IR 05000382/1999007

Insp Rept 50-382/99-07 on 990601-11.Noncited Violations Identified.Major Areas Inspected:Operations

ML20211Q566
Person / Time
Site:	Waterford
Issue date:	09/08/1999
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20211Q447	List: IR 05000382/1999007 ML20211Q442
References
50-382-99-07, NUDOCS 9909150094
Download: ML20211Q566 (24)

Text

1

. )

~

ENCLOSURE U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket No.: 50-382 License No.: NPF-38 Report No.: 50-382/99-07 Licensee: Entergy Operations, In Facility: Waterford Steam Electric Station, Unit 3

- Location: Hwy.18 Killona, Louisiana

. Dates: June 1 to 11,1999 Inspectors: Paul C. Gage, Senior Reactor Engineer, Operations Branch Gary W. Johnston, Senior Reactor Engineer, Operations Branch Jack M. Keeton, Resident inspector, Project Branch D Approved By: John L. Pellet, Chief, Operations Branch

. Division of Reactor Safety ATTACHMENTS:

Attachment 1: Supplemental Information Attachment 2: Initial Material Requested

!

!

l

9909150094 990909 PDR

G ADOCK 05000382 PDR ,

!

=

l

.

-2-EXECUTIVE SUMMARY Waterford Steam Electric Station, Unit 3 NRC Inspection Report No. 50-382/99-07 Three NRC Region IV inspectors performed a routine core inspection of the corrective action program implementation at the Waterford Steam Electric Station, Unit 3, from June 1 to 11, 1999, followed with inoffice review through July 2,1999. The inspectors used NRC Inspection Procedure 40500 to evaluate the licensee's effectiveness in identifying, evaluating, resolving, and preventing problems that could affect safe plant operation The licensee maintained a low threshold for initiating corrective action document Management and craft personnel shared a common understanding about program expectations, capabilities, and goal Operations

Conditions that could affect safe plant operations were identified, evaluated, and resolved. The inspectors noted examples of slow or untimely condition report processing. These were delayed maintenance rule functional failure determinations, procedure updates, and reporting conditions outside design basi *

The licensee's corrective action processes provided adequate guidance for identifying, classifying, and prioritizing adverse conditions. Licensee personnel interviewed were willing to initiate condition reports for any nonconforming or questionable issue or event (Section 07.1b.1).

The licensee's failure to determine that identified conditions for the emergency diesel generator sequencer relays were maintenance preventable functional failures was a Severity Level IV violation of 10 CFR 50.65(a)(2). Subsequently, as a result of the inadequate periodic evaluation, the licensee failed to establish goals commensurate with safety for the emergency diesel generator sequencer relays. This violation is being .

treated as a noncited violation (50-382/9907-01), consistent with Appendix C of the NRC l enforcement policy (Section 07.1b.3).

• Based on the recommendations made in the three licensee audits reviewed by the inspectors, and the condition reports written from the audit findings, the audit process provided little substantive feedback to enhance the quality of plant activities. The identified concerns, although self-critical, tended to be administrative in nature (Section 07.1b.4).

• The failure to provide a report to the NRC within 30 days when the control room envelope was in a condition outside its design basis was a Severity Level IV violation of 10 CFR 50.73(a)(2)(ii)(B). This violation is being treated as a noncited violation (50-382/9907-02), consistent with Appendix C of the NRC enforcement policy (Section 07.1b.6).

..

.

-3-

The ongoing failure to correct control room damper failures over a 3-year period was a Severity Level IV violation of 10 CFR Part 50, Appendix B, Criterion XVI. This violation is being treated as a noncited violation (50-382/9907 03), consistent with Appendix C of the NRC enforcement polity (Section 07.1b.6).

The licensee's treatment of missed surveillances was narrowly focused without reviewing for common root cause conditions. Several opportunities were missed regarding the potential generic impact. Specifically, assessment of recent missed

{

surveillances had not been integrated to consider common causal factors for each event in relation to other similar events. A more detailed generic impact review would preclude corrective actions being limited in scope (Section 07.1b.6).

l I

l

,

.

,

-4-Report Details Summary of Plant Status The Wate ford 3 Steam Electric Station operated at approximately full power during the entire inspection perio . Operations 07 Quality Assurance in Operations O7.1 Condition Reoortina Process and Corrective Actions Insoection Scoce (40500)

The inspection consisted of a review of the licensee's programs intended to identify and correct problems discovered at the facility. The review focused on the following seven specific areas: (1) the identification and reporting threshold for adverse conditions, (2) the setting of problem resolution priorities that were commensurate with operability and safety determinations, (3) program monitoring used by the licensee to assure continued program effectiveness, (4) program measurement or trending of adverse conditions, (5) the understanding of the program by alllevels of station personnel, (6) the ability to identify and resolve repetitive problems, and (7) resolution of noncited violation l The inspectors reviewed plant documents, interviewed management and working level personnel, and attended licensee meetings. The inspectors reviewed, in varying detail, condition reports, listed in the attachment to this inspection report, to ascertain the effectiveness of the licensee actions in resolving and preventing issues that degrade the quality of safe plant operations. The specific areas were selected, in part on the basis l i

of the risk significance of the system or components, included the high pressure safety I injection system, emergency feedwater system, emergency diesel generator system, and the control room ventilation system. The condition reports were also reviewed for 1 the disposition and evaluation of operability issues, as well as, the adequacy of the root cause analysi The inspectors reviewed the corrective action program interface with other lower-tier programs, such as procedure revisions and maintenance action items, that could result in corrective action. The inspectors monitored the performance of the licensee's condition review group. The inspectors reviewed quality assurance audits, self assessments, and licensee response to NRC and industry generic communication The inspectors also reviewed a sample of licensee event reports, listed in Attachment 1 of this report, for compliance with 10 CFR 50.73 and for the effectiveness of licensee personne!in identifying, resolving, and preventing the occurrence of problems that affect safe plant operation I.

!

l I

~

!

