IR 05000373/1986018
| ML20199C805 | |
| Person / Time | |
|---|---|
| Site: | LaSalle  |
| Issue date: | 06/09/1986 |
| From: | Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20199C792 | List: |
| References | |
| 50-373-86-18, 50-374-86-17, NUDOCS 8606180255 | |
| Download: ML20199C805 (9) | |
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U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Reports No. 50-373/86018(DRP); 50-374/86017(DRP)
Docket Nos. 50-373; 50-374 Licenses No. NPF-11; NPF-18 Licensee: Commonwealth Edison Company Post Office Box 767 Chicago, IL 60690 Facility Name:
LaSalle County Station, Units 1 and 2 Inspection At:
LaSalle Site, Marseilles, IL Inspection Conducted: April 15 through May 9,1986 Inspectors:
M. J. Jordan J. Bjorgen R. Kopriva R. DeFayet Approved By:
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Reactor Project ction 2C Dat6 Inspection Summary Inspection from April 15 through May 9, 1986 (Reports No. 50-373/86018(DRP);
50-374/86017(DRP))
Areas Inspected:
Routine, unannounced inspection conducted by resident and region inspectors of licensee actions on previous inspection findings; operational safety; surveillance; maintenance; Licensee Event Reports; training; unit trips; bomb threat; refueling / outage; and followup of 10 CFR 50.54(f)
request for information.
Results: Three violations were identified, all of which were caused by personnel errors. Two violations were related to fuel movement operations (Paragraph 10). The other violation was related to surveillance activities on Unit 1 during the shutdown (Paragraph 4). The errors were mainly caused by failure to follow written procedures.
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DETAILS 1.
Persons Contacted G. J. Diederich, Manager, LaSalle Station
- K.
L. Grasser, Divisional Vice President
- R. D. Bishop, Services Superintendent
- C. E. Sargent, Production Superintendent D. Berkman, Assistant Superintendent, Technical Services
- W. Huntington, Assistant Superintendent, Operations J. C. Renwick, Assistant Superintendent, Work Planning
- R.
W. Stobert, Quality Assurance Supervisor
- P. Manning, Tech Staff Supervisor
- T. Hammerich, Assistant Tech Staff Supervisor W. Sheldon, Assistant Superintendent, Maintenance The inspectors also talked with and interviewed members of the operations, maintenance, health physics, and instrument and control sections.
- Denotes personnel attending the exit interview held on May 9, 1986.
2.
Licensee Action on Previous Findings (92701)
(Closed) Open Item (373/85007-07(DRP)): The licensee was able to retrieve the documentation necessary to substantiate their formula for determining Standby Liquid Control (SBLC) tank net volume. They verified the difference between the gross and net volumes of the SBLC tark through initial system preoperational documentation.
The licensee has revised the equation for figuring net volume of the SBLC tank in procedure LCP-310-9 which is used to determine SBLC tank concentration.
(Closed) Violation (374/85034-01(DRP)): The violation was for failure to take the required technical specification action with two Emergency Core Cooling Systems (ECCS) out of service. This was identified after the minimum flow valve for a low pressure core injection valve was closed and the High Pressure Core Spray System had been inoperable two days earlier.
This violation included a Civil Penalty for fifty thousand dollars issued March 19, 1985. The action taken by the licensee addressed in its correspondence dated April 18, 1986 to correct and prevent recurrence is considered acceptable.
3.
Operation Safety Verification (71707)
The inspector observed control room operations, reviewed applicable logs and conducted discussions with control room operators during the inspection period. The inspector verified the operability of selected emergency systems, reviewed tagout records, and verified proper return to service of affected components. Tours of Units 1 and 2 reactor buildings and turbine buildings were conducted to observe plant equipment conditions, including potential fire hazards, fluid leaks and excessive vibrations and to verify
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that maintenance requests had been initiated for equipment in need of maintenance. The inspector by observation and direct interview verified that the physical security plan was being implemented in accordance with the station security plan.
The inspector observed plant' housekeeping / cleanliness conditions and verified implementation of radiation protection controls.
During the month of April 1986, the 11:spector walked down the accessible portions of the following systems to verify operability:
Unit 1 and 2 Emergency Diesel Generators
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Unit 1 and 2 Standby Gas Treatment Systems
Unit 1 and 2 Standby \\ Liquid Control Sy. stems 4.
Monthly Surveillance Observation (61726)
The inspector observed, technical specifications required surveillance testing and verified that testing was. performed in accordance with adequate procedures, that test instrumentation was calibrated, that limiting conditions for operation were met, that removal and restoration of the affected components were accomplished, that test results conformed with technical specifications and procedure requirements and were reviewed by personnel other than the individual directing the test, and that any deficiencies identified during the testing were properly reviewed and resolved by appropriate management personnel.
