IR 05000387/1992002

Insp Repts 50-387/92-02 & 50-388/92-02 on 920102-0210. Violations Noted.Major Areas Inspected:Operations, Radiological Controls,Maint,Emergency Preparedness,Security & Engineering/Technical Support

ML17157B067
Person / Time
Site:	Susquehanna
Issue date:	02/27/1992
From:	Jason White NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML17157B065	List: IR 05000387/1992002 ML17157B064 ML17157B066
References
50-387-92-02, 50-387-92-2, 50-388-92-02, 50-388-92-2, NUDOCS 9203050014
Download: ML17157B067 (23)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION

REGION I

Inspection Report Nos.

50-387/92-02; 50-388/92-02 License Nos.

NPF-14; NPF-22 Licensee:

Pennsylvania Power and Light Corripany 2 North Ninth Street Allentown, Pennsylvania 18101 Facility Name:

Inspection At:

Susquehanna Steam Electric Station Salem Township, Pennsylvania Inspection Conducted:

Inspector:

January 2, 1992 - February 10, 1992 G. S. Barber, Senior Resident Inspector, SSES Approved By:

J.

>te, Chief ctor Projects Section No. 2A, Date In i n mm radlolo 1ccal Ar In: Safety inspections were conducted in the following area'i s:

opera ons, gi""'ontrols, maintenance, emergency preparedness, security, and engineering/technical support.

~tse uit: Two apparent violations and two unresolved items were id ttfed d 'h i en i

using e

peri

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e enclosed Executive Summary provides an overview of the sp-'f e sp"=i ic mspecbon 9203050014 92022S PDR ADOCK 050003S7 G

PDR

EXECUTIVESUMMARY Susquehanna Inspection Reports 50-387/92-02; 50-388/92-02 January 1, 1992

- February 10, 1992

~Oem ion (30702, 71707)

On January 18, hydrogen in an open ended section of offgas piping ignited and detonated when a worker began a planned grinding activity. Following the event, the licensee promptly initiated a comprehensive and thorough review to identify causal factors and corrective measures.

Significant management attention was directed to the occurrence.

Though several causal factors were identified, the most significant involved (1) the improper closeout of a 1989 Work Authorization that was originally issued to effect repair of the globe valve (HV-16907) that was presumed to effect isolation of the work area from the offgas stream (apparent violation of Technical Specification 6.8); the failure to sufficientl in'estigate the cause for earlier anomalous offgas instrument indications that were apparently iien y caused by a hydrogen detonation in the recombiner system on January 16 (apparent violation of Technical Specification 6.8); and insufficient attention to generic communications and notifications of previous industry events involving combustible gas hazards associated with offgas processing systems (unresolved item). Section 2.2.1 pertains.

Radiolo ical Controls (71707)

The licensee's implementation of radiological controls was generally effective for this period, with one exception.

Three individuals were subject to clothing and skin contamination while adjusting ventilation.louvers in the Unit 1 Reactor Building overhead.

Though certain portions of the overhead in this building are considered as radiologically controlled areas, insufficient communication of such information, poor coordination of work activities, and ineffective radiological controls were apparent in this particular instance.. However, the occurrence appears to be an isolated example and not indicative of the usual quality of radiological control application.

Though corrective measures have been initiated to prevent recurrence and strengthen specific weaknesses, this item is considered unresolved pending further review of this area.

Section 3.2.1 pertain Maintenance (62703)

The licensee exercised good control over maintenance activities, excepting certain repair and maintenance activities associated with the common offgas recombiner (as previously noted).

No,scrams or ESF actuations were attributable to either maintenance or surveillance activities.

Emer en Pre aredne (71707)

The licensee declared an Unusual Event on January 18 due to an on-site explosion involving the common offgas recombiner and the consequent transport of a contaminated, injured individual to an off-site medical facility.'he event was properly classified and effectively managed.

The Emergency Plan was effectively implemented.

Licensee emergency response actions were good.

All event notifications occurred as required,

~ecurit (71707)

The inspector reviewed PP&L Fitness for Duty Program (FFD) relative to the licensee's determination of the effects of excessive alcohol consumption prior to the five hour abstinence period before normal work periods, and disposition of cases of resultant elevated blood alcohol concentration (BAC)., The inspector verified the 'effectiveness of the licensee's program and process relative to the dispositioning of cases involving excessive alcohol consumption.

The review indicated that the licensee is proactive in identifying potential problem areas and initiates measures to promptly address them.

PP&L FFD controls to address this concern were found to be thorough.

Section 6.2.1 pertains.

En ineerin /Technical Su ort (71707, 92720, 93702)

The inspector reviewed a condition that the licensee reported relative to a notification from their fuel vendor (Siemens Nuclear Power Corporation (SNP).

Fuel rods containin'g nonconforming Zircaloy-4 end caps were inadvertently manufactured and delivered to PP&L in preparation for the March 1992 Unit 1 refueling outage.