! -5-l l Observations and Findinas b.1 Threshold of Reportina The primary method used for the identification, evaluation, and resolution of problems was clocumented in Procedure W2.501," Corrective Action," Revision 8. This procedure prescribed the method for processing condition reports for the identification, documentation, notification, evaluation, correction, and reporting of conditions, events, activities and concerns that could affect, or that had the potential for adversely affecting, the safe, reliable, and efficient operation of the Waterford 3 Steam Electric Station. The inspectors found that there was a clear understanding of the requirements for initiating a condition report among all levels of plant staff (see Section b.5), and that the condition review group consistently applied the guidelines for condition report initiation given in Procedure W2.501," Corrective Action," Revision 8. The inspectors reviewed 20 condition reports classified "below scope" by the condition review group during this screening process and, in each case, this classification was justified and in accordance with those guidelines. "Below scope" condition reports typically involved a situation or condition that was not adverse to qualit Based on a review of the work management system for the identification of system or component deficiencies, the inspectors found that equipment problems were adequately identified as maintenance action items. Equipment problems were exemplified by situations involving maintenance that could be performed on-line or did not affect the availability of the equipment in question. These maintenance action items were reviewed daily at work planning meetings attended by all plant work disciplines. Based on the inspectors review of four lower-tier documents, the inspectors noted an appropriate threshold existed for identifying problems, and raising identified problems to an appropriate condition report level. One example, MAI 400576, identified that Diesel Fire Pump B run out flow was 10 percent below the pump operability curve. The pump l was subsequently replaced to resolve the performance problem. The condition I identification system was in place prior to November 1,1998, as the facility's lower tier ;

problem reporting system. The maintenance action item program replaced the condition I identification program on November 1,199 The inspectors' review of these programs focused on the classification of problems captured by the program, which included determining whether the identified problem met the threshold for a condition report. The inspectors found no instance where a condition report should have been issued in lieu of the reviewed condition identification or maintenance action ite From the review of approximately 50 lower-tier documents contained in the maintenance history report, the majority of the maintenance action items and condition identifications

' involved routine corrective maintenance items. The balance of those were typically items identified during routine maintenance, plant tours, inspections, or equipment performance problems that did not constitute a concern with a condition adverse to j quality. These included items such as minor valve packing leaks, component lubrication, surface corrosion, and other routine activitie .

.

-6-The inspectors determined that the current maintenance action item program was adequately implemented. The inspectors found the licensee's corrective action processes to be designed and implemented with an appropriate threshold for identifying, classifying, and prioritizing adverse conditions. The reviewed condition reports indicated a willingness on the part of licensee personnel to initiate appropriate documentation for events or nonconfoiming issue b.2 Priority of Resolution The licensee's prioritization of condition reports was delineated in Procedure W2.501,

" Corrective Action," Revision 8, which included three classifications: significant, nonsignificant, and below scope. Significant classifications, designated by Category A, B, or C, were associated with the more important issues at the station, and required a root-cause determination to be documented for each condition report. The initial classification of condition reports and organizational res; mibility for action were assigned at daily condition review group meeting Information contained within the condition report system data base revealed almost 2000 condition reports. Approximately 9 percent of initiated condition reports had received a significant classification rating by the condition review group, which required a root-cause assessment to be completed with guidance provided by "Entergy Root Cause Analysis Desk Guide," Revision 1, and " Problem Trending Guide Root Cause Analysis," Revision 2. Nonsignificant condition reports required an apparent cause

! determination onl Out of approximately 30 condition reports reviewed during direct observation of 5 condition review group meetings, the inspectors found the reviews performed by the l condition review group to be thorough and timely. The inspectors noted that a probabilistic risk assessment representative was not included as part of the condition review group, since risk significance was subjectively considered in the condition report prioritization process by the condition review group members. The inspectors concurred with the licensee's activity assignment and prioriteation, and noted no errors with respect to risk significance during direct observation of the review group meeting The inspectors reviewed corrective action documents associated with 21 identified operator workaround condition reports and maintenance action items. The inspectors determined these items were appropriately identified as operator workarounds by operations staff in the work management center. Review and categorization were performed in accordance with Operating instruction O1-002-000, " Annunciator, Control Room Instrumentation and Workarounds Status Control," Revision 17. An example was

! the inability to maintain proper auxiliary boiler pressure with normal valve operation. The inspectors verified that these workarounds were appropriately documented and prioritized within the corrective action process. During the review of the corrective action document samples, the inspectors did not identify any unaddressed operator workaround .--_- ____ _ _ _ ____________ ______ . _ _ _ _ _ _ _ _ _ _ _

.

i 7-The inspectnrs also noted that the granting of extensions for corrective action due dates was not well controlled. The process allowed a first extension for corrective action completion to be granted by the immediate supervisor. Additional extensions were approved by the next level of management within the cognizant organization. As such, extensions were granted without oversight by an organization external to the assigned responsible department. A number of extensions were approved due to illness, vacation, or training. No corrective action extension reviewed by the inspectors involved an operability determination. However, the potential for overlooking operability concerns, or delaying operability reviews existe The inspectors noted that licensee personnel reviewed industry information according to approved Procedures OEEP-103," Operating Experience Review," Revision 2, and OEEP-102," Independent Technical Review," Revision 0. The inspectors reviewed the corrective action processes as related to the operational events engineering (OEE)

organization, including the implementation of Procedures OEEP-103 and OEEP-10 The inspectors noted that the OEE organization performed activities, which included identifying potentialissues requiring the issuance of a condition report, and providing the independent technical review for industry-related information. However, Condition Report 1998-0987 documented that the organization was reliant on other plant organizations to assure an adequate review was conducted. The issuance of Condition Report 1998-0987, based on a 10 CFR Part 21 report that year, noted that OEE originally concluded after review of plant data bases that the facility did not have any  ;

Hydromotor actuators with a potentially defective internal dump valve as roferenced by the 10 CFR Part 21 report. Failure of the dump valve could result in the actuated valve exceeding the associated inservice test stroke-time requirement. The component engineering group subsequently identified ten actuators in the plant that could be affected by the Part 21 notification. The inspectors determined that, in spite of the limitation of the plant data bases as a reliable source of information to perform an independent screening review, component engineering demonstrated a questioning attitude and high degree of attention to detail to appropriately address the Part 21  ;

notification. The corrective actions of Condition Report 1998-0987 included j identification of the affected actuators, determination of operability, and scheduling for 4 upgrading of the actuator The OEE organization relied on forwarding independent technical reviews to other plant organizations to provide backup assurance that pertinent plant information was not inadvertently overlooked due to limitations of the site equipment data bases. In spite of the limitation of the plant data bases to provide a reliable source of information to perform an independent screet:iag review, the component engineering group demonstrated a questioning attitude and high degree of attention to detail to appropriately address industry related information. The licensee was evaluating the generic implications of this issue at the end of the inspection.