The inspector observed friction testing, procedure LTP 700-2, being performed on the Unit 1 Control Rods No. 22-51, 26-15, and 38-23.
During testing of Control Rod No. 22-51, the inspector observed a technical staff person operating the scram accumulator charging water supply valve with an out of service card attached to the valve. Although permission to operate the valve had been obtained, the out of service card should have been removed prior to operating the valve. Technical Specifications, Section 6.2.A.8, requires that detailed written procedures be prepared, approved, and adhered to for tests and experiments. The licensee's equipment out of service procedure being utilized for control of the valve operations during the test, LAP 900-4 Paragraph 3a, requires that all personnel protection cards and all necessary out of service cards must be removed before energizing, operating, or changing the position of components for a test.
Contrary to the above, the charging water supply valve for Control Rod No. 22-51 was operated without the out of service card being removed.
This is considered to be a violation (373/86018-01(DRP)).
A discussion with the person indicated he had received permission to operate the valve, he had just failed to remove the card before operating the valve.
Following final operation of the valve, after the inspector expressed concern for operating the valve with an cut of service card attached, the valve position was independently verified by an equipment operator.
Although the safety significance of the observed violation of procedures is minimal because the plant was in cold shutdown and no personnel protection hazard existed, the continued lack of adherence to procedures by licensee personnel remains a concern.
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The inspector also observed calibration of the Unit 2 reactor vessel pressure switch 2821-N039N being performed in accordance with procedure LIS-NB-214. No items of concern were identified.
The inspector held a discussion with the Fire Marshall on a concern with the fire protection surveillance program. The inspector determined that the monthly surveillance on the fire door supervision system was being accomplished in accordance with Technical Specification 4.7.6.2.d.
The test was done by a security procedure as part of the security supervision system. However, if a door failed the surveillance, neither the shift engineer nor the Fire Marshall were required to be notified. Without the Fire Marshall or the shift engineer being notified, the action required by the technical specification to be accomplished within one hour may not have been accomplished. After discussing this with the Fire Marshall and station security personnel, the licensee agreed to change the surveillance procedure to require notification of failure to the shift engineer or Fire Marshall. Also, continuous alarms from the doors greater than 15 minutes are to be reported to the shift engineer or Fire Marshall so fire-related technical specifications can be adhered to.
A review of the surveillance procedure identified that although the surveillance was being accomplished, the procedure was a " post order" issued to the security officer.
It did not have the onsite review and control system of normal procedures.
This was brought to the attention of the station management and they agreed to look into this. This will remain as an open item until this review is done (373/86018-02; 374/86017-01(DRP)).
5.
Monthly Maintenance Observation 62703)
Work requests were reviewed to determine status of outstanding jobs and to assure that priority is assigned to safety related equipment maintenance which may affect syster. performance.
6.
Licensee Event Reports (92700)
Through direct observations, discussions with licensee personnel, and review of records, the following Licensee Event Reports (LER's) were reviewed to determine that reportability requirements were fulfilled, immediate corrective action was accomplished, and corrective action to prevent recurrence had been accomplished in accordance with technical specifications.
373/86002-01 - Three main steam relief valves failed to meet setpoint tolerances.
This revised LER was issued to reflect the change in testing of these valves to prevent reoccurrence of this problem.
373/86011-00 - Primary containment isolation resulting from personnel error.
The Nuclear Station Operator (NS0) failed to follow instructions causing the isolation.
Personnel were counseled on importance of attention to details.
This item was addressed in Inspection Report 373/86011; 374/86011.
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373/86013-00 - Loss of Bus 141Y and auto-start of "0" diesel due to Operational Analysis Department (OAD) personnel error.
Followup on this sub.act will be accomplished in conjunction with unresolved item 373/86011-02, 374/85032-02 - Leak detection for Division 1 and 2 Residual Heat Removal differential temperature not operable. This revision was issued to change the cause code back to Management / Quality Assurance deficiency after it was inadvertently changed in Revision 1 to design.
374/86007-00 - Excessive drift in Static-0-Ring pressure switch.
This event initiated a special inspection anc is documented in Inspection Report 373/86013; 374/86013.
374/85027-01 - High Pressure Core Spray-CY return line ruptured due to biological corrosion. This LER revision was issued to identify the cause of the failure to the pipe. This issue was previously inspected and documented in Inspection Report 373/85028; 374/85029. Open Item 374/85029-01 will close this item.