SNP determined that thirteen fuel bundles were affected.

PP&L committed to replace all affected fuel rods in these bundles prior to the refueling outage.

The inspector found that the licensee promptly documented the nonconforming condition and attempted to determine the extent of the problem through frequent contact with SNP.

However, the licensee did not require a written response from the vendor that provided the initial scope of the problem, its generic implications, and any preliminary findings and conclusions.

The inspector considered this a significant licensee oversight.

Minor administrative discrepancies were noted with the associated Nonconformance Report (NCR).

Section 7.2.1 pertain TABLEOF CONTF<WTS EXECUTIVE SUMMARY......;...............................

ii SUMMARYOF OPERATIONS......

1.1 Inspection Activities.:.......

1.2 Susquehanna Unit 1 Summary...

1.3 Susquehanna Unit 2 Summary...

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2.

OPERATIONS 2.1 Inspection Activities........... ~......

2.2 Inspection Findings and Review of Events 2.2.1 Unusual Event due to Localized Hydrogen Contaminated Injured Man

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3.

RADIOLOGICALCONTROLS 3.1 Inspection Activities......................

3.2 Inspection Findings 3.2.1 Personnel Contamination during Reactor Building Adjustment

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4 MAINTENANCE/SURVEILLANCE 4.1 Maintenance Inspection Activity 4.2 Maintenance Observations........

4.3 Inspection Findings

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EMERGENCY PREPAREDNESS 5.1 Inspection Activity..................

5.2 Inspection Findings

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ECURITY

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S 6.1 Inspection Activity........................

6.2 Inspection Findings 6.2.1 Fitness for Duty - Excessive Alcohol Consumption Five Hour Abstinence Period

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Table of Contents (Continued)

7.

ENGINEERING/TECHNICALSUPPORT 7.1 Inspection Activity.-...... "................

7.2 Inspection Findings 7.2.1 Nonconforming New Fuel Rod Lower End Caps

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MANAGEMENTAND EXIT MEETINGS.......................

8.1 Resident Exit and Periodic Meetings.......................

8.2 Inspections Conducted By Region Based Inspectors.;............

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~Detail 1.

SUMMARYOF OPERATIONS 1.1

'Inspection Activities The purpose of this inspection was to assess licensee activities at Susquehanna Steam Electric Station (SSES) as they related to reactor safety and worker radiation protection.

Within each inspection area, the inspectors documented the specific purpose of the area under review, the scope of inspection activities and findings; along with appropriate conclusions.

This assessment is based on actual observation of licensee activities, interviews with licensee personnel, independent calculation, and selective review of applicable documents.

Abbreviations are used throughout the text.

Attachment 1 provides a listing of these abbreviations.

1.2 Susquehanna Unit 1 Summary Unit 1 operated at or near full power throughout the inspection period until it began its planned end-of-life coastdown of January 27.

Scheduled power reductions were conducted during the period for control rod pattern adjustments, surveillance testing, and maintenance.

Unit 1-ended the inspection period at 94.5% power.

No scrams or ESF actuations occurred in Unit 1 during the inspection period.

A small hydrogen detonation occurred on January 18.

Section 2.2.1 pertains.

1e3 Susquehanna Unit 2 Summary Unit 2 operated at or near full power throughout the inspection period.

Scheduled power reductions were conducted during the period for control rod pattern adjustments, surveillance testing, and maintenance.

No scrams or ESF actuations occurred in Unit 2'during the inspection period.

2.

OPERATIONS 2.1 Inspection Activities The inspectors verified that the facility was operated safely and in conformance with regulatory requirements.

Pennsylvania Power and Light (PP8cL) Company management control was evaluated by direct observation of activities, tours of the facility, interviews and discussions with personnel, independent verification of safety system status and Limiting Conditions for Operation, and review of facility records.

These inspection activities were conducted in accordance with NRC inspection procedure 7170 The inspectors performed ten hours of deep backshift inspections.

These deep backshift inspections covered licensee activities between 10:00 p.m. and 6:00 a.m. on weekdays, weekends, and holidays.

2.2 Inspection Findings and Review of Events 2.2.1 Unusual Event due to Localized Hydrogen Ignition and Contaminated Injured Man Introduction At 8:47 a.m., January 18, a worker was injured when hydrogen gas in a pipe ignited during.

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grinding activity on the plant's common recombiner system.

The worker received first and second degree burns to his chest, throat, and face and was transported offsite to the Berwick hospital.

While surveying the individual's'chest prior to transport, very low levels of contamination (3000 dpm/100 square centimeters) were detected.

As a result, an Unusual Event was declared at 9:00 a.m., January 18.

An Emergency Notification System (ENS) call was made at 9:51 a.m. and the resident inspector was contacted..The Unusual Event was terminated at 10:40 a.m. after the individual was successfully decontaminated at the hospital.

The licensee issued a Press Release at 1:00 p.m., January 18.

The Associated Press (AP)

was informed and national news media attention was received.

