IR 05000445/1998001

Insp Repts 50-445/98-01 & 50-446/98-02 on 980104-0214. Violations Noted.Major Areas Inspected:Operations,Maint, Engineering & Plant Support

ML20248L885
Person / Time
Site:	Comanche Peak
Issue date:	03/19/1998
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20248L881	List: IR 05000445/1998001 ML20248L879 ML20248L883
References
50-445-98-01, 50-445-98-1, 50-446-98-01, 50-446-98-1, NUDOCS 9803240331
Download: ML20248L885 (19)

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ENCLOSURE 2 U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket Nos,: 50-445 50-446 License Nos.: NPF-87 NPF-89 Report No.: 50-445/98-01 50-446/98-01 Licensee: TU Electric Facility: Comanche Peak Steam Electric Station, Units 1 and 2 Location: FM-56 Glen Rose, Texas Dates: January 4 through February 14,1998 Inspectors: Harry A. Freeman, Senior Resident inspector Rebecca L. Nease, Resident inspector l Approved By: Joseph I. Tapia, Chief, Project Branch A Division of Reactor Projects Attachment: Supplemental Information I

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l 9803240331 980319 PDR ADOCK 05000445 G PDR 4

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l l EXECUTIVE SUMMARY Comanche Peak Steam Electric Station, Units 1 and 2 NRC Inspection Report 50-445/98-01; 50446/98-01 i l

The resident inspection included aspects of licensee operations, engineering, maintenance, and plant support. The report covers a 6-week period of resident inspectio Ooerations

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The conduct of operations was professional and safety conscious. Operators continued to demonstrate attention to detail and good self-verification techniques. Evolutions such as surveillance were well-controlled, deliberate, and performed in accordance with procedures. Prejob briefings were comprehensive and well-attended. Management involvement was evident and expectations were clearly communicated (Section 01). )

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The licensee failed to follow procedures which required the documentation of an adverse condition when the licensee failed to document the heat related degradation of a safeguards sequencer on an operations notification and evaluation form. This was a violation (Section 01.2).

- The licensee failed to perform a safety evaluation screen to temporarily modify the seismically qualified configuration of the safeguards sequencer (Section 01.2).

- The licensee's operability determination process was not clearly defined in a procedure. The guidance contained in the procedure for processing operations notification and evaluation forms was confusing and poorly worded. Previous  ;

operability determinations have been appropriate even though there has been heavy reliance on operator knowledge in completion of the determination process (Section 01.2).

- The licensee did not aggressively address a known vulnerability and consequently was forced to enter Technical Specification 3.0.3 when two feedwater isolation valves became inoperable during surveillance testing. A weakness was identified in the work planning process for the lack of guidance with respect to revising standard work order steps (Section 01.3).

- The licensee identified that a licensed reactor operator failed to perform a channel calibration on the power range nuclear instruments and the nitrogen-16 detectors within the required surveillance interval (Section 04.1).

Maintenance

- The maintenance activity on the safeguards sequencer was well controlled and professional. The decision to replace the power supply and the card frame was i

conservative. The prejob briefing thoroughly reviewed the maintenance activity, l potential problems, and expected responses. Management and quality control l

I personnel observed the briefing (Section M1.1).

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The licensee identified a failure to stake the motor pinion key of a safety-related valve motor operator (Section M1.3).

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The turbine-driven auxiliary feedwater surveillance was performed in a professional manner with substantial engineering support. Unexpected problems were dealt with promptly and appropriately. The licensee demonstrated good attention-to-detail and safety techniques (M1.4).

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The licensee was not literally complying with procedural requirements regarding when a revision to a work order was required. The procedures needed clarification on what constituted a scope or intent change (Section M3.1).

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Electricians had several indicators available to inform them that the bus was energized when an industrial fatality occurred. While the licensee did not determine why an ;

electrician raised the protective shutter doors, the plant incident investigation was I thorough (Section M7.1).

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The licensee's quick technical evaluation of the Train B emergency diesel generators was reasonable, based on sound engineering principles, and provided the required engineering support to the operation of both facilities. The licensee continued to conduct a thorough review of the testing of safety-related circuits (Section E2.1).