373/86007-00 - VQ System containment gaskets of incorrect type since original construction.
7.
Training (41400)
The inspector, through discussions with personnel and a review of training records, evaluated the licensee's training program for operations personnel to determine whether the general knowledge of the individuals was sufficient for their assigned tasks. No items of concern were identified.
8.
Unit Trips (93702)
On April 25, 1986 while performing half scram surveillances, Unit I received a full scram signal. The unit was shut down for refueling at the time with all control rods inserted.
An investigation into the cause of the scram determined that while performing half scram surveillances, a set of contacts on a relay (K14E) failed to open when the half scram was reset.
As a result, the backup scram solenoid in the "A" trip system did not close.
The indication in the control room on reset of a scram comes from the scram solenoids and not the backup scram solenoids.
The "B" scram channel was then tested which opened the "B" scram solenoids and the "B" backup scram solenoids. With the "A" and "B" backup scram solenoids both open the scram air header started depressurizing which started the depressurization of the Control Rod Drive (CRD) header. As the CRD header depressurized, the new scram on low CRD header pressure was initiated. All systems functioned as expected.
No further action was taken.
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9.
Bomb Threat (93702)
On April 25, 1986 at 9:30 p.m. (CST), the Radiological Control Technician (RCT) at the access to the Unit I drywell-received a bomb threat. The caller said, "This is Momar Kadafy and I have planted a bomb in the Unit I reactor." He then hung up.
The licensee restricted access to and egress from the site. A search of both reactor buildings and Unit I drywell was conducted and no bomb was found. The licensee is continuing to investigate.
The final resolution to this event will be followed up by security personnel during their next visit.
10. Refueling / Outage (61701)
On April 22 the licensee commenced reloading fuel into Unit 1.
The first fuel bundle that was installed into the vessel only went in about one-third of the way (approximately four feet) before it stopped when it came in contact with the adjacent control rod.
Investigation revealed that the control rod was " tilted" because the bottom of one leg of the double blade guide was not properly positioned.
Instead of the two legs being inserted in opposite corners of the fuel assembly cluster, the bottoms were on the same side. This was not noticed because the top orientation of the guide looked correct. When the control rod was inserted it was therefore forced to one side by the blade guide. When the fuel bundle was inserted it could only be lowered about four feet before it became wedged between the blade guide and the control rod.
In all probability, the mispositioning of the blade guide occurred on April 11. At that time the control rod and guide in question were removed to inspect a newly installed Local Power Range Monitor.
Subsequent to that inspection, the control rod and blade guide were reinserted in the core.
Upon discovery of the problem, the control rod and the channel on the fuel bundle were replaced. The blade guide was reinstalled correctly and all other blade guides and control rods were verified to be installed correctly.
Refueling operations then recommenced.
On April 25, 1986, the refuel platform communicator contacted the Nuclear Station Operator (NS0) at about 5:30 a.m. for permission to move the 177th fuel bundle. The NSO stated that the refueling personnel should " hold for five minutes". Although he did not specifically tell the communicator why to hold, he was in the process of obtaining the signal-to-noise ratio for the required SRM and, therefore, the SRM was withdrawn from the core.
Each of the SRMs was to be demonstrated operable at least each 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. This required a signal-to-noise ratio calibration. This was done by removing the detector from the core; the background signal generated was considered the " noise" level.
Reinserting the detector then gave the " signal" level.
The communicator misinterpreted the NS0's communication to mean that in about five minutes the NSO would tell him when the SRM check would be accomplished and that he had permission to move the bundle.
He then informed the personnel on the bridge to move it.
After it was installed in its proper location in the core, he so informed the NSO.
LaSalle Technical Specification 3.9.2 and operating procedure LFP-100-1,
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Section C.1.b.2, require that during core alterations at least two Source Range Monitors (SRMs) be operable and inserted to the normal operating level. One of these SRMs must be located in the quadrant where core
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alterations are being performed and the other SRM must be located in an adjacent quadrant. This was not done. This is considered a violation (373/86018-03A(DRP)).
Upon learning that the fuel bundle was in the core and the SRM was not, the NSO immediately reinserted the SRM and ceased refueling operations.
The SRM reading upon reinsertion was not significantly different than the inserted reading before this bundle was placed in the core. All control rods were fully inserted during this entire sequence of events. Operations were not resumed until it was determined by monitoring the SRM's that no unsafe condition existed.
Contributing to the violation identified above were the following procedural violations:
a.
