IR 05000346/1989019

Insp Rept 50-346/89-19 on 890717-0913.No Violations Noted. Major Areas Inspected:Lers,Plant Operations,Radiological Controls,Maint/Surveillance,Licensee Action on Previously Identified Items,Emergency Preparedness & Security

ML19325C682
Person / Time
Site:	Davis Besse
Issue date:	09/29/1989
From:	Defayette R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML19325C681	List: IR 05000346/1989019 ML19325C679
References
50-346-89-19, NUDOCS 8910170175
Download: ML19325C682 (18)

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U.S.. NUCLEAR REGULATORY COMMISSION

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REGION III

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I Report No'.'.'50-346/89039(DRP).-

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~ Docket No. 50-346 Operating License No.-NPF-3

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F Licensee:

Toledo Edison Company-Edison' Plaza, 300 Madison Avenue Toledo, OH.43652

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Facility Name:. Davis-Besse Unit I Inspection At:. 0ak Harbor, Ohio g

Inspection Conducted.

July 17 to September 13, 1989 s

Inspectors:-

P.-M._ Byron E. R. Schweibinz

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W. G. Rogers

.D. C. Kosloff

~R. K. Walto g

Approved By:

R. DeFayette, Chief

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Reactor Projects Section 3A Date

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Inspection Summary Inspection on July 17 through September 13, 1989-(Report No. 50-346/89019(DRP))-

-Areas-Inspected:

A routine unannounced safety -inspection of licensee action on previously identified-items, licensee event reports, plant operations,-

radiological controls, maintenance / surveillance, emergency preparedness, security, engineering and technical support,- and safety assessment / quality

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' verification was performed.

Results:

The adequacy and effectiveness of. the licensee's corrective actions for

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previous operational events is challenged as demonstrated by a power drop l transient'(Paragraph 4) and the continued existence of the procedure

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problems-(Paragraph-10).

A single-rod dropped into the core due to a blown fuse and was recovered-satisfactorily (Paragraphs 4 and 9).

The backlog of maintenance' work is slowly being~ reduced (Paragraph 6).

The licensee j

continues'to experience operational problems with station and instrument air

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systems'(Paragraph 9).

An enforcement conference was held with the licensee (Paragraph 11).

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9910170175 890929

. PDR,;ADOCK 05000346

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DETAILS

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Persons'Cantacted=

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-Toledo Edison'Comt.any-(TED)-

D.- Shelton, Vice President, Nuclear

"G. Gibbs, Quality Assurance Director.

• L'. Storz, Plant Manager W.. Johnson, Plant Maintenance Manager J. Kasper, Operations Superintendent--

• E. Salowitz, Planning and Support Director

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S. Jain,-Engineering Director

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G.- Grime, Industrial Security Director

• D. Timms,. Systems Engineering Supervisor

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'T. Anderson, Maintenance and Outage Management Manager

• C.'Hengge, Fire Protection Compliance Supervisor

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R. Schrauder, Nuclear LicensingLManager

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.G..Skeel, Nuclear Security Operations Manager

.~J. Polyak',: Manager Radiological, Control

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• .R.,Collings, Supervisor, Quality Audits

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• J.. Lash,-Independent Safety Engineering Manager

• J. Gates, Manager Systems Engineering

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.. G.JHonma,= Compliance Supervisor L**J. Sturdavant,1 Licensing-Engineer

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J. Moyers,1 Mgr. Quality Verification

~*D.~ Wuokko,' Regulatory Affairs -. Supervisor

• L'. Worley,'. Quality-Systems Manager L

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• R.' Brandt, Manager Plant Operations (Admin.)

• R.L Gaston,- Licensing Engineer :

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-USNRC

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• P.', Byron, Senior Resident Inspector

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• T. Wambach, NRR Project = Manager

• D. Kosloff,-Resident. Inspector

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E..Schweibinz, Reactor Inspector-

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W. Rogers,1 Senior Resident Inspector.(Fermi)

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_ R. Walton, Resident Inspector in Training

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Parczewski, NRC/NRR'

• Denotes those personr. 1 attending the September 13, 1989, exit meeting.

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Attendees at Enforcement Conference on September 8, 1989, in

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Glen Ellyn, Illinois

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l Robert W. Schrauder, Toledo Edison, Manager. Nuclear Licensing

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Mary E. O'Reilly,. Toledo Edison, Attorney-D. C. Shelton, Toledo Edison, Vice President L. F. Storz, Toledo Edison, Plant Manager J. Patrick Hickey, Shaw Pittman,. Attorney

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Lee S. Dewey, NRC, OGC Robert DeFayette, Section Chief, Region III r.