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Performance in the area of plant support was characterized by careful radiological work practices, and knowledgeable radiation workers. Fire protection equipment was formally controlled (Section IV).

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Report Details

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l Summary of Plant Status Units 1 and 2 operated at 100 percent power throughout the inspection period. On November 17,1997, a fatality occurred when a contract employee touched energized 6.9kV contacts inside a breaker housing in the Unit 1 nonsafety-related switchgear room The breaker had been removed for cleaning. OSHA conducted an investigation and issued a citation to both the licensee and to the contractor for failure to provide appropriate personnel protective equipmen The licensee and contractor contested the citations. On February 27,1998, the OSHA area director agreed to withdraw the citation l. Operations 01 Conduct of Operations 01.1 General Comments (71707)

The conduct of operations was professional and safety conscious. Operators continued to demonstrate attention to detail and good self-verification techniques. Evolutions such as surveillance were well-controlled, deliberate, and performed in accordance with procedures. Prejob briefings were comprehensive and well-attended. Management-involvement was evident and expectations were clearly communicate O1.2 Seismic Qualification of the Solid State Safeauards Seauencer Cabinet Insoection Scoce (71707. 37551)

The inspector reviewed the licensee's corrective measures to a series of solid state safeguards sequencer automatic tester trouble alarms. The inspector reviewed Final l Safety Analysis Report Chapter 8.3, "Onsite Power Systems;" Procedure STA-716,

" Modification Process;" Procedure STA-602, " Temporary Modifications;" Alarm Procedure ALM-0022B, for Window 2.8,"SFGD SEQR TRN A/B AUTO TEST TRBL;"

Procedure STA-421, " Operations Notification and Evaluation (ONE) Form;" and Procedure STA-422, " Processing of Operations Notification and Evaluation (ONE)

Forms." i Observations and Findinas On February 2,1998, the Unit 2 Alarm Panel 2-ALB-2B, Window 2.8, "SFGD SEQR TRN A/B AUTO TEST TRBL," was activated. Operators appropriately used the alarm response procedure to respond to the alarm. Step 2J stated that, if the fault condition cleared for greater than 15 seconds and reappeared sometime later, the tester should be reset each time the alarm occurred. This would mean that the operator was manually maintaining the operability of the automatic tester, and that the tester would continue to monitor the operability of the sequencer. Based on further alarms with different fault

, codes, the professional maintenance performance team (PROMPT) concluded that the

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15 voit power supply was probably being affected by heat and was beginning to fail and that keeping the sequencer cabinet doors open would help lower the temperature. The l

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2-front and back cabinet doors were opened to help maintain the sequencer operable until the maintenance activity to repair the sequencer could be completed (Section M1.1).

The doors were left open for approximately 21 hour2.430556e-4 days <br />0.00583 hours <br />3.472222e-5 weeks <br />7.9905e-6 months <br /> Procedure STA-421 defined an adverse condition, in part, as an undesired condition that reduces plant safety, personnel safety, or plant reliabihty, or required actions to be in compliance with requirements. Step 6.2 required that, any individual discovering an adverse condition document the condition or ensure that another individual documents the condition on a ONE form in a timely manner except under the following conditions:

(l) the condition can be corrected by normal maintenance, calibration, or replacement, (ii)

the condition is reported or corrected in accordance with other approved procedures, or (iii) the condition is corrected in process, in accordance with management expectations, and prior to relying on the affected function. The heat related degradation of the sequencer was not a condition that could be corrected by normal maintenance, calibration or replacement. It was not a condition that was corrected by other approved procedures, and it was not a condition that was corrected prior to relying on the affected function. The licensee's failure to document the heat related degradation of the Unit 2, Train B, solid state safeguards sequencer on a ONE form was a violation of Technical Specification 6.8.1 (50-446/9801-01).