!

.. . . . .. .

.

._ _ _ _ - _ _

- - _ _ _ - _ _ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _

.

.

-8- Effectiveness of Proarar,.

Based on review of the licensee's maintenance rule implementation and maintenance preventable functional failure determinations, the corrective action program generally satisfied the requirements of the maintenance rule program, in that, system, structure, and component status or classification was appropriately determined. However, prolonged delays in the determination of mairitenance preventable functional failures were observed. As of April 12,1999, a backlog of approximately 200 condition reports, including some over 3 years old, were awaiting a functional failure determination. The inspectors noted a concerted effort had been in place to reduce this backlog in the recent weeks prior to this inspection, as evidenced by only 68 condition reports awaiting functional failure determinations as of June 4,1999. On June 9,1999, Condition Report 1999-0673 was initiated to address the examples of delayed reviews related to functional failure evaluation for maintenance rule implementation. This backlog would increase the average time to respond to rnaintenance problem Emeraency Diesel Generator Seauencer As stated in the technical manual for the emergency diesel generator sequencer time delay relays, the manufacturer recommended replacement of the relays as they approach the end of their 10-year qualified life, and that the relays be monitored for substantial change in timing delay. Licensee representatives stated that prior to January 1996, the facility had work orde:s in place to replace all associated safety-related timing relays within the10-year recommendation, but that periodic calibration tasks were not performed. Engineering evaluation, as documented in Problem Evaluation Information Request DE-57, recommended that the work orders be extended or deleted, provided that the periodic calibration checks were performed. Stosequently, the work orders to replace the relays were not performed, but no calibrations were initiate On June 16,1997, Condition Report CR 1997-1503 was written because four relays associated with the emergency diesel generator sequencer failed to meet their performance test acceptance criteria for time to actuate. Three of the relays had not timed out within the timing tolerances and the fourth relay contacts had failed to change state. The three relays that were outside the timing' tolerances were calibrated and the relay that had failed was replaced as part of the corrective actions to address the j problem. The licensee's initial investigation revealed that these relays had not been calibrated in the past, nor were they identified for future calibration or replacement. A task was assigned to the component engineer to evaluate the failures and a due date of January 31,1998, was establishe On April 29,1998, the system engineer initiated Condition Report CR 1998-0591 in accordance with Engineering Procedure UNT 001-002, "The Maintenance Rule,"

Revision 14, to evaluate the emergency diesel generator sequencer for Category (a)(1)

status. On May 7,1998, the reliability improvement team met and considered placing the emergency diesel generator sequencer system in Category (a)(1). The reliability improvement team decided to delay changing the emergency diesel generator

_ _ _ _ - _ _ _

.

. sequencer status until they received additional failure information. At a subsequent meeting, the reliability improvement team placed the emergency diesel generator sequencer in Category (a)(1) status on June 25,1998, approximately 12 months after the emergency diesel generator sequencer had failures in excess of the established reliability performance criteri The inspectors verified that the emergency diesel generator sequencer was in Category (a)(1) status, being monitored against established goals, and an appropriate recovery plan in place during the inspection. The recovery goal was "no relay failures for 3 years following relay replacement." The licensee had also established a program to address similar relays throughout the facility. The inspectors noted the recovery plan included a recently implemented replacement program consistent with the manufacturer's recommended ten year interval. The recovery plan also included a calibration program of the effected relays during refueling outage The emergency diesel generator sequencer was a subsystem of the emergency diesel generators with an established maintenance rule reliability performance measure of no more than one maintenance preventable functional failure over a 2-year period. As stated in 10 CFR 50.65(a)(2), " monitoring as specified in paragraph (a)(1) of this section is not required where it has been demonstrated that the performance or condition of a structure, system, or component is being effectively controlled through the performance of appropriate preventive maintenance, such that the structure, system, or component remains capable of performing its intended function." The inspectors noted that multiple failures, in excess of the established reliability performance measure, were indicative of lack of effective control of relay performance, although no additional failures were observe The licensee's failure to determine identified conditions for the emergency diesel generator sequencer relays constituted maintenance preventable functional failures challenging the relays' function was a violation of 10 CFR 50.65(a)(2). The licensee's failure to establish goals commensurate with safety for the emergency diesel generator sequencer relays was a violation of 10 CFR 50.65(a)(1). This Severity Level IV violation is being treated as a noncited violation (50-382/9907-01), consistent with Appendix C of the NRC enforcement polic Hioh Pressure Safety Iniectio.r!

!

'

The inspectors reviewed nine condition reports documenting high pressure safety injection (HPSI) system issues. The inspectors determined that corrective action identified in the condition reports were appropriately classified and when corrective action was identified the actions addressed the concerns expressed in the condition reports. Generally, the corrective actions were completed within the proposed completion schedule, extensions granted for various reasons, which were associated with work loads or scheduling conflict .