An NRC Commissioners Assistants'riefing was conducted at 1:00 p.m., January 18.

Event Description The event occurred when the mechanic began grinding on the offgas recombiner system.

The offgas recombiner system is a non-safety related system that functions to recombine hydrogen and oxygen generated as a normal byproduct of the fission process.

The recombiners are designed to limit the buildup of combustible hydrogen gas in the main condenser offgas system.

There'are three offgas hydrogen recombiners; i.e., one for each Unit and a common recombiner to function as an installed backup.

Before the event occurred, the common recombiner vessel had been removed from the 10 inch inlet pipe to permit replacement.

The grinding was being performed as a weld preparation activity for installing a new common offgas recombiner vessel.

The licensee isolated (blocked) the Unit 1 and 2 offgas supplies to the common recombiner by closing the air operated globe valves between the respective Unit offgas systems and the 10 inch open ended pipe.

Upstream manual ball valves, which were also closed to support previous recombiner vessel replacements, were not closed in this instance.

Several days before this event, the licensee purged the 10 inch piping by using an installed purge connection downstream of the closed air operated globe valves.

The purging was effective at sweeping hydrogen out of the open ended pipe.

However, a leak through the

Unit 1 air operated globe valve (HV-16907) allowed the hydrogen to continue to accumulate in the pipe.

The accumulation of hydrogen was sufficient to detonate as a result of a spark generated by a worker grinding on the pipe.

Response Activities Control room operators first became aware of the hydrogen detonation when they received Steam Jet Air Ejector (SJAE) Secondary Ejector High Discharge pressure alarms.

An operator was dispatched to the area and found an individual in the vicinity in an apparent dazed condition.

The licensee determined that when the hydrogen ignited, the blast force caused the individual's cloth protective clothing to become charred from his head down to his knees.

The individual's burns were apparently due to the initial blast effect.

There was no fire involved.

The worker was knocked down from the blast, but quickly returned to his feet.

Plant emergency response staff responded to the site, treated the individual's burns and surveyed him for radioactive contamination prior to transport to Berwick Hospital.

Low level contamination was detected on his chest.

Consequently, he was treated as a contaminated injured person and was transported to the hospital at 10:00 a.m., January 18.

The review of the radiological controls and decontamination efforts applied in this instance was previously reviewed in NRC Inspection Report 50-387/92-03.

The contaminated injured worker was treated at the Berwick Hospital and returned to work on January 20.'mmediately after the event, plant staff took prompt actions to control the area.

Barricades were erected, all work activities were suspended, and area entry was controlled by shift supervision.

Hydrogen monitoring was established for the pipe opening and the entire room.

A slow build-up of hydrogen was detected in the piping.

Consequently, the upstream ball valves in both Unit 1. and 2 offgas systems were closed.

The pipe was subsequently purged with air.

These actions were successful in preventing further accumulation of hydrogen in the area.

To promptly investigate the event, the licensee formed a 16 person Event Review Team that corivened at 1:00 p.m., January, 18. Their role was to review the event, identify root causes and causal factors, and to propose corrective action.

The results of their preliminary investigation were reviewed on January 19 by the Plant Operations Review Committee (PORC).

The inspector reviewed the licensee's initial actions and noted that the licensee's preliminary list of root causes and causal factors appeared to be complete and comprehensive as it related to the work activity and the surrounding industrial safety issues.

Proposed corrective actions appeared to adequately address the noted causes.

To ensure that all important facets of the event were adequately identified, reviewed, and corrected prior to resuming work, the NRC staff requested formal notification from the licensee prior to resuming work. The licensee

also agreed not to resume work activities until their investigation was complete, and their findings and conclusions were discussed and accepted by the NRC.

The licensee discussed their preliminary review activities with the inspector.

The inspector noted that their corrective actions relative to work control appeared complete.

However, the inspector noted that the ERT's review did not consider previous similar events.

This omission was discussed with the licensee.

As a result, the ERT expanded their review to include similar internal and external events, As a result, additional root causes and corrective actions were identified.

The final listing of root causes and corrective actions is contained in Attachment 2.

The licensee completed their initial review of the event on January 23 in preparation for a conference'all with NRC Region I. This call was held to review PP&L's findings and.

conclusions.

During the call, the licensee discussed the sequence of events, root causes and corrective actions identified by the ERT.

The licensee's investigative effort was considered as sufficiently comprehensive and thorough by the NRC.

Findings and Conclusions

'he inspector reviewed the root causes and corrective actions identified by the ERT and interviewed the injured worker and his assistant.

The inspector also examined the common recombiner room where the work was performed and noted the actions taken by the licensee in response to the event.

The inspector used these and other inspection activities as a basis for assessing the licensee's activities relative to this event.

During this assessment, the inspector noted the following:

The licensee's immediate response to care for the individual was rapid, conscientious, and showed due regard for the individual's safety.

Licensee's controls to minimize the spread of contamination and to ensure proper care at the hospital are reviewed in inspection report 50-387/92-03.