Bruce Berson, Regional Counsel, Region III

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Stephen H. Lewis, NRC, OGC i

-James, N. Kalkman, NRC, OI, Region III

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Martin J. Farber, NRC, Region III

Thomas.V. Wambach, NRC, NRR J. G. Luehman,-NRC, OE Jim Lieberman, Director Office of Enforcement, NRP

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Ed Greenman, Director, Div.:of Reactor Projects, Region III A. Bert Davis, Regional Administrator

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J. G.;Partlow,' Associate Director, NRC

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Licensee Action on Previous Inspection Findings ~(92701, 92702, 92720),

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a.

(Closed) Open Item (346/85003-04(DRP)):

Licensee review of

essential inverter failures and changes resulting from the review.

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This item resulted'from the review of LER 84-010.

The licensee developed Facility Change Request (FCR) 36-0272 to replace the inverters.

FCR 86-0272 was reviewed by the Station Review Board on

June 13, 1989, and the recommendation to replace all four inverters

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and associated equipment.was approved.

The new inverters have been

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purchased and are now in storage.

The licensee is planning to

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insta11Ltwo inverters during the next (sixth) refueling outage and

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the last.two in the seventh refueling outage.

The inspectors

' observed conduit installation.in' progress for this FCR.

This item

is closed.

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(Closed) Open Item (346/85003-06(DRP)):

Completion of-FCR's.

• associated with returning ventilation duct work to conformance

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with the long term seismic design acceptance criteria.

This item

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resulted from the review of LER 84-021.

This item was previously reviewed in Inspection Report No's 50-346/85025 and 86005.

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inspectors reviewed licensee FCR records and determined that all

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required seismic support modifications had been completed. The inspectors also reviewed a licensee intra company memorandum dated

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May 28, 1986, which addressed 10 CFR 21 reportability of the overstressed seismic duct supports.

Licensee engineering personnel had indicated that the condition was reportable under 10 CFR 21;

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- however, the LER did not indicate that it.was also reportable-in 3;

accordance with 10 CFR 21.

The-licensee memo concluded that

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b engineering hadLimproperly classified the-condition and the LER was

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E r eorrectLin not reporting the. condition in accordance with 10 CFR 21.

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This item is closed.

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-(Closed)'Open Item (346/85004-06(DRP)):. Complete FCR 83-0009 as

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- corrective action for LER 82-061.

This' item was reviewed in

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Inspection Report No. 50-346/85037.

The impl_ementation-of the FCR-jwas completed on January 5,- 1987, and closed out on March

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This item is closed.- '

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18, 1988.

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-(Closed)'Open' Item (346/85009-05(DP.P)):

Comparison of performance W

of,one fuel assembly against predicted behavior of another.

The

'. licensee requested Babcock and Wilcox (B&W):to: respond to this item.

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B&W determined that this had been previously addressed.by B&W in a December. 20, 1977, response to an NRR October 19, 1977, question

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regarding Topical Report No. BAW-10119P.

The inspectors' review S

of.the-B&W response to Question 14 of the NRR letter indicates that the licensee had previously addressed-this item and it is closed.

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(Closed)-Violation (346/85025-03(DRP)):

Failure to initiate a

surveillance report per Procedure NFEP-50 for the water-cooled

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subsystem of.the CREVS'and failure to issue-a condition adverse to h

quality report regarding erroneous information on pitch and stem diameter /of motor operated valves.

Review of the licensee response of January 21~, 1986, and its training records associated with its

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corrective actions-indicates. appropriate response to this item and it'is closed.

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(C1o' sed) Open Item (346/85025-12(DRP)):

Implementation of

FCR.85-083 to install redundant moisture separator reheater high level: switches.

This item 'is scheduled for the next (sixth)

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' refueling outage and'is also.being tracked by.the Toledo Edison Regulatory Management System-(TERMS).

Based on the above, this item is closed.

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(Closed) Open Item (346/85025-19(DRP)):

Monitoring of licensee's W

initiatives to improve the DVR/LER system.

The inspectors review

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- of this item in Inspection Report 50-346/86005 identified a need to review LERs generated in 1986 for assignment of corrective action

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completion dates. ~ This review has been completed and completion

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Hic dates-have been assigned.

This item is closed.

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(Closed). Violation (346/85025-22(DRS)):

Performance of a calibration without a p"rocedure.

The licensee wrote a generic procedure, IC-4001.00, Instrument String Check / Calibration," and has a program for development of data packages for each instrument L

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'being calibrated..The-inspectors review of IC 4001.00 and a

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selected data package indicate appropriate-corrective action by the-

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licensee.and this item is closed.