-10-One of the nine condition reports identified instrumentation loop uncertainty as a concern (Condition Report 1998-0734). The identified concem was the use of panel instrumentation that did not meet the ASME,Section XI, accuracy requirement of i 2 percent of full scale. The licensee was utilizing control room panel instrumentation that had an accuracy of 3-4 percent. The licensee, in the disposition of Condition Report 1998-0734, determined that the equipment tested using the instrumentation was not degraded or inoperable. The determination was made by calculating acceptance criteria accommodating the increased inaccuracies of the instrumentation used. The net effect of the calculations narrowed the acceptance criteria. The licensee's long-term corrective action for this issue was to change the inservice test procedures for the ;

'

affected systems to require the use of instrumentation that meets the ASME,Section XI, requirement. This issue was discussed in NRC Inspection Report 50-382/99-06 and dispositioned therein as a noncited violatio The inspectors also reviewed related Condition Report 1997-1452, which involved another issue related to control room panel instrumentation accuracy. A reviewer noted that emergency operating procedure steps verifying minimum HPSI flow of 25 gpm following a recirculation actuation signal (RAS) could be accomplished using the HPSI flow indicating instruments in the control room only if the flow was near 100 gpm, due to instrument precision limitations. The specified instruments (Sl SIF-0311,0321,0331, and 0341) had an accurate indicating range of 100 to 500 gpm. The inspector reviewed the licensee's analysis and determined that appropriate guidance was added to the emergency operating procedures to monitor HPSI pump amperage and discharge pressure for determining low flow conditions after a RA Further NRC and licensee evaluation was necessary to determine the ability of the high pressure safety injection to provide adequate flows to meet design requirements under all accident conditions. This issue was identified and discussed as an unresolved item in NRC Inspection Report 50-382/99-06 (50-382/9906-04).

b.4 Prooram Measurement The licensee's trending processes were delineated in Procedure UNT-006-018,

" Condition Report Trending," Revision 5. The licensee's in-house events analysis group compiled and issued trended data with established criteria to provide a measure of the corrective action program. The compiled results were provided weekly to plant management at a condition review group meeting. The inspectors observed that the reports contained data for the number of initiated condition reports, closed condition reports, open condition reports, including the associated category of significance of the condition reports. Open condition report data also correlated condition report age and overdue corrective action The inspectors noted that the weekly report provided condition report information for diverse plant organizations. Included within the informal weekly report to the condition review group, was a brief summary of maintenance rule-related information. This summary included the total number of condition reports evaluated from the last periodic

.

d-11-evaluation (October 1,1997); the average number of days from the time of discovery to functional failure evaluation; the oldest condition report with no functional failure evaluation; the number of condition reports, which needed functional failure evaluations; and a brief status of systems, structures, and components, which were monitored by 10 CFR 50.65(a)(1).

The inspectors noted that system engineers were responsible for making functional failure determinations for conditions documented within the corrective action process, as described within Procedure UNT-006-029, Maintenance Rule," Revision 1. The initial screening for functional failures were reviewed weekly by the maintenance rule coordinator for ascertaining the number of condition reports, which still needed failure determinations to be performe Monthly reviews by line management were conducted to determine possible emergent trends and provide feedback opportunities to assess the effectiveness of previous actions. All condition reports were evaluated for four trended areas: (1) administrative controls, (2) configuration controls, (3) equipment deficiencies, and (4) work practice The existence of degraded or adverse trends was determined on the basis of the results of data base searches. Subjective criteria considered the severity of occurrence, the number of occurrences, and the time span of repeat occurrences, as applied to the data base search results. Licensee staff then determined why the significant trend change was occurring, and a condition report was initiated. The inspectors considered this process effective in providing an early notification to plant management of significant trend change Additional aspects measured by the licensee were assessment of the number of open corrective actions, and the number of condition reports initiated each month. Data provided at the weekly meetings included the number of overdue or late corrective actions associated with each of the organizational groups. The inspectors noted that no direct indication existed to provide a measure of the number of extensions granted, nor whether it was associated with a significant condition report. The licensee trended data for the open condition reports as to their age. The inspectors noted that the open corrective actions greater than 2-years old without condition review group approval were listed within the licensee reports, including information relating to the responsible organization. Recent licensee data indicated that approximately 40 percent of the open condition reports were greater than 1 year of age. A review of the weekly reports I

covering the last 12 months indicated a steady trend existed for condition reports opened greater than 3 years, with a gradual increasing trend in condition reports, which were open for greater than 2 years, but less than 3 year The inspectors reviewed the licensee's self-assessment activities related to the corrective action program. This included review of Quality Assurance Audit Reports SA-97-004.2 (September 23,1997, through March 31,1998), SA-98-00 (March 30,1998 through June 25,1998), and SA-98-004.2 (September 30,1998, through February 4,1999). The inspectors determined that the objectives and assessment activities were clearly stated. The self-assessment and audit teams had an l appropriate mix of talent and disciplines, but did not include personnel from areas

o-

-

-12-

)

outside Waterford Steam Electric Station. These audits documented two findings, which addressed administrative needs to update a desk top guide for a material inspection form and an outdated quality assurance procedure for stoppage of work. Based on the recommendations made in the audits and the condition reports written from the audit findings, the inspectors concluded that the audit process provided little feedback to enhance plant operation, and that concerns, although self-critical, tended to be administrative in nature, and documented as recommendations within the audit process, b.5 Proaram Understandina The inspectors determined that four safety-related procedures had not been revised to accurately reflect the latest implementation of the corrective action program, in that Procedures W2.501, " Corrective Action," Revision 1, UNT-005-002, " Condition Identification," Revision 13, UNT-007-025, " Plant Equipment Trending Program,"

Revision 5, and 01-002-000, " Operator Workaround," Revision 17, described outdated references to the master equipment list, "O" or safety-related list, and environmental qualified data related to the station information system and the processing of condition identifications, in lieu of current program practices utilizing the work rnanagement system and maintenance action item processe Procedure UNT-005-040, " Control of Work," Revision 0, was developed to implement the work management system at the Waterford Steam Electric Station, and documented the use of parallelimplementation of process procedures to accommodate the data transition of the station information management system to the work management system. Licensee representatives stated that the transition period began November 16, 1998. As stated in the transition plan, following Refueling Outage 9 (after May 1,1999),

that all work must be documented in the work management system, and condition identifications were replacec by maintenance action items. Subsequently, the ability to upgrade the station informaton management system was removed as of June 1,199 Although the inspectors noted that while the transition plan was adequate and accounted for the relocation of data from one system to another,it did not incorporate of or schedule revisions to ensure the corrective action program procedures were maintained. Licensee representatives stated the intention to update the applicable procedures at the termination of the transition period (September 1,1999); however, this intention was not documented within the transition plan or by any other method within the corrective action proces The inspectors interviewed approximately 15 members of the plant staff to determine the depth of understanding of the corrective action program. During interviews with personnel in craft positions, supervisory positions, and management positions, it was evident that the corrective action program was well understood and appreciated by the interviewees.' There was no indication that any of those interviewed would be reluctant to document an issue for resolution within the corrective action program. The inspectors determined that there was a clear understanding of what issues should be documented by a condition report and when a lower tier resolution would suffic l l

l

__

n

.