f The inspector reviewed the licensee's decision to open the sequencer cabinet doors to increase cooling to the power supply and, thus, maintain the sequencer operabl Specifically, the inspector reviewed the seismic qualification of the sequencer cabinet with the doors open. As described in Final Safety Analysis Report Chapter 8.3, the ,

sequencer had met the required seismic testing fully assembled and energized. In response to the inspector's questions, the licensee concluded that the seismic testing was conducted with the cabinet doors closed and that they did not have an evaluation proving the seismic qualification of the sequencer with the doors open. Therefore, during the time that the doors were left open, the sequencer was in an unanalyzed conditio The licensee subsequently analyzed this condition and concluded that the sequencer would remain seismically qualified with the cabinet doors ope The inspector reviewed the operabihty determination process utilized by the licensee to address the sequencer heating problem. The inspector noted that the licensee did not have a procedure that separately implemented an operability determination proces ;

Attachment 8.1 of Procedure STA-422," Processing of ONE Forms", did provide  ;

guidelines for initial operability determination; however, the licensee did not write a ONE form until the inspector raised the seismic operability concern. This was after the licensee had relied on opening the doors of the sequencer to maintain it operable with a '

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heat related degradation. The licensee informed the inspector that they periodically trained the operators on Generic Letter 91-18. "Information to Licensees Regarding NRC j l Inspection Manual Section on Resolution of Degraded and Nonconforming Conditions." l The licensee stated that the operators probably did not think that leaving the cabinet doors open was an issue because they had left them open on previous occasions.

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-3-The inspector found that Procedure STA-422, Step 6.2.1 was poorly worded. However, it defined a "cntical" priority ONE form, in part, as one that required actions to meet regulatory requirements (e.g. Technical Specifications), or that might require a reduction in generating capacity or a plant shutdown. Technical Specification 3.3.2.11 required

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that an inoperable solid state safeguards sequencer channel be restored to operable status within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> or that the plant be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />. This short Technical Specification action statement met the definition of a " critical" priority ONE form and required that the )

initial operability determination, caused by the heat related degradation and by leaving the cabinet doors open, be accomplished in a short time. Step 6.3.5 stated that the shift manager "should" request initiation of a OTE (quick technical evaluation) if on the initial I determination of operability sufficient information and expertise was not immediately available to fully determine operability. The shift manager should have requested a QTE based on the lack of information regarding the seismic qualification of the cabinet with the doors ope Conclusions The licensee failed to follow procedures which required the documentation of an adverse condition in that the licensee failed to document the heat related degradation of the Unit 2, Train B solid state safeguards sequencer on an Operations Notification and Evaluation for The licensee also failed to perform a safety evaluation screen to temporarily modify the seismically qualified configuration of the Unit 2, Train B solid state safeguards sequencer. If the licensee had written the ONE form, as required, the need to perform a safety evaluation screen for a temporary modification would have been identified and the impact on the seistnic qualification would have been recognized.

l The licensee's operability determination process was not clearly defined in a procedur )

The guidance contained in the procedure for processing Operations Notification and 1 Evaluation forms was confusing and poorly worded. Although the licensee's operability determination process relies heavily on operator knowledge, it has generally been appropriately implemented.

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01.3 Feedwater isolation Valve Nitroaen Leaks Insoection Scoce (71707)

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Based on the licensee's entry into Technical Specification 3.0.3 for not meeting the limiting condition for operation for feedwater isolation valves (FWlVs), the inspectors :

reviewed past performance concerns with the FWlVs and factors that might have contributed to this even _ _ _ _ _ _ _ - _ _ _ -

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b. Observations and Findinos On January 10,1998, the licensee performed a surveillance in which the Unit 1 i feedwater isolation valves (FWlVs) were partially stroked in accordance with OPT-511 A, j

"FW [feedwater] Section XI isolation Valves", Revision 7. After stroking FWlV 2137, the nitrogen low pressure annunciator alarmed but did not clear as expected. At 1:17 a.m., -

the licensee declared FWlV 2137 inoperable and entered the limiting condition for operation action requirements of Technical Specification 3.7.1.6. While the PROMPT l was dispatched to add nitrogen to FWlV 2137, the control room received a low nitrogen l pressure alarm for FWiV 2134, which had also been stroked in performance of this  !