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11 ', - c(Clo. cad)'Open Item (346/85037-06(DRP)):

Elimination of--remaining

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. alpha drawings:through-the FCR-process.

Procedure NEP-030, " Project

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Drawings ~," has eliminated the issuance'of new alpha design drawings-

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and revisions.

The procedure now requires new design drawings for

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. plant modifications to be issued at' revision-level zero.

Alpha drawings.are: drawings with an alphabetic character indicating the

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W revision status instead of a number.

Discussions with the Document

Control? staff. indicate-they are knowledgeable of these requirements

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and'the_ remaining alpha drawings are adequately controlled.

This

. item is. closed,

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(Closed)-00en Item (346/86032-04(DRP)):

Inconsistencies in the relative performance of operations personnel on different shifts.

The licensee constantly reviews shift: composition and performance.

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Crew composition has been adjusted to achieve a better balance of-experience _and performance between the crews.

The inspectors have

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. observed a better balance and improved perfor' nance with the various operations' crews.'. The inspectors will continue to monitor shift

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g; t performance.

This item'is closed.

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-(0 pen) Potential Violation (346/85039-05):

Inadequate post-

maintenance testing, resulting in a containment air cooling fan

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' running backwards.

Review of the licensee response and the

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implementing procedures. raised some questions as to the adequacy of the Monthly Surveillance procedures used to determine operability per T.Si This item =will be reviewed in a future inspection.

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(Closed) Open Item (346/87014-03(DRP)):

Review the effect a

. partially filled. Reactor Coolant Pump-(RCP) oil collection tank had Lon,the licensee's fire protection; capability and r'eview the licensee's corrective action.. The inspectors-reviewed NEP-08309

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" Engineering; Evaluation For Water in RCP Oil Collection Tanks." The evaluation determined that the partially filled tank would not have L

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a detrimental effect because, if the tank,would have been filled-with. oil and water, any addition oil would have flowed from a vent

'in the top of the tank and along an identifiable path to a containment sump.

The licensee determined that the oil would not

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have been exposed to an ignition source.

The inspectors reviewed

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RCP preventive maintenance items PM 0056, 0057, 0058, and 0059 and B

continuation sheet MP-058A which is used with each PM.

These PM's

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1-are scheduled to be performed each refueling outage and MP-058A

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includes a step to check the level in the oil collection tank, drain it if necessary, and record the conditions found.

This item is

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closed.

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(0 pen) Violation (346/89016-01(0RP)):

Failure to protect the

Service Water pump from flooding from a rupture of Circulating Water

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. piping.: On August 31, 1989, the inspectors' observed that the hole'

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5which could allow CW to flow into the SW tunnel had been permanently g

R plugged by the licensee, thus eliminating the hazard to the SW pump.

The review of this item will'be completed after the licensee responds.to the violation.

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(Closed)' Generic' Letter 85-005:

Inadvertent boron dilution events.

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The licensee evaluated this Generic Letter and modified the-i appropriate boron concentration and control system procedures and

-the' plant shutdown and cooldown procedure to add precautions to R

prevent this type of event.

This item is closed, i

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.(Closed) Generic. Letter 85-006:

QA guidance for ATWS equipment that istnot. safety related.

Review of this item will be through

. Temporary Instruction 2500/20.

Therefore, this item is closed.

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(Closed) Generic Letter 85-007:

Im schedules for plant.modific'iUons. plementation of integrated p.

On July 16, 1989, the licensee F

initially submitted a license amendment request to incorporate its Integrated Living Schedule Program (ILSP) plan. It referenced the

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ILSP and provided an update to-it in its response to this Generic

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Letter indicating that it would participate in the NRC program by

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providing an updated schedule periodically.

It later withdrew the ILSP license' amendment request on March 22, 1989.

The ILSP has been

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replaced with the Resource and Management Program which the licensee

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established to optimize allocation of resources in meeting its

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NuclearGroupLobjectives'

This new program will not be submitted to

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the NRC on a periodic basis.

This item is closed.

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(Closed) Generic Letter 85-013:

NUREG-1154, the Davis-Besse loss of main and auxiliary feedwater event.

This item is addressed in

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detai1 in NUREG-1177, " Safety Evaluation Report Related to the-Restart of-Davis-Besse' Nuclear Power' Station Unit 1 Following the Event of-June 9,1985." The review'in this' NUREG closes this item.

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(Closed) Generic Letter 85-014:

Commercial storage at power reactor

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sites of low-level radioactive waste.

The licensee review of this

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item indicates that it is not considering commercial storage now or in the future.

This item is closed.

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(Closed) Generic Letter 85-020:

High pressure injection makeup nozzle cracking in B&W plants.

