judgement