The licensee's formation of the Event Review Team (ERT) was prompt and effective.

Sixteen qualified individuals, having sufficient event investigation experience and expertise, were assembled onsite within four hours of the initial event.

The ERT used established event investigation methods (such as event flow charting) to determine the sequence of events, identify causal factors, and assess safety significance.

Eight causes were initially generated, primarily from the flow chart.

After discussions with inspector and additional follow-up activities, the ERT identified four other contributing causes, Two of these causes were related to previous industry

events.

The initial omission of previous industry events and communications was considered a defect in an otherwise well performed event review effort.

The Plant Operations Review Committee (PORC) reviewed the ERT's findings on two separate occasions within five days of the event.

Feedback and direction from PORC improved the ERT's focus. This'as a positive initiative.

During a conference call with the NRC on January 23, the licensee discussed their plans to segregate corrective actions into a short-term and long-term plan.

The short-term plan was to include all necessary actions prior to the resumption of work on the common offgas recombiner.

It's focus was on ensuring worker and equipment safety prior to resuming work. The long-term plan was to include broad scope enhancements to improve existing programs.

During the call, the NRC discussed the need to review the licensee's plans prior to resuming work. The licensee acknowledged this agreement and established it as a integral part of their short-term schedule.

The inspector reviewed the licensee's short-term plan prior to implementation and determined that it adequately addressed worker and equipment safety issues.

The short-term actions were completed on January 31, and reviewed with the inspector.

The inspector noted that all the planned activities were completed satisfactorily.

Subsequently, work on the common recombiner was resumed on February 3.

From an assessment of the licensee's ERT effort, the inspector identified defective performance in three areas.

The performance deficiencies involve:

1) a lack of comprehensive identification and corrective action for events identified in the licensee's early Industry Experience Review program (IER), and the consideration of'those events by the Event Review Team, 2) incomplete investigation of a previous anomalous condition affecting the common recombiner offgas system on January 16, and 3) improper closeout of an earlier work authorization (WA) in 1989 to repair a known seat leak in the globe valve that was used. for isolation of the work area from, i.e., HV-16907.

The following pertains:

The inspector noted that the licensee's early industry experience review program did not provide comprehensive corrective actions for past similar events.

The licensee's ERT identified six documents (See Attachment 2, Corrective Action 12) that pertained to past similar events.

More extensive corrective action might have provided improved barriers in preventing the hydrogen ignition of January 18.

Many of these events were reviewed by the licensee's early IER program.

However, the corrective actions generated for these events was either not implemented or insufficien According to the licensee, this performance defect resulted from poor coordination between the IER reviewers and the task groups assigned to establish corrective actions.

Licensee quality assurance audits for the period indicated that the quality of the review was sufficient, but that the establishment of corrective measures was questionable.

From discussions with the licensee, the inspector found the current IER program has eliminated many of these earlier coordination concerns by allowing the affected work groups a much larger role in determining the scope of corrective action needed.

The inspector reviewed the preliminary and initial findings of the ERT; and independently evaluated the comprehensiveness of the ERT review.

The inspector found that the licensee's ERT missed older generic communications that were applicable to the event.

For example, the licensee's ERT did not list Information Notice (IN) 81-27,=Flammable Gas Mixtures in the Waste Gas Decay Tanks in PWR Plants; Generic Letter (GL) 79-38, BWR Offgas Systems Pertaining to Explosions; or Inspection and Enforcement Bulletin (IEB) 78-03, Potential Explosive Gas Mixture Accumulations Associated with BWR Offgas System Operations, as being applicable.

The omission of IEB 78-03 was particularly noted, since this notification required establishing preventive measures in maintenance procedures to ensure that inadvertent actions (such as arc strikes) did not cause the ignition of explosive gases.

In view of this, it appears that the January 18 event could have been avoided ifcorrective measures for this action were effectively implemented.

This item willremain unresolved pending further review of this area.

(UNR 50-387/92-02-01 (Common))

The inspector noted that a precursor event may have occurred on January 16, and that the licensee's investigation of anomalous indications of potential problems with the common offgas system appeared cursory and insufficient, In this instance, control room operators received alarms related to high pressure in the offgas system.

Subsequently, the operators questioned the mechanics that were working on the common recombiner.

The mechanics stated that a suspended pipe shifted and struck the floor. Without further evaluation, the operators concluded that the shifting pipe incident was related to the offgas alarms.

No further review was performed.

A more thorough review may have revealed to the operators that shifting pipe event was not a causal factor for the high pressure alarms in offgas system.

The licensee-believes that, more probably, an actual hydrogen detonation occurred on that date and caused the alarms.

Since the licensee was unaware of the detonation, the recombiner replacement work continued without recognizing that combustible gases were accumulating in the area.

While the offgas system is not considered safety-related, the inspector noted that the insufficient investigation effort had the potential to affect the maintenance of safe operating conditions.