Review of licensee correspondence B

addressing this issue dated May 23, 1986, and September 25, 1986, indicates appropriate action by the licensee and this item is closed.

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(Closed) Generic Letter' 85-022:

Loss of post-LOCA-recirculation 'due.

'to insulation. debris blockage.

Review of licensee correspondence

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dated September 10, 1986, determined that this would_not be a

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problem at the Davis-Besse plant since its design does not contain

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the type of insulation which can lead to significant blockage of the emergency sump.

Design specifications are also in place to preclude future use of-such materials.

This item is closed, 3.: -Licensee Event' Reports Followup (92700, 90712)

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Through direct observations, discussions with licensee personnel, and review of records, the following licensee event reports were reviewed to -

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-determine that reportability requirements were fulfilled, that immediate M

corrective action was accomplished, and corrective action to prevent recurrence was. accomplished in accordance with Technical Specifications

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(TSs).

The-LERs listed below are considered closed:

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(Closed) LER 87011:

Reactor' trip from full power on September 6,

-1987, caused by improper control rod movement.

This event was the subjectof:

NRC Augmented Inspection Team (AIT) as documented in an i

October 1,:1987 report.(50-346/87025 (AIT)); a Confirmatory Action Letter (CAL): September 9, 1987; and the licensee-response to the CAL

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on October 9, 1987.

Review of these documents indicates appropriate actions by the licensee and this LER is closed.-

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(Closed)-LER 87015:

Reactor trip due to loss of instrument air

. pressure.

In this LER, the licensee committed to: evaluate-the

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instrument air dryer solenoid for preventative maintenance (PM);

evaluate the MSR.second stage reheat steam source valves for possible preventative maintenance; to check the MSR second stage

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reheat system' dynamics; to evaluate'the MSR second stage steam supply auto controller tilure; to evaluate the turbine bypass valve for possible preventative maintenance; to improve the

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integrated control system (ICS) response to lowering steam generator n

level signals; and to check the seat leakage on one of the valves.

The licensee: added a PM for the air dryer solenoid valve, and for the second stage' reheat steara source valves; checked the reheat

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system dynamics; evaluated the auto controller failure and determined that the long term corrective action was to continue to manually operate'the MSR second stage steam supply controller; evaluated the-turbine bypass valve for PM and determined.the two existing PMs were appropriate;;made a modification to the ICS to improve its response

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to lowering steam generator levels; and checked the seat leakage on t

the valve in question.

Review of the subsequent licensee corrective actions described above indicates appropriate followup and this LER is closed.

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(Closed) LER 89008: -Missed fire ~ system monthly valve inspection.

This LER is closed because the events were discussed in inspection-

-report'No.L346/89016 and are.the subject'of two violations in that'

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' report (No. 346/89016-11'and No. 346/89016-12).

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(Closed) LER 89009:. Improper operation of the High Pressure LInjection System Line isolation' valves.

This:LER is closed because the events were discussed in inspection

report No. 346/89016 and are-the subject of a vioaltion in that report (No.

346/89016-13).'

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(C1osed)' LER 89010:

Control Room emergency ventilation system inoperable.due to compressor high. pressure trips.

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This LER is closed because the events'were discussed in inspection'

report No.:346/89016 and are the subject of a violation in that-report

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(No. 346/89016-05).

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Unplanned re' ease of 1700 gallons from the f.

'(Closed)-LER 89012:

l clean waste receiver' tank 1-1.

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~This LER is closed because the events were discussed in inspection report No.- 346/89016'and are the subject of an unresolved item in that l

report-(No. 346/89016-08).

l The following LER's were reviewed but require further inspection:

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'(0 pen)4LER 89005:

Reactor trip from full power due to main turbine L.

trip on loss of vacuum.

_ b.' - -(0 pen) LER 89007:

One of four strong motion triaxial accelerometers

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H inoperable for more_than 30 days.

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(0 pen)=LER 89011:

Testing of decay heat cooler valves did not

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satisfy ASME requirements, o

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Plant'0perations (42700, 71500, 71707, 71710, 93001)

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Operational Safety Verification u

Inspections were routinely performed to ensure that the licensee conducts activities at the facility safely and in conformance with

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regulatory requirements.

The inspections focused on the implementation and overall effectiveness of the licensee's control

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of_ operating activities, and on the performance of licensed and non-licensed operators and shift managers.

The inspections included

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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 s

reviews of facility procedures, records, and reports.

The following y

items were considered during these inspections.

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. Adequacy of-plant staffing and sWervision.

h Cont'rol room' professionalism, including procedure

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adherence, operator attentiveness, and response to alarms,

. events, and off-normal conditions.

Operability of selected safety-related systems, including

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attendant alarms, instrumentation, and controls.