.

-13-b.6 Recetitive Problems Control Room Ventilation Norma 1 Outside Air intake Damoers The inspectors reviewed 41 condition reports related to the control room ventilation systems and the control room envelope. The control room normal air intake dampers represented 11 of the condition reports. The function of these dampers was to provide a portion of the control room envelope when either a toxic gas or radiological condition was present. The balance involved a diverse sample of conditions identified from plant activities. Condition Report 1999-0616 identified two maintenance preventable functional failures, which involved Emergency Outside Air Valve HVC-204A. Theae were two instances identified in Condition Reports 1999-0104 and 1999-0223, where a blown fuse was caused by a crimped wire in a valve actuator, such that, the valve actuator would not reposition when required. Condition Report 999-0616 recommended that the control room ventilation system be placed in 10 CFR 50.65(a)(1) monitoring statu Consideration of the recommendations was scheduled for the reliability improvement team's next regularly scheduled meetin The control room normalintake dampers had a history of failing surveillance leakage testing and demonstrated poor performance in this regard over the past 3 yeart The history of the dampers prior to July 1996, was largely unknown as the licensee did not identify these dampers as requiring testing for leakage prior to that date. This condition was reported to the NRC initially in Licensee Event Report 96-11, and followed up in NRC Inspection Report 50-382/96-2 Condition Report 1996-1156 identified that the control room normal intake dampers were not performing as expected. The function of these dampers was to isolate the normal air supply to the control room when either a toxic gas or radiological condition was present. These dampers would automatically close on the initiation of a broad range toxic gas alarm or when a high radiation alarm was present in the intake process radiation monitor. The dampers were provided a closure signal from both trains of instrumentation and had spring-to-close, air-operated actuators. The dampers resembled butterfly valves in series, and were located in a 16-inch line penetrating the north wall of the control room on the outside of the control buildin Condition Report 1996-1156 noted that during testing of the control room emergency ventilation system on July 26,1996, the operators observed a discrepancy in the performance of the dampers followina a swapover of emergency filtration units. This swapover during testing re=md in an unexpected increase in overallleakage into the control room. An immediate investigation of the dampers indicated a presence of air l flow noises in the Train B Damper HVC-101, and determined tile leakage through the l damper to be approximately 45 scfm. When both dampers were closed, the leakage j dropped to about 10 scfm, indicating that both dampers were leaking. Subsequent l determinations revealed that HVC-102, the Train A damper, was leaking at about j 22 scfm. Licensee personnel subsequently submitted Licensee Event Report 96-11 to j report the condition as outside the leakage design basis of the control room envelop !

.

!

.

l I

e-14-

The basis was the design ana'ysis assumption that the dampers would be leak tigh The dampers were repaired and returned to service on August 13,199 The overall control room envelope leakage limits of the Updated Final Safety Analysis Report (UFSAR), Section 6.4.2.3, " Leak Tightness," specified that the actual control room leakage should be less than or equal to 200 scfm and that the gross leakage was less than 0.06 volume changes per hour. Updated Final Safety Analysis Report, Section 6.4.2.2, " Control Room Air Conditioning System Design," specified that the total gross volume of the envelope was 220,000 cubic feet. Licensee Calculation LPL-Vil-1,

" Repeat Study of Control Room Habitability Following Accidental Chlorine Release,"

specified that the total not free volume of the control room envelope, after allowing for equipment, was 214,500 cubic feet. Updated Final Safety Analysis Report, Table 6.4-1, indicated that the theoretical minimum leakage for the envelope was 43.799 scfm and that the actual maximum design leakage was 200 scfm. During the testing, the damper leakage was more than assumed in the desion analysis, but the overall control room envelope leakage was within the design valu The licensee calculated the radiological implications of the damper leakage with regard to the standard review plan and the facility safety analysis. This analysis was reviewed and accepted in the NRC Inspection Report 50-382/96-2 As documented in NRC Inspection Report 50-382/96-21, the licensee indicated that the long-term corrective actions to be implemented included: (1) establishing an 18-month frequency for leak rate checking the isolation dampers (Note: initially the licensee performed quarterly testing to establish a trend), (2) developing a procedure with an administrative limit of 8 scfm to leak rate test Dampers HVC-101 and -102, and (3) reviewing by December 31,1996, testing configuration for the control room pressure test to ensure compliance with alllicensing documents. The inspectors determined that the actions described were complete On January 19,1998, Damper HVC-101 failed a scheduled leak test. The leak test involved a visual observation of smoke moving toward the damper seat. If, in the I judgement of the engir;eer performing the test, the observation indicated leakage, then the damper was declared to have failed the test. Work was performed to adjust the T-ring seat, which was a resilient seal for the damper. The damper passed the post- l maintenance test and Condition Report 1998-0074 was generated to address the even Subsequently on February 11,1998, Damper HVC-102 failed a leak test, and an adjustment was made to the T-ring seat. Damper HVC-102 also passed a post-maintenance test and Condition Report 1998-0215 was generated to address the failure. Therefore, since each damper failed its scheduled leak test, the control room envelope was outside its design basis assumption of no damper leakage for some portion of the period of August 13,1996, when the system was returned to service until January 19,1998, when Damper HVC-101 was repaired and then determined to be operable. However, as in 1996, the overall control room envelope leakage was within the design value. The licensee did not report this instance of the control room envelope l outside its design basis, as was previously reported in Licensee Event Report 96-11 for l a prior occurrence. The failure to provide a report to the NRC within 30 days when the l l

.