Consequently, this matter is considered as an apparent violation

of NDAP-QA-300, Conduct of Operations.

NDAP-QA-300 requires that safe operations be maintained, and that anomalous instrument indications be sufficiently investigated.

(NV4 50-387/92-02-02 (Common))

3.

On June 12, 1989, a WA (WA T73111) was released to correct problems'with the actuator and seat leakage through the Unit 1 air operated globe valve (HV-16907), the valve that directed Unit 1 offgas flow to the common recombiner.

The WA required a repair of both the actuator and the valve.

However, only the actuator was repaired but the WA was signed-off as completed and subsequently closed out.

No further WAs were written to identify the need to repair the existing seat leakage.

In the current instance, prior to the event, this valve was used as the only blocking device between the Unit 1 offgas system (which was operating) and the common recombiner.

The existing seat leakage allowed hydrogen to accumulate to combustible concentrations.

The improper closeout of the WA-to repair this valve is considered as a performance deficiency and a violation of the licensee's work authorization procedure (AD-QA-502).

AD-QA-502, Section 6.7.1 requires work to be conducted in accordance with work instructions, and Section 6.8.1 requires the worker in charge to sign the "work completed" line when the work package is complete.

Though all of the work described by the WA was not completed, the WA was still closed out.

No new WA was initiated.

These actions constituted an apparent procedural violation of AD-QA-502, Work Authorization System.

(NV4 50-387/92-02-03 (Common))

3.

RADIOLOGICALCONTROLS 3.1 Inspection Activities PP&L's compliance with the radiological protection program was verified on a periodic basis.

These inspection activities were conducted in accordance with NRC inspection procedure 71707.

3.2 Inspection Findings Observations of radiological controls during maintenance activities and plant tours indicated that workers generally obeyed postings and Radiation Work Permit requirements.

No inadequacies were noted, except as identified in Section 3.2.1.

3.2.1 Personnel Contamination during Reactor Building Ventilation Adjustment On February 4, tw'o contractors and one engineer were contaminated while adjusting the ventilation system in the Unit 1 Reactor Building (RB). Prior to the event, two contractors and one PP&L engineer were adjusting louvers on the Zone 1 RB ventilation system near the reactor protection system (RPS) motor generator (MG) sets.

Apparently, residual

contamination in overhead areas became airborne when the louvers were repositioned to blow air in that area.

This contamination was detected on the individuals when attempting to exit the Unit 1-Radiologically Controlled Area (RCA). When the PCM's alarmed the contaminated personnel were questioned by the licensee to determine the source of the contamination.

Licensee personnel determined that the contamination resulted from the individuals'ork activities.

On February 5, the inspector reviewed Significant Operating Occurrence Report (SOOR) 1-92-041 that documented the contamination.

Normally, personnel contaminations are documented only in Personnel Contamination Reports (PCRs).

However, because three PCRs were issued for the same event a SOOR was generated.

The inspector reviewed the SOOR, the three PCRs (92-31, 92-32, 92-33), the Area Contamination Report (ACR) 92-07 and interviewed two of the three individuals involved. In addition, Radiation-Work Permit (RWP)92-072 was reviewed.

This RWP required a contamination survey for work in the overhead.

When questioned by the inspector, the affected individuals stated that they were unaware that the louver adjustment in a clean area constituted a work activity per the RWP.

They also stated that their activities were reviewed with the Health Physics (HP) technician and they were not made aware of the potential for contamination in the overhead spaces.

The HP technician indicated that he was not informed that the individuals'ere going to work in the overhead.

Consequently, the briefing the individuals received from the HP technician did not address this radiological concern.

The inspector noted that RWP 92-072 required the performance of a contamination survey prior to any work in the overhead.

They individuals stated that louver adjustments were needed to redirect the ventilation supply to blow air towards the RPS MG sets.

The first of two louvers was adjusted without incident.

When the second was adjusted, one of the contractors indicated that he felt a dust particle hit him on the side of his neck as he proceeded with the adjustment:

The other individuals did not notice anything unusual at the time.

The affected individuals did not realize they were contaminated until the contamination was detected by the Personnel Contamination Monitor (PCM).

As a result of this review, the inspector identified the following:

The affected individuals did not understand what constituted work in overhead areas.

The second louver adjustment required the use of a ladder.

However, its use caused no additional consideration by the individuals as to whether their activities constituted work in overhead areas.

During the pre-job briefing, the HP technician was unaware that the affected individuals would be working in overhead areas.

Station policy and/or procedures did not adequately define what constituted work in overhead area The affected individuals relied totally on the HP technician briefing relative to the identification of any radiological control concerns.

They did not independently review all of the specific RWP requirements or the applicable survey maps prior to the start of work.,

In response to this event, the licensee formed an Event Review Team (ERT) to identify the root causes for this incident and propose corrective actions.

The ERT had not completed their review at the conclusion of this inspection.

Therefore, this item remains unresolved pending assessment of the licensee's event review.