• 1 Maintenance of quality records and reports.

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R-i 0n July 23,1989, at 9:12 a.m. control rod 7-5 dropped into the core a

b due to a~ blown Control-Rod Drive (CRD) Motor fuse.

This event was similar to an April 24, 1989, rod drop.

However, this event was

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complicated by another blown fuse in the CRD system that prevented transfer of control rods to the auxiliary power supply.

This second

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fuse had apparently blown on an earlier shift but its significance

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'was not realized until. attempts were made to transfer a rod to the

. auxiliary power supply.

A work request had been submitted because of a. loss of indication resulting from the blown fuse, but the need for'immediate repair,had not been identified.

Since the dropped rod

could not be recovered within an hour the licensee reduced plant

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power to'about 50 per cent as required by the Technical

-Specifications.

Tne inspectors verified that the the licensee had complied with the appropriate Technical Specifications.

Rod 7-5 was realigned with~ its group at-2:03 p.m. and the licensee began increasing power at 5:30 p.m.

The plant was returned to full power at.9:50 a.m. on July 24' 1989.

The blown fuses are discussed

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further in Paragraph 9.

On July 26, 1989, increased balance of plant (B0P) demand for Service Water (SW) caused SW pressure to drop low enough for the SW System to protectively isolate itself from the B0P.

The circulating-water (CW) system then automatically supplied cooling water to the

-B0P.as designed.

However, since the CW was warmer than the SW,

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plant power had to be reduced to about 90 per cent to reduce BOP l

heat loads.

The operators then returned the SW system to its normal configuration and returned the plant to full-power.

Corrective l

actions are discussed in Paragraph 9.

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On~ August 18, 1989, the unit was subjected to approximately a 10 i

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percent reduction in power while tuning the Integrated Control System (ICS).

The power change was caused by changes in feedwater flow and no safety systems were challenged.

The event was not

L significant but the circumstances which led to the event were.

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the event.

The team held a critique of the event and concluded that

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the following deficiencies were the contributing factors:

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Lack of Maintenance Work Order control ~

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'a b. 'L'ackof.adequatepre-jobbriefings

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Lack of constant communication ~between the testers and the Control Room

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d; Inadequate turnover between Reactor Operators

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Lack of SR0 oversight during testing.

'The inspectors determined that the circumstances leading to this event are similar to those of several previous events.

The inspectors were concerned that the corrective actions of the

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previous events were not effective.

These concerns were discussed with the licensee.

This is an unresolved-item (346/89019-01(DRP)).

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' After ~ reviewing the transient critique = report, the Plant Manager and the Engineering Director. directed that a task force be organized to

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?l review;the conditions leading to the event and provide

recommendations. ~The task force commenced work on August 23, 1989,

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September 6, 1989. This report is discussed in Paragraph 10.

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On September 13, -1989, at 11:58 a.m. the control room was informed

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that funnel clouds had been sighted east of the plant site.

The

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inspectors observed control room activities and verified that the.

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~ licensee had made preparations'for a possible tornado-and was maintaining communications with the National Weather Service and i

the Ottawa County Sheriff for current weather information.

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inspectors lalso observed the operation of.the Emergency Diesel j

Generators.

Ottawa County declared a tornado warning at 12:16 p.m.

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and activated the Prompt Notification Sirens.

No tornados or funnel-l clouds'were observed within the protected area or near the plant

~ite.

The. tornado warning was cancelled at about 12:58 p.m.

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10ff-shift Inspection ~of the Control Room The inspectors performed routine inspections of the control room

.during off-shift and weekend periods; these included inspections

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between the hours of'10:00 p.m. and 5:00 a.m.

The inspections l

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were conducted to assess overall' crew performance and, specifically, control room operator attentiveness during-night shifts.

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The inspectors determined that both licensed and non-licensed s

E operators were alert and attentive to their duties, and that administrative controls for the conduct of operation were being

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adhered to.

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.ESF-System Walk-down!

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. The.operab!11ty.of' selected' engineered safety features was confirmed

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g W by. the-inspectors during walk-downs of the accessible portions of

. several/ systems. - The following items were included:

verification

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that procedures match the_ plant drawings, that equipment,-

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instrumentation, valve and electrical breaker line-up status is in agreement with procedure checklists, and verification that locks,

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'y tags, jumpers, etc., are properly attached and identijfiable.