e-15-control room envelope was in a condition outside its design basis was a Severity Level IV violation of 10 CFR 50.73(a)(2)(ii)(B), which requires reporting such condition This violation is being treated as a noncited violation (50-382/99-07-02), consistent with Appendix C of the NRC enforcement policy. Subsequent to the onsite inspection, licensee personnelinitiated Condition Report 99-0788 to address the corrective actions associated with this violatio On July 20,1998, Damper HVC-102 failed a leakage test, and was documented in Condition Report 1998-0966. During the investigation of the failure, an inspection of the damper found the T-ring had been installed in a reversed position. To address the reversed position of the T-ring, Condition Report 1998-0994 was issue Damper HVC-101 passed the leakage test prior to an inspection which subsequently discovered its T-ring was also reversed, as documented in Condition Report 1998-100 The T~ rings were reinstalled in the correct position and retested satisfactorily. The licensee's determination, at that time, ascribed the failures to the reversed T-ring Following, on October 12,1998, Damper HVC-102 passed the leakage test; however, the leakage was determined to be over the 8 scfm administrative limit set as a result of commitments made in NRC Inspection Report 50-382/96-21. Condition Report 1998-1335 was initiated to document leakage above the administrative limit, and that the T-ring was r' adjusted and retested. The damper passed two subsequent leakage tests on Jan, try 19, and April 21,199 Damper HVC-101 failed a leakage test on February 3,1999, the T-ring was adjusted, and the damper passed the retest. Condition Report 99-0109 was initiated and the licensee planned investigative testing to determine the root cause of the failure During the initial test the licensee instrumented the damper to gather "as found" data because of the observed deterioration of the HVC-102 damper. On April 19,1999, Damper HVC-101 again failed the leakage test. After adjustment of the T-ring, the damper passed retes Licensee engineering personnel were engaged at the time of this inspection in determining the root cause of the failures. Two factors appeared to be contributors; the dampers were equipped with an air operated actuator that utilized a spring to close feature, and the damper shaft has a packing ring arrangement that currently utilizes five rings on each end of the shaft. A combination of friction from the packing or a condition where the spring, which was normally under compression, appeared to lose some of its force over time was believed to be the caus Additional consideration was given to the actuator oeing undersized for this applicatio The inspector examined instrumentation traces of closure forces from a strain gauge that indicated that the closure force diminishes significantly toward the end of the actuator stroke. The nature of a resilient seat was such that it providad a slight increase in closure force required as the disc seats. The same actuator was used on the smaller 12-inch emergency air intakes. However, since the information was not complete at the

~

.

d-16-time of the inspection, the licensee had not characterized or formulated the root caus Further, the long-term corrective actions that may be needed to address the leakage problem were not identified at the time. Overall, the complexity of determining the actual root cause of the damper leakage was challenging the licensee's engineering staff. Selecting a replacement design was also complicated by the location of the dampers in a confined location. At the time of this inspection, the licensee had not identified a corrective action to address directly the performance of the dampers. A continued effort to resolve the exact cause of the damper leakage problem was still underwa The reliance of the facility on these dampers to maintain the control room envelope was critical to the operation of the facility in the event of a need to isolate the control room environment from toxic gases or radiological events. The inspector emphasized that the approach taken in resolving this issue relied on further tests, conducted at quarterly intervals. This would likely mean a continuation of failures, until a root cause was fully identified and addressed with an effective corrective action plan. While the intent of the licensee was to identify a corrective action plan, the inspector regarded the methodology chosen incorporated prolonged delays since the first failure was identified in July 1996. The apparent lack of expeditious action was tempered by the need to determine a root cause. The inspectors acknowledged the complexity of the issue, that plant management included the control room ventilation dampers on the list of top 10 plant equipment problems, and that a formal plan was prepared to address the ongoing issue. The plan, however, was focused at the time of this inspection at identifying a root cause at the component level for the dampers. When that process was finished, the dampers would be modified, repaired, or replaced on the basis of the root cause determination. in summary, proper operation of these safety-related dampers had been an ongoing problem since at least 1996. During the subsequent 3 years, the licensee has been unable to prevent repetition of this significant condition adverse to quality. This was a Severity Level IV violation of 10 CFR Part 50, Appendix B, Criterion XVI. This violation is being treated as a noncited violation (50-382/9907-03), consistent with Appendix C of the NRC enforcement policy. This issue was captured in licensee Condition Report 99-010 Identification of Similar Occurrences in Licensee Event Reports During review of a sample of licensee event reports, the inspectors noted that within a 6-month period at least four licensee event reports dealt with missed technical specification surveillances. Further review of the licensee event reports showed that in the paragraph discussing "Similar Events," each of the reports stated that there were

"no similar events." The inspectors concluded that the licensee event reports had been narrowly scoped in relation to the broader issue of missed surveillance A licensee representative explained that the missed surveillances were dissimilar events based on their interpretation of NUREG 1022, Revision 1, as the source of reporting criteria for 10 CFR 50.73. Their view was that these related occurrences were frequent events and they could use a narrower definition, which would not identify the missed surveillances as generic or recurring problems. Individual condition reports were

l

. \

!

e-17-initiated M addressed the cause and effect of each isolated missed surveillance. As part of the corrective action program, plant personnel reviewed the reports for the specific condition, but did not consider the more generic impact on the missed surveillance events. The inspectors considered the treatment of missed surveillances as " frequent" events as the supporting basis to document no previous occurrences to be narrowly focused without revicwing for common root-cause conditions. Several opportunities were missed regarding the potential generic impact, in that, assessment of recent missed surveillances had not been integrated to consider common causal factors for each event in relation to other similar events. The inspectors determined that a more detailed generic impact review would preclude corrective actions being limited in scope in this case, although no specific generic factors were identified in a limited review by the inspectors. The inspectors found that the licensee event reports were coded in the corrective action program with unique identifiers and they could be retrieved for trending as missed surveillances, although this was not captured within the trending proces b.7 Notice Of Violation /Noncited Violation Followup The licensee had a total of 26 noncited violations from previous NRC inspections that covered the period of January 1998 through March 1999. The inspectors reviewed 6 of these noncited violations, that were not previously reviewed by the NRC, to determine if the violations were entered into the corrective action program and if they were resolved or being resolved in a timely manner commensurate with their significanc Noncited Violations 50-382/9801-01 (addressed by Condition Report 97-0629),