(UNR 50-387/92-02-04 (Common))

4.

MAINTENANCE/SURVEILLANCE 4.1 Maintenance Inspection Activity On a sampling basis, the inspector observed and/or reviewed selected maintenance activities to ensure that specific programmatic elements described below were being met.

4.2 Maintenance Observations The inspector observed and/or reviewed selected maintenance activities to determine that the work was conducted in accordance with approved procedures, regulatory guides, Technical Specifications, and industry codes or standards.

The following items were considered during this review, as applicable:

Limiting Conditions for Operation were met while components or systems were removed from service; required administrative approvals were obtained prior to initiating the work; activities were accomplished using approved procedures and quality control hold points were established where required; functional testing was performed prior to declaring the involved component(s) operable; activities were accomplished by qualified personnel; radiological controls were implemented; fire protection controls were imple-mented; and the equipment was verified to be properly returned to service.

These observations and/or reviews included:

Offgas Recombiner Vessel Replacement, dated 1/18/92

"E" Diesel Generator Repair, dated 2/6/92 Division II 24 volt Battery Filter Capacitor Replacement, dated 2/10/92 4.3 Inspection Findings Relative to this area, the inspector determined that work was properly released before its commencement; that systems and components were properly tested before being returned to service and that surveillance and maintenance activities were conducted properly by qualified

personnel.

%here questionable issues arose, the inspector verified that the licensee took the appropriate action before system/component operability was declared.

Except for the offgas recombiner maintenance (see Section 2.2.1), no unacceptable conditions were identified.

'I 5.

EMERGENCY PREPAREDNESS 5.1 Inspection Activity The inspector reviewed licensee event notifications and reporting requirements for events that could have required entry into the emergency plan.

5.2 Inspection Findings One event was identified that required emergency plan entry. The licensee declared an Unusual Event on January 18 due to an on-site explosion (involving the common hydrogen recombiner system) and the consequent transport of a contaminated injured individual to an off-site medical facility. The inspector noted that the event was properly classified and managed.

The Emergency Plan was effectively implemented.

No inadequacies were identified. Allnotifications were accomplished satisfactorily.

6.

SECURITY 6.1 Inspection Activity PP&L's implementation of the physical security program was verified on a periodic basis, including the adequacy of staffing, entry control, alarm stations, and physical boundaries.

These inspection activities were conducted in accordance with NRC inspection procedure 71707.

6.2 Inspection Findings The inspector reviewed access and egress controls throughout the period.

No unacceptable conditions were noted.

6.2.1 Fitness for Duty - Excessive Alcohol Consumption prior to the Five Hour Abstinence Period The inspector reviewed PP&L Fitness for Duty Program (FFD) to determine how the program addressed the effects of excessive alcohol consumption prior to the five hour abstinence period.

The inspector initiated this review in response to problems noted at other plants.

Certain personnel from other nuclear power plants have been found to have had blood alcohol concentration (BAC) greater than the legal limit (0.04%) even though they did

not consume alcohol in the preceding five hours.

These individuals were unaware that their slow metabolism caused them to violate the BAC limiteven though their consumption was before the five hour abstinence period.

The inspector found that PP&L's Fitness for Duty (FFD) program required supervisor notification for BAC levels from.011% to.039%.

The supervisor is required to review results in this range with the individual and back-calculate the individual's probable BAC from the beginning of the duty.

The supervisor may,also identify,potential violations of the FFD program requirement relative to alcohol consumption.

These controls indicate that the licensee's program is proactive in identifying potential problem areas and establishing prompt corrective measures.

No inadequacies were noted.

7.

ENGINEERING/TECHNICALSUPPORT 7.1 Inspection Activity

=The inspector periodically-reviewed engineering and technical support activities during this inspection period.

The on-site Nuclear Systems Engineering (NSE) organization, along with Nuclear Plant Engineering (NPE) in Allentown, provided engineering resolution for problems during the inspection period.

NES generally addressed the short term resolution of problems, and NPE scheduled modifications and design changes, as'appropriate, to provide long term problem correction.

The inspector verified that problem resolutions were thorough and directed at preventing recurrences.

In addition, the inspector reviewed short term actions to ensure that they provided reasonable assurance that safe operation could be maintained.

7.2 Inspection Findings

/

7.2.1 Nonconforming New Fuel Rod Lower End Caps On January 16, PP&L's nuclear fuel supplier, Siemen's Nuclear Power Corporation (SNP)

notified PP&L that 57 individual fuel rods fabricated for the March 1992 Unit 1 refueling outage contained nonconforming end caps.

The end caps were manufactured from Zircaloy-4 (Zirc-4) instead of the specified Zircaloy-2 (Zirc-2). Nonconformance report (NCR)92-011 was issued to document this nonconforming condition.

The 57 affected rods were contained in 8 fuel bundles which had been received at Susquehanna and 4 others that were still at SNP.

The affected fuel rods in the 4 SNP bundles were subsequently replaced and shipped to Susquehanna.