The

following systems were walked down during this inspection period:

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• ~ Auxiliary Feedwater System

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• Control Room Emergency-Ventilation System -

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' Direct Current Electrical Distribution System a

• Low Pressure Injection System i

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• Reactor Protection System

* : Safety Features Actuation System F

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. Service, Water System

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• '480 VAC Electrical Distribution System

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Plant Material' Conditions / Housekeeping The inspectors ' performed routine plant tours to assess material

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conditions within-the plant, ongoing quality activities and

. plant-wide housekeeping,

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Plant deficiencies lwere appropriately tagged for deficiency correction.

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No violations.or deviations were identified.

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5.;

Radiological-Controls (71707)

The' licensee's radiological. controls and practices were routinely m

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l observed by the inspectors during plant tours and during the inspection

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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 radioactive waste controls.

The inspection also

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' included a routine review of the licensee's radiological and water

. chemistry control records'and reports.

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t Health physics controls and; practices, housekeeping in the radiological

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controlled areas, and knowledge and training of personnel were generally e

satisf actory.

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h-No violations or. deviations were identified.

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6..

Maintenance / Surveillance (61700, 61726, 62703, 71500, 92701, 93702)

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Selected portions of plant surveillance, test and maintenance activ W es

w on systems and components important to safety were observed or reviewed

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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 tnese.!nspections:

limiting conditions for operation were met while a

components or systems were removed from service; approvals were obtained

!

prior to initiating work; act ' itles were accomplishod using approved procedures And were inspectes as e.pplicable; 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 maintained.

The licensee has been slowly reducing the backlog of maintenance work.

This requires support t om operations, planning, engineering and procurement.

As the backlog has been reduced, licensee management has identified areas outside of the maintenance department that require

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improvement.

It appears that appmpriate resources have been applied to support maintenance activities.

'the inspectors discussed the maintenance

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backlog reduction effort with licensee management personnel.

The inspectors informed the licensee that they believe that the back1~g o

reduction ~ effort needs to continue and that coordinated management effort will continue to be required to identify and resolve work restrictions.

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The licensee's response indicated that it plans to continue reducing the backlog until it reaches an appropriate level and that it recognizes and intends to maintain the resources and management attention necessary to

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complete the reduction.

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a.

Maintenance The reviewed mcintenance activities included:

Repair of Component Cooling Water Valve CC 7 manual operator.

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Installation of conduit for Facility Change Request (FCR)

86-0272 for the replacement of the essential inverters.

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Data gathering for evaluation of Reactor Protection System

(RPS) testing methodology.

t Repair of structural steel fireproofing.

• Troubleshooting of the number 3 and number 4 Instrument Air

Dryer.

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Inspection of circuit cards for Motor Driven Feedwater Pump

solenoid flott control valves.

Preventive maintenance on the Station Air Compressor.

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Repair of bent stem on valve CC 1474.

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Modification of the Station Vent Radiation Monitor, i

h Regreasing and toro.ue switch replacement for motor operator for

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Control Room Emergency Ventilation System outside air damper.

b.

' Surveillance

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The reviewed surveillances included:

i I

Procedure No.

Activity f

• ST 5030.02 RPS Monthly Functional Test

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• DB-PF-03220 Imbalance, Tilt and Rod Index Calculations - Group 38 Alarms Inoperable

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• DB-PF-03230 Daily Heat Balance Check l

• DB-SC-04177 Quarterly Functional Test of RE 1003B, Condenser Vacuum Discharge to Station Vent

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Radiation Monitor

• DB-SP-03294 Containment Air Cooling Unit 1 Monthly

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Test

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• DB-SP-03295 Containment Air Cooling Unit 2 Monthly Test

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• DB-SP-03296 Containment Air Cooling Unit 3 Monthly Test e

• DB-SP-03159 Auxiliary Feedwater Pump Monthly Jog Test

• DB-SP-03357 Reactor Coolant System Water Inventory Balance

• 1C-2005-04 Process Radiation Monitor Calibration No violstions or deviations were identified.

7.

Emergency Preparedness (71707, 82301, 82302)

An inspection of emergency preparedness activities was performed to assess the licensee's imp ementation of the emergency plan and implementing procedures.

The inspection included monthly observation of

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L emergency. facilities and equipment, interviews with licensee staff, and

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a rt. view of selected emergency implementing procedures.

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The licensee held its annual-emergency preparedness exercise en August 8

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l and 9, 1989.

The exercise included participation by the states of

L Michigan and Ohio.

Both FEMA and the NRC evaluated the exercise.

The j

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licensee's' performance was satisfactory.

The exercise is documented in j

more detail in Inspection Report 50-346/89013.

)

No violations or deviations were identified.

i 8.