Refueling Procedure LAP 1600-2, " Conduct of Operations",
Section F.1.n, states that " communications to operating personnel
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must be clear and concise. These directions shall be given in such a manner that they are explicit and understandable.
This shall be verified by having the operator repeat back verbal instructions... so the director i's satisfied he is understood." This was not done by either the communicator on the refuel platform or the NSO in the control room.
(373/86018-03B(DRP))
b.
Refueling Procedure LFP 400-1 states in Section F.6.d that when transferring the fuel assembly from the fuel pool to the core, the personnel on the refuel platform are to notify the control room when moving over the core. There also is such a note under the
" Precautions" section of the procedure. This was not done.
(373/86018-03C(DRP))
A contributing factor to this event may be a failure of licensee personnel to appreciate the reasons for communications between the refuel platform and the control room during core alterations. -One major reason is to make certain that all involved personnel, especially the NSO, are constantly aware of the status of the core.
Technical Specification 3.9.5, which requires direct communications between the refuel floor and the control room, was not technically violated; however, the communications system was not used sufficiently. Ccmmunications were direct, but they were not continuous.
If continuous communications had been maintained, the NSO probably would have been aware of the fuel movement and stopped it.
Furthermore, investigation revealed that it was common practice for personnel on the refuel platform to have no communications with the control room from the time they received permission to move a fuel bundle until the bundle was installed in the core.
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The licensee's long term corrective action was to issue a directive and require that all appropriate personnel be trained on it.
The directive required that continuous communications be maintained between the refuel bridge and the control room during fuel loading. This training and directive were implemented before commencement of fuel loading on the afternoon of April 25, 1986.
During the week of April 28, 1986, the Resident Inspector observed several fuel bundle and blade guide movements in the refueling pool and in the reactor vessel.
Due to the previous problems, the licensee's communication between the refueling bridge and the control room was more continuous stating different locations of the fuel bundles as they were moved. These communications appeared to be adequate.
On May 2, 1986, the licensee loaded a wrong fuel bundle into a location in the core. The licensee had preloaded fuel in the fuel pool in the sequence and orientation in which it was to be loaded into the vessel.
Due to a problem with the drive mechanism on the "A" Source Range Monitor (SRM), a change was made to the loading sequence procedure for the final few fuel bundles. The change was made in case a " dunker" monitor would have to be installed. The loading of fuel into the core was changed such that the core location where the dunker would have been installed was to be loaded last. The fuel handlers failed to recognize the change in the sequence and picked up the fuel bundle from fuel pool location A-18-8 and installed it into core location 3-18.
The sequence procedure called for the fuel bundle from A-18-9 to be loaded into core location 3-18, thus
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skipping fuel bundle A-18-8 until another sequence.
Both the fuel handler and the refueling foreman failed to recognize the removal of the wrong bundle from the fuel pool.
The refueling foreman indicated that water was cloudy around the area in which the fuel was removed and the wrong bundle removal was not recognized until the next step in the loading sequence.
Failure of the fuel handlers to follow the fuel loading sequence is considered a violation of fuel loading procedure LFP 100-1 which requires that steps on the Nuclear Component Transfer List must be performed in the exact order listed. (373/86018-04(DRP))
11.
Followup to 10 CFR 50.54(f) Request For Information (71707, 92701)
On April 30, 1986, a monthly meeting was held at USNRC Region III to discuss the progress of the station on actions resulting from the 50.54(f)
letter. The meeting was attended by Mr. J. G. Keppler of the NRC Region III and Mr. B. Thomas of Commonwealth Edison and members of their respective staffs. Mr. A. Bournia of the NRC Nuclear Reactor Regulation Office also attended. The discussion covered work request backlog, control room annunciators, modifications, and procedure changes.
The licensee also addressed the action being taken on the improvement of the Feedwater Control System, Reactor Water Cleanup System, valve repairs, and how jumper installation required by procedures will be controlled. The final major discussion was on personnel errors and the number of such errors that have happened in the recent past.
Some of these errors caused such events as a scram and some actuations of the Engineered Safety Features.
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12. Open Items Open items are matters which have been discussed with the licensee, which will be reviewed further by the inspector, and whic! involve some action on the part of the NRC or licensee or both. Open items disclosed during the inspection are discussed in Paragraph 4.
13.
Exit Interview (30703)
The inspectors met with licensee representatives (denoted in Paragraph 1)
throughout the month and at the conclusion of the inspection period and summarized the scope and findings of the inspection activities. The licensee acknowledged these findings.
The inspector also discussed the-likely informational content of the inspection report with regard to documents or processes reviewed by the inspector during the inspection.
The licensee did not identify any such documents or processes as proprietary.
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