On January 27, SNP notified PP&L that they had discovered an additional 22 rods with the Zircaloy-4 end caps.

These rods were contained in 5 fuel bundles previously shipped to Susquehanna.

As a result of this communication, PP&L initiated action to replace all individual fuel rods containing the nonconforming end caps prior to the refueling outag To ensure that the generic implications of this nonconformance were properly evaluated, the licensee considered reportability in accordance with 10 CFR 21.

Although the fuel bundles containing Zirc-4 end caps deviated from design specification, the effects of this deviation did not constitute a substantial safety hazard since" the material differences between Zirc-2 and Zirc-4 were not sufficient to adversely impact the metallurgical, geometric stability or the weld properties for either zirconium alloy. The licensee also noted that although hydriding and corrosion tendencies differ somewhat between Zirc-4 and Zirc-2, there was no expected adverse impact on fuel performance.

However, even iffuel reliability were to be diminished as a result of the Zircaloy-4 lower end caps, the worst case expectation would be incipient fuel pin leakage.

Based on the above, the licensee concluded that there would not be a substantial reduction in the degree of protection provided to public health and safety.

Therefore, this nonconformance was determined to not meet 10 CFR 21 reporting requirements.

The licensee conducted a conference call with the NRC on January 31.

During the call, the licensee discussed the nonconformance and also noted excellent performance from SNP supplied fuel. In the previous nine reloads, only one fuel rod failure could be directly attributable to a manufacturing defect.

Past quality assurance (QA) audits noted good SNP quality control.

Relative to this matter, the inspector was informed that SNP convened an internal Incident Review Board (IRB) to review this event.

As part of the assessment effort, SNP intends to identify their assessment of root causes and corrective measures to PP&L upon completion.

In order to ensure adequate review by SNP, PP&L has agreed to postpone any fuel loading activities until SNP has:

1) identified the root cause(s) of this deviation, 2) assured PP&L that all fabrication documentation relevant to the subject reload has been reviewed and verified to meet the required fuel bundle specifications, and 3) provided PP&L with a formal presentation of the results of their investigation.

To assess the safety impact of the nonconforming fuel rod end caps, the inspector performed the following review activities.

PP&L's reactor engineering (RE) staff was contacted.

Some REs were interviewed.

Since no written notification existed, the REs reconstructed a pictorial representation of the number of affected fuel rods which was reviewed.

Nonconformance report (NCR)92-011 was reviewed.

The operability/reportability evaluation was noted.

The inspector attended a conference call between the licensee and NRC on January 31.

The need for a 10 CFR 21 notification was reviewed as a part of the conference cal As a result of this review, the inspector concluded the following:

While SNP promptly brought this matter to the attention of the licensee, at the'close of this period, none of the notifications or commitments were actually documented.

The lack of written documentation from SNP was not initiallyconsidered as significant by the licensee.

However, upon review of the inspector's concerns, the licensee agreed that formal documentation should be established for this matter.

Accordingly, the licensee and SNP have initiated actions to document this occurrence.

NCR 92-011 was determined to be well-written, and contained a good operability/reportability evaluation.

However, the inspector noted that the operability/reportability evaluations and disposition occurred prior to Quality Control's disposition review and approval of the NCR.

Though the NCR procedure (AD-QA-120) allows some degree of flexibility,the departure from the normal NCR processing sequence was the result of an administrative error.

The licensee agreed to take actions as necessary to address these deficiencies.

The inspector had no further questions at this time.

8.. MANAGEMPlTAND EXITMEETINGS 8.1 Resident Exit and Periodic Meetings The'inspector discussed the findings of this inspection with station management during and at the conclusion of the inspection period.

Based on NRC Region I review of this report and discussions held with licensee representatives,'t was determined that this report-does not contain information subject to 10 CFR 2.790 restrictions.

8.2 Inspections Conducted By Region Based Inspectors ate

~In pecLi nn gypper~

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~ngGer 1/21-24 Operator Requalification Routine Health Physics 92-01 92-03 T. Walker J. Noggle