Security (71707, 81020)

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The licensee's security activities were observed by the inspectors during routine facility tours and during the inspectors' site arrivals and departures. Observations included the security personnel's performance

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associated with access control, security checks,ity staffing, the and surveillance activities, and focused _on the adequacy of secur

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security response (compensatory measures), and the security staff's attentiveness and thoroughness.

l The security personnel were observed to be alert at their posts, i

Appropriate compensatory measures were established in a timely manner.

l Vehicles entering the protected area were thoroughly searched.

No violations or deviations were identified.

9.

Engineering and Technical Support (42700, 62703, 64704, 71707, 92701,

92702, 94702)

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 r

activities.

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, and maintenance personnel.

a.

On July 24, 1989, a control rod dropped into the core due to a tlown Control Rod Drive (CRD) motor fuse.

A similar event occurred on April 24, 1989.

In both cases the manufacturer's analysis of the j

fuse revealed that the fuse had blown due to a substantial over current.

However, routine weekly thermographic inspections of the

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CRD fuses had not indicated that the fuses which blew had been overheating.

Systems engineering identified a possible source of 1;

such an over current.

Troubleshooting of the CRD System is difficult at power because of the possibility of dropping rods or causing a plant trip during troubleshooting.

However, the licensee was able to determine that the identified potential source of the over current problem was not the problem.

The licensee discussed the problem with the CRD System manufacturer and hired an independent consultant to evaluate its troubleshooting plan.

Discussions between the consultant

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and the fuse manufacturer revealed that the manufacturer's fuse over current measurement technique was not as accurate as had been thought.

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F This means that the fuses may not be experiencing large over currents

but may ba blowing due to repeated small current transients which

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occur during normal operation.

The CRD system engineer is now

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finalizing an action plan to identify and correct the blown fuse

problem, b.

On' July 26, 1989, increased balance of plant (BOP) demand for Service L

Water (SW) cooling caused the safety-related portion of the SW system to protectively isolate itself from the B0P heat loads.

This type of L

SW transient is undesirable because if the circulating water (CW)

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system autoh.atic supply valve does not open to supply cooling water to BOP equipment a turbine trip and reactor trip is probable.

Based on an engineering review of measured flows, the licensee manually

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throttleu SW valves to limit SW flow to the Turbine Plant Cooling

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Water heat exchangern.

It is anticipated that this will resolve the SW isolation problem.

c.

The licensee continues to experience operational problems with the station and instrument air system.

Although this system is not a safety related system it has a significant effect on plant operation.

In each case, when problems t.ccurred, operations personnel have restored the system to norma, operation and avoided plant transients.

The licensee's Engineering and Maintenance Departments have expended substantial resources to improve the. system.

As identified in a

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previous Inspection Report 50-346/89011, as problems are solved by i

engineering, additional problems are identified.

Overall, the

,

resolution of the numerous problems appear to be going slow and no+

meeting the licensee's expectation. Work on system improvements is

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continuing in accordance with an action plan which Systems and Design Engineering have developed.

Successful completion of the action plan 1-

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is necessary to ensure that the plant has a reliable air system.

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No violations or deviations were identified.

10.

Safety Assessment / Quality Verification (30703, 35502, 40500, 92720, 92702)

An' inspection of the licensee's quality programs was performed to assess the-impiementation and effectiveness of programs associated with management control, verification, and oversight activities.

The inspectors considered areas indicative of r/erall management involvement in quality matters, self-improvement programs, response to regulatory and industryinitiatives,thefrequencyofmanagementplanttoursandcontrol room observations, and management personnel s participation in technical and planning meetings.

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 activities.

Performance in this area included the following major items:

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a.

The licensee identified during the previous inspection period (Inspection Report 50-346/89016) that an improper electrical lineup L

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of a Service Water Pump Strainer was caused by the inadequacy of procedure SP1104.11, " Service Water System Operations." The inspectors were concerned with this finding because SP1104.11 was one of the procedures which they had requested the licensee add tc

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I the procedures which it was to revalidate during December,1988 (Inspection Report 50-346/88039). The comments dated December 16, L

1988, of the two revalidators of SP1104.11 were reviewed and the p

inspectors could not find any comments which related to the electrical lineup for service water (SW) pump 1-3 in either validation list.

On May 6, 1989, an operator wrote Procedure Change Request (PCR) 89-3376 to place the' strainer electrical. lineup in the applicable section of

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the procedure.

The writer of the PCR stated that he would have missed the step had it not been for an experienced operator.

The PCR uas dispositioned to be incorporated during the next revision or periodic review.

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The failure of the two revalidators to identify the procedural weakness of the SW pump 1-3 strainer electrical lineup during the

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massive. procedure revalidation effort indicates either a weakness.in the validation process or in the sensitivity to procedure requirements.

The failure to incorporate the requested change is significant because-during the December 1988, revalidation process procedures which could cause. confusion or be difficult for inexperienced operators to implement were to he changed before usage.