50-382/9812-01 (addressed by Condition Report 98-0802),50-382/9819-01 (addressed by Condition Report 98-1548),50-382/9819-02 (addressed by Condition Report 96-1250), and 50-382/9819-03 (addressed by Condition Report 97-0573) were found to be entered into the corrective action program and that the identified corrective actions adequately addressed the violation Noncited Violation 50-382/9808-02 addressed missed technical specification surveillances for verifying control element assembly position. The inspectors noted that Condition Report 98-0566 was initiated on April 22,1998, which appropriately entered the missed surveillance into the corrective action process. The condition report identified 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> and 40 minutes had elapsed between valid control element assembly positions as indicated by the plant monitoring computer. The inspectors noted that appropriate corrective actions were taken to immediately restore compliance with the affected technical specifications. The inspectors verified that technical specifications, which addressed transient insertion limits, group alignment, position indicator channels, and shutdown groups fully withdrawn required a surveillance interval of once per 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. Technical Specification 4.0.2 required that surveillances shall be performed within the specified surveillance interval with a maximum allowable extension not to exceed 25 percent of the specified surveillance interval (3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />).

Since 10 CFR 73(a)(2)(i)(B) specified any operation or condition prohibited by plant technical specifications as reportable, the inspectors reviewed the basis for not reporting the specified missed surveillance through the licensee event report process. Licensee

L

,

o-18-representatives documented within Condition Report 98-0566 that a review of the reporting guidance document, NUREG-1022," Event Reporting Guidelines," Revision 1, issued January 1998, permitted not only the surveillance interval and the 25 percent maximum extension, but also the inclusion of the allotted time for the limiting condition )

for operation action statement for determining the reportable condition prohibited by the j associated technical specification. The inspectors confirmed the basis to be consistent !

with the latest guidance endorsed by the NRC program office. The inspectors verified that the most limiting action statement applicable to the control element assembly position indication was 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />, given a total reportable interval of 17 hours1.967593e-4 days <br />0.00472 hours <br />2.810847e-5 weeks <br />6.4685e-6 months <br />. The inspectors concluded that the missed surveillance was not required to be reporte Based upon the review of noncited and cited violations, the inspectors found that, in general, condition reports were initiated to document the conditions associated with each respective violation, and adequately addressed by the corrective actions Conclusions The licensee's corrective action processes were designed and implemented with an appropriate threshold for identifying, classifying, and prioritizing adverse conditions, and a willingness on the part of licensee personnel to initiate condition reports for any nonconforming or questionable issue or even The licensee's failure to determine identified conditions for the emergency diesel generator sequencer relays as maintenance preventable functional failures in a timely manner was a Severity Level IV violation of 10 CFR 50.65(a)(2). The failure to establish goals commensurate with safety for the emergency diesel generator sequencer relays was a Severity Level IV violation of 10 CFR 50.65(a)(1). This violation is being treated

.as a noncited violation (50-38PJ9907-01), consistent with Appendix C of the NRC enforcement polic Based on the recommendations made in the three licensee audits reviewed by the inspectors, and the condition reports written from the audit findings, the audit process !

provided little feedback to enhance plant operation, and that concerns, although self-critical, 'anded to be administrative in natur The failure tc ; ovide a report to the NRC within 30 days when the control room envelope was in T condition outside its design basis was a Severity Level IV violation of 10 CFR 50.73(a)(2)(ii)(B). This violation is being treated as a noncited violation (50-382/99-07-02), consistent with Appendix C of the NRC enforcement policy. The licensee had submitted a Licensee Event Report (50-382/99-08).

f The ongoing failure to correct control room damper failures over a 3-year period was a Severity Level IV violation of 10 CFR Part 50, Appendix B, Criterion XVI. This violation is being treated as a noncited violation (50-382/9907-03), consistent with Appendix C of the NRC enforcement policy.

_

,

o-19-The licensee's treatment of missed surveillances was narrowly focused without reviewing for common root cause conditions. Several opportunities were missed to identify the potential generic impact. Specifically, assessment of recent missed surveillances had not been integrated to consider common causal factors for each event in relation to other similar event V, Manaaement Meetinas X1 Exit Meeting Summary The inspectors discussed the progress of the inspection on a daily basis and presented the inspection results to . members of licensee management at the conclusion of the onsite inspection on June 11,1999. Inoffice inspection of supplementalinformation was performed through July 23,1999. Following the inoffice inspection, an exit was conducted telephonically on September XX,1999, with your staff. The licensee's representatives acknowledged the findings presente The inspectors asked the licensee staff and management whether any materials examined during the inspection should be considered proprietary. No proprietary information was identifie l

<

.

O ATTACHMENT 1 SUPPLEMENTAL INFORMATION PARTIAL LIST OF PERSONS CONTACTED Licensee C. Alday, Supervisor, Reactor Engineering E. Beckendorf, Superintendent, Plant Security A. Bergeron, Superintendent, Chemistry R. Blanche, Supervisor, Control Room M. Brandon, Supervisor, Licensing R. Burski, Director, Site Support R. Conner, Technical Assistant L. Dauzat, Supervisor, Radiation Protection R. Douet, Manager, Maintenance C. Dugger, Vice President, Operations K. Embry, Supervisor, Chemistry E. Ewing, Director, Nuclear Safety and Regulatory Affairs G. Fey, Supervisor, in House Events Assessment R. Fletcher, Supervisor, Operations Training C. Fugate, Superintendent, Operations P. Gropp, Manager, Design Engineering Electrical / l&C L. Hall, Operations A. Harris, Manager, Plant Engineering J. Hoffpauir, Manager, Operations J. Howard, Manager, Procurement / Programs Engineering R. Killian, Supervisor, Quality Engineering K. Kunkel, Engineer, Programs and Components T. Leonard, General Manager, Plant Operations T. Lett, Superintendent, Radiation Protection A. Lewis, Licensing Engineer D. Marpe, Manager, Programs and Components B. Morrison, Supervisor, Quality Assurance J. O'Hern, Director, Training and Emergency Planning E. Perkins, Manager, Licensing G. Pierce, Director, Oversight / Quality R. Pollock, Technical Coordinator, in House Events Assessment A. Prendergast, Site Communications Specialist D. Rieder, Quality Assurance Engineer L. Rushing, Manager, System Engineer G. Scott, Licensing Engineer T. Smith, Technical Coordinator B. Thigpen, Manager, Planning and Scheduling D. Whiddon, Supervisor, Planning and Scheduling A. Wrape Ill, Director, Engineering l

l

I-

-

)