surveillance. At 1:48 a.m., the licensee declared FWlV 2134 inoperable and entered the i Technical Specification 3.0.3 action requirements due to not meeting the limiting condition for operation of Technical Specification 3.7.1.6. The licensee exited Technical Specification 3.0.3 at 1:52 a.m. when nitrogen pressure for FWlV 2134 was restored to an acceptable level. At 2:09 a.m., when nitrogen pressure for FWlV 2137 was restored to an acceptable level, the licensee exited Technical Specification 3.7,1.6. The licensee ,

re-entered the action requirements for Technical Specification 3.7.1.6 at 4:20 a.m. to !

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replace a leaking solenoid valve on the nitrogen line to FWlV 2137. The licensee initiated a plant incident report to document this event and to investigate the causes that lead to their entry into Technical Specification 3. The inspector interviewed the system engineer, and found that the FWlVs were prone to nitrogen leaks. The system engineer had been tracking nitrogen additions to the FWlVs and in late 1997 noted a correlation between the stroking of the FWlVs and the appearance of nitrogen leaks. He found that nitrogen leaks appeared after stroking the valves and the rate of the leak tended to be higher directly after the valves were stoke In November of 1997, the system engineer recommended that a note be added to the standard surveillance work order to require operators to monitor nitrogen pressure after stroking the valve in order to identify a nitrogen leak prior to challenging the operability of the valve. On November 11, the operations surveillance coordinator added the note to the standard work order but did not change the work orders that were already planned and printed. The work order for stroking the FWlVs on January 10,1998, had been planned and printed on October 21,1997, and was not revised to include the note to monitor nitrogen pressure after stroking of the valves. Had the requirement to monitor nitrogen pressure after stroking the valves been included in this work order, entry into Technical Specification 3.0.3 might have been avoided. The inspector concluded that, in failing to revise the planned and printed surveillance work order to include this requirement , the licensee missed an opportunity to address this potential vulnerability before it became a challenge. The inspector found this to be a missed opportunity to prevent a known vulnerability from affecting the operability of safety-related equipment.

i The work orders associated with surveillance are planned and printed by operations

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support work coordinators months before the actual surveillance is performed. All other f worF. orders are planned by maintenance planners. The inspector interviewed maintenance planners and operations support work coordinators and found that there was no formal guidance concerning the requirement to update planned work orders to

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The inspector found no guidance concerning what information was appropriate for inclusion in a procedure versus a work orde Conclusions The inspector concluded that the licensee did not aggressively address a known vulnerability and, as a consequence, resulted in two FWlVs becoming inoperable and forced entry into Technical Specification 3.0.3. In addition, the inspector identified a weakness in the work planning process in that the licensee's procedures did not provide guidance with respect to revising standard work order step Operator Knowledge and Performance 04.1 Missed Technical Specification Surveillance Insoection Scooe (71707)

The inspector reviewed the causes and implications of missed Technical Specification surveillance for daily channel calibrations of the power range neutron flux high setpoint, the overtemperature nitrogen-16, and overpower nitrogen-16 trip functions. The inspector attended the licensee's review committee meeting investigating the causes of the missed surveillance and reviewed the licensee's corrective action Observations and Findinas On January 16, the licensee identified that the daily channel calibrations for the power range nuclear instruments and nitrogen-16 detectors in Unit 2 had not been completed within the required time interval. Technical Specification Surveillance Requirement 4.3.1.1 requires, in part, that the power range neutron flux high setpoint, the overtemperature nitrogen-16, and the overpower nitrogen-16 channels be demonstrated operable by the performance of the daily calibrations specified in Table 4.3-1. Note 2, applicable to these surveillance, requires that the detector channel gains be adjusted, consistent with calorimetric power, if the absolute difference of the respective channelis greater than 2 percen The licensee immediately performed the required surveillance and found the detectors to be within the required tolerance. Plant computer data revealed that the power range nuclear instruments and the nitrogen-16 detectors had been within tolerance since the last surveillance. The inspector noted that keensed operators typically monitor a plant computer screen which continuously displays calorimetric power, nuclear instrument l power, and nitrogen-16 detector power. Additionally, annunciators were available to alert l operators of channel deviation alarms for the excore detectors and for the nitrogen-16 i detectors. While these alarms would not specifically alert the operators to differences between the detectors and calorimetric power, they could have identified problems with