The inspectors met with 0A during the previous inspection period to discuss their concerns and observations related to procedures.

The

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discussion focused primarily on fire protection and operation procedures.

The inspectors suggested to the licensee that a procedu al audit would be beneficial because it would clarify the i

extent of their concerns and it could also be used to verify the

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corrective actions of Management Corrective Action Report i

(MCAR)88-002,.The licensee performed a surveillance of operations procedures rather than an audit.

The surveillance was conducted by a-team of seven management personnel, all of whom hold or have held-an SRO license for Davis-Besse.

The surveillance report (SR-89-PLOPS-16) was issued on August 25, 1989.

The conclusions

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drawn from the surveillance indicated the problems described in MCAR 88-002 still exist.

The surveillance substantiated the inspectors concerns.

The surveillance transmittal memorandum dated August 25, 1989, stated that management attention and dedicated resources would be required to achieve acceptable results in the operations procedure rewrite program including scheduler commitments.

i The inspectors also reviewed the Safety System Functional Inspection (SSFI) final report of the Station and Instrument Air System dated August 25, 1989, and noted that the operating procedure (DB-0P-06251)

contained numerous technical errors.

The inspectors have concluded that there were sufficient indicators for the licensee to have observed that the corrective actions taken for the conditions described

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in MCAR 88-002 and Inspection Report 50-346/88037 were not adequate and additional management attention was required.

This is an unresolved itew (346/89019-02(DRP)).

The licensee has implemented so'ne of the corrective actions described in the surveillance transmittal memorandum.

A shift supervisor has been detailed to be the Operations Procedure Task Manager.

He is in the process of organizing and staffing the task force.

He plans to prioritize the rewrite program.

The inspectors plan to meet with the

' Task Manager soon after the task force has been organized.

h.

The inspectors have reviewed several previous events as a result of observations made involving the August 18, 1989, event and the operations procedure issue.

They reviewed Licensee Event Reports, Transient Assessment Program (TAP) reports, licensee correspondence, NRC reports, and other documentation.

The review revealed that repeated events had similar causes and that corrective actions for eaci one were similar.

The inspectors have concluded that the licensee's follow-up of corrective actions is inadequate. This has been discussed with the licensee which has initiated efforts to remedy the problem. This will be monitored by the inspectors.

The licensee' initiated an effort to review corrective action effectiveness as a result of the Au2ust 18, 1989, transient.

A task force headed by Performance Engineering was organized to review the contributing factors to the event and the frequency of occurrence in previous events.

The task force was multi-disciplined and included several individuals who have or have had SRO licenses for Davis-Besse.

The task force made observations and recommendations in each of the areas it looked at, which were essentially the causal factors (Paragraph 4) of the event.

The most sianificant conclusions rea:hed were that both inter and intra organization communication deficiencies were the principal weakness.

Inadequacies in the procedure relating-to SR0 overview and inadequacies in the corrective action program were theothermajorweaknesses.

The task force also identified that approximately 35% of the corrective actions for deficiencies identified in transient assessment reports since December 1986, remain open.

The effectiveness of the licensee's corrective action program is an unresolved item (346/89019-03(DRP)).

The inspectors also are evaluating the significance of the open recommendations.

11.

Enforcement Conference On September 8, an Enforcement Conference was conducted in Glen Ellyn,

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Illinois, between the NRC staff and representatives of Toledo Edison Co.

The purpose of the enforcement conference was to seek additional

'information from the utility and the Davis-Besst plant manager on the handling of a revision and ariroval of a quality assurance procedure.

This matter was originally the subject of a special inspection in 1988 (Inspection Report 88-04) and a subsequent investigation by the NRC's Office of Investigations.

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The NRC staff is reviewing the information from the inspection report,

the utility's response to that report, and the Office of Investigations report, and from the Enforcement Conference.

P 12.

Commissioner Visit p

. On' August 29, 1989, Commissioner James Curtiss, accompanied by his

!

Technical Alde, the Director of the Region III Division of Reactor Projects,andtheinspectorsmetwithseniorToledoEdisonmanagement and toured the plant.

I 13.

Unresolved Items

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Unresolved items are matters about which more information is required

,r" in order to ascertain whether they are acceptable items, violations, or deviations.

An unresolved item disclosed during the inspection is

!

discussed in Paragraphs 4 and 10.

i 14; Exit Interview (30703)

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

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throughout the inspection period and at the conclusion of the inspection and summarized the scopa and findings of the inspection activities.

The

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licensee acknowledged the findings.

After discussions with the licensee, r

the inspectors have determined there is no proprietary data contained in

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.this inspection report,

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