>

-2-NRC T. Farnholtz, Senior Resident inspector i J. Pellet, Chief, Operations Branch INSPECTION PROCEDURES USED IP 40500 Effectiveness of Licensee Controls in identifying, Resolving, and Preventing Problems ITEMS OPENED AND CLOSED OPENED AND CLOSED 50-382/9907-01 NCV Failure to monitor emergency diesel generator sequencer in accordance with the Maintenance Rule (Section O7.1.b.3)

50-382/9907-02 NCV Failure to provide a report to the NRC for conditions outside the design basis of the plant (Section 07.1.b.6)

50-382/9907-03 NCV Failure to correct control room damper failures (Section 07.1.b.6)

PROCEDURES

.

Procedure Title Revision W2.501 - Corrective Action 8 j UNT-005-002 Condition identification 13 UNT-007-025 Plant Equipment Trending Program 5 OP-100-012 Post Trip Review 5 UNT-006-010 Event Notification and Reporting 16 W1.106 Excellence in Human Performance 1 UNT-006-026 Significant Event Response Team 2 DEPT-l-004 Engineering Request Process Guide 4 UNT-005-015 Work Authorization Preparation and implementation 7 UNT-006-029 ' The Maintenance Rule 1 OAP-024 QA Surveillance and Assessments 4

~_

N ',

.'

'

y 3-OAP-302 Audit Program 18 UNT 006-018 Condition Report Trending 5 01-002-000 Annunciator, Control Room Instrumentation and Workarounds 17 Status Control OEEP-102 Independent Technical review 0 OEEP-103 Operating Experience Review 2 Licensee Event Reports98-005 98-012 98-013- 98-020 Quality Assurance Audit Reports SA-97-00 SA-98-00 SA-98-00 Condition Reoorts I

CR 1995-0052 CR 1995-0093 CR 1995-0485 - CR 1995-0536 CR 1995-1142 l CR 1996-1048 CR 1996-1156 CR 1996-1197 CR 1996-1958 CR 1997-0290 L CR 1997-0806 CR 1997-1452 CR 1997-1566 CR 1997-2695 CR 1998-0310 l

CR 1998-0317 CR 1998-0397 CR 1998-0434 CR 1998-0444 CR 1998-0476 CR 1998 0478 CR 1998-0491 CR 1998-0514 CR 1998-0518 CR 1998-0523 l~ CR 1998-0537 CR 1998-0540 CR 1998-0553 CR 1998-0558 CR 1998-0560 CR 1998-0566 CR 1998-0576 CR 1998-0591 CR 1998-0598 CR 1998-0610 l

'

CR 1998-0627 ..CR 1998-0628 CR 1998-0631 CR 1998-0639 CR 1998-0695 CR 1998-0708 CR 1998-0734 CR 1998-0735 CR 1998-0748 CR 1998-0755

- CR 1998-0790 CR 1998-0819 CR 1998-0822 CR 1998-0858 CR 1998-0872

' CR 1998-0877 CR 1998-0900 CR 1998-0914 CR 1998-0947 CR 1998-0948 CR 1998-0960 CR 1998-0966 CR 1998-0969 CR 1998-0984 CR 1998-0985 CR 1998-0987 CR 1998-0988 CR 1998-0994 CR 1998-1000 CR 1998-1013 CR 1998-1019 CR 19981026 CR 1998-1066 CR 1998-1076 CR 1998-1089 l

_ . _ __ - _-__ _____-____ _ __ _ _ _ _ - _ - _ _ - _ _ _ _ _ _ _ .__ _ - _ . _ _ . _ _ _

.

..

a

o-4-CR 1998-1102 CR 1998-1109 CR 1998-1112 CR 1998-1117 CR 1998-1119 CR 1998-1121 CR 1998-1144 CR 1998-1154 CR 1998-1159 CR 1998-1195  ;

CR 1998-1196 CR 1908-1197 CR 1998-1214 CR 1998-1246 CR 1998-1313 I CR 1998-1335 CR 1998-1383 CR 1998-1402 CR 1998-1439 CR 1998-1445 CR 1998-1447 CR 1998-1449 CR 1998-1480 CR 1998-1485 CR 1999-0029 CR 1999-0063 CR 1999-0098 CR 1999-0102 CR 1999-0104 CR 1999-0109 CR 1999-0126 CR 1999-0134 CR 1999-0203 CR 1999-0223 CR 1999-0285 CR 1999-0289 CR 1999-0379 CR 1999-0426 CR 1999-0455 CR 1999-0471 CR 1999-0472 CR 1999-0502 CR 1999-0511 CR 1999-0523 CR 1999-0528 CR 1999-0550 CR 1999-0673

_ _ _ _ - _ _ _ _ _ _ _ _

U e

o ATTACHMENT 2 INITIAL MATERIAL REQUESTED Initial material reauested for the 40500 inspection at Waterford 3: Index of all corrective action documents (e.g., CR's, CI's, PIRs, etc.) for the last 12 month . All corrective action documents in response or related to plant transients, the equipment malfunctions that initiated them or that were previously written on the same equipment, for the last 12 month . All corrective action documents related to external operating experience, especially vendor information not included in plant procedures and documents, for the last 12 month . All major corrective action documents (i.e., those that subsume or roll-up one or more smaller issues), for the last 12 month . All corrective action documents associated with: High Pressure Safety injection system, Emergency Feedwater system, Emergency Diesel Generator system, Maintenance rule implementation, preventable functional failures, and baseline inspection results, and Operator workarounds.

, Control Room Ventilation System All correctivo action documents associated with non-escalated no response required or non-cited violations, for the last 12 month . All corrective action program assessments for the last 12 month . All corrective action program tracking and effectiveness internal reports or metrics, for the last 12 month . Description of any informal systems, especially used by operations, for issues below the threshold of the formal corrective action system (e.g., CR's) and the content of those system . All procedures governing or applying to the corrective action progra L j