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-6-one or more detector channels. The inspector concluded that the missed surveillance had little safety consequenc The inspector attended the review committee meeting and found it to be oper, and candid. Potential corrective actions discussed included revising or clarifying the operator logs which require the surveillance, and developing a design modification to the plant computer to alarm if a detector channel differed from the calorimetric by more than 2 percen Conclusions The failure to perform a channel calibration on the power lange nuclear instruments and the nitrogen-16 detectors at least once during the preceding 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> (including a 25 percent maximum allowable extension as allowed by Technical Specification 4.0.2)

was a violation of Technical Specification 4.3.1.1. This nonrepetitive, licensee-identified and corrected violation is being treated as a noncited violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy (50-446/9801-02).

O.4.2 Unit 2 Diesel Generator Monthlv Surveillance (71707. 61726)

On January 23, the inspectors observed the licensee perform Procedure OPT-2148,

• Diesel Generator Operability Test," on the Unit 2, Train A, diesel generator. The prejob briefing was well-attended and conducted in a clear, concise and thorough manne ;

Topics covered included the purpose of the surveillance, individual responsibilities and '

duties, precautions and limitations, and expected plant response. Management  ;

expectations, such as attention to detail, self-checking techniques, three-way communication, and conservative decision making were stressed. The inspector noted  ;

that a reactor operator trainee performed part of the surveillance under the direction of a l licensed reactor operator. Before the surveillance began, the reactor operator and the i trainee again reviewed the steps in the procedure and discussed potential problems and contingency actions at length. The reactor operator questioned the trainee on knowledge of the system, the purpose of the surveillance, and how the controls should be manipulated. The inspectors noted that at all times when the trainee was manipulating the controls, the licensed reactor operator was with him. During the surveillance, the operators had the procedure in hand and referred to it often. The inspector concluded that the surveillance was performed in a well-controlled and professional manner, and in accordance with procedures and management expectation In addition, the licensed reactor operator provided very good supervision of the traine Miscellaneous Operations issues (90712)

08.1 (Closed) Licensee Event Reoort 50-445/97-010-00: Technical Specification required shutdown due to an inoperable solid state safeguards sequencer. This issue was discussed in inspection Report 50-445/97-23; 50-446/97-23. No new issues were revealed by the report.

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-7-08.2 (Closed) Licensee Event Raoort 50-446/97-002-00: manual reactor trip due to failure of rod control system. This issue was discussed in Inspection Report 50-445/97-20-50-446/9720. No new issues were revealed by the repor .3 (Closed) Licensee Event Reoort 50-445/96-007-00: automatic reactor trip caused by I lightning strike. This issue was discussed in Inspection Report 50-445/96-10; 50-446/9610. No new issues were revealed by the repor .4 (Closed) Licensee Event Reoort 50-446/98-001-00: missed Technical Specification for reactor trip system instrumentation due to personnel error. This issue is discussed in this inspection report (Section 04.1). No new issues were revealed by the licensee event repor II. Maintenang M1 Conduct of Maintenance M1.1 Unit 2 Solid State Safeguards Secuencer Maintenance Activity Insoection Scoce (62707. 61726)

The inspector observed the licensee replace the 15 volt power supply and the card frame on the Unit 2, Train B, solid state safeguards sequencer. Following the maintenance, the inspector observed the licensee perform an operability test to restore operability of the sequencer, Observations and Findings On February 3, the inspector observed the licensee replace the sequencer's 15 volt power supply and the card frame. Power supply degradation was suspected based on multiple, nonrepetitive auto-tester alarms. No additional alarms were received when the doors were kept open to provide additional cooling. Based on past histcry, the licensee suspected that the 15 volt power supply was