A%I'ACHMENT 1 A

r vi tion List AD ADS ANSI CAC CFR CIG CRDM CREOA DG DX ECCS EDR EP EPA ERT ESF EWR FO FSAR HVAC ILRT

. I&C JIO LCO LER LLRT LOCA LOOP MSIV NCR NDI NPE NPO NQA NRC OI PC PCIS PMR PORC QA

- Administrative Procedure

- Automatic Depressurization System

- American Nuclear Standards Institute

- Containment Atmosphere Control

- Code of Federal Regulations

- Containment Instrument Gas

- Control Rod Drive Mechanism SS - Control Room Emergency Outside

- Diesel Generator

- Direct Expansion

- Emergency Core Cooling System

- Engineering Discrepancy Report

- Emergency Preparedness

- Electrical Protection Assembly

- Event Review Team

- Engineered Safety Features

- Emergency Service Water

- Engineering Work Request

- Fuel Oil

- Final Safety Analysis Report

- Heating, Ventilation, and Air Conditioning

- Integrated Leak Rate Test

- Instrumentation and Control

- Justifications for Interim Operation

- Limiting Condition for Operation

- Licensee Event Report

- Local Leak Rate Test

- Loss of Coolant Accident

- Loss of Offsite Power

- Main Steam Isolation Valve

- Non Conformance Report

- Nuclear Department Instruction

- Nuclear Plant Engineering

- Nuclear Plant Operator

- Nuclear Quality Assurance

- Nuclear Regulatory Commission

- Open Item

- Protective Clothing

- Primary Containment Isolation System

- Plant Modification Request

- Plant Operations Review Committee

- Quality Assurance Air Supply System

'

RB

- Reactor Building RCIC

- Reactor Core Isolation Cooling RG

- Regulatory Guide RHR.

- Residual Heat Removal RHRSW

- Residual Heat Removal Service Water RPS

- Reactor Protection System RWCU

- Reactor Water Cleanup SGTS

- Standby Gas Treatment System SI

- Surveillance Procedure, Instrumentation and Control SO

- Surveillance Procedure, Operations SOOR

- Significant Operating Occurrence Report SPING

- Sample Particulate, Iodine, and Noble Gas TS

- Technical Specifications TSC

- Technical Support Center WA

. - Work Authorization

Attachment 2 UNUSUALEVENT DUE TO LOCALIZEDHYDROGEN IGNITIONAND CONTAIVDNATED INJURED MAN ROOT CAUSES AND CORRECTIVE ACTIONS Listed below are the identified causes.

1.

2.

3.

4.'.

6.

7.

8.

9.

10.

Less than adequate purge of the offgas piping prior to work.

Less than adequate maintenance on the Unit 1 air operated globe valve.

Two-valve protection was'available for blocking but n'ot used.

Preferred valve type was not used for blocking. (Ball valve preferred)

The offgas recombiner system was not identified as potentially containing hydrogen.

Poor follow up on a similar precursor (1/16/92) event.

Safety and Fire Protection personnel were not consulted even though employees questioned the potential for hydrogen during the pre-job briefing.

The procedures and training on potentially hazardous combustible gas systems were inadequate.

Less than adequate work planning relative to the hydrogen hazard.

Less than adequate review of industry events involving hydrogen hazards.

Less than adequate review of internal events involving hydrogen hazards.

Less than adequate communications between various work groups.

The Event Review Team developed 13 specific corrective actions to address the identified causes.

1.

Provide improved procedural controls (OP172/272-001) for purging or ventilating the Offgas system.

Considerations should be given to purge time, H, monitoring and followup purging..

2.

3.

4.

.5 6.

Repair HV16907/HV26907 during appropriate system work window.

Address appropriate periodic testing and maintenance.

Hold training with work groups on the need to initiate a new WA to continue to track a remaining/unresolved problem when an existing WA is closed.

Revise permit and tag program to:

a.

Properly list ball valves as a preferred valve designs for blocking.

b.

Consider two valve protection for appropriate systems and hazards.

c.

Consider valve leak integrity when specifying blocking boundaries.

Revise Offgas system alarm response procedures to address potential hydrogen detonation.

Revise Planners Guides/Manuals to specifically identify "Special Personal Safety Precautions" as a separate section in each Work Authorizatio.

9.

10.

u.

ntify systems with potential for Flammable or Combustible gas.

a.

Physically label such systems.

b.

Revise Hot Work Permit procedures to address flammable/combustible gas.

c.

Communicate identified systems to Operations and Planning groups for inclusion in operating and planning procedures.

d.

Revise Planners Guides/Manuals to address flammable/combustible gas safety precautions.

Specifically identify who in the work planning and review cycle is accountable for the inclusion of Personal Safety Precautions in a work authorization.

Develop a specific SSES Safety Procedure for working with the potential for

"

Flammable/Combustible gas.

Consider additional BWR systems training for work planning personnel in MIG and work groups, Revise General Employee Training and include in continuing training and pre-outage training as appropriate the following topics:

a.

Hydrogen hazards b.

Lessons, learned from this event c.

Re-emphasize availability of Safety Group personnel and Fire Protection personnel if doubt or concern exists with a combustible hazard.

d.

Importance of Feedback to Operations of unusual conditions and need for good communications Perform a re-evaluation of the following industry events:

SIL 150,Prevention of Hydrogen Ignitions Related to the Offgas System SER 84-08, Hydrogen Fires During Primary Plant Maintenance Activities IE 82-28, Hydrogen Explosion while Grinding in the Vicinityof Drained and Open Reactor Coolant System SIL 497, Hydrogen Ignition in Offgas System SIL 246, Control of Sustained Combustion in Offgas Systems INPO 0: MR 320, Oxygen-Hydrogen Explosions in Relief,Valve Pilot Valves 13.

Evaluate the need for IER program changes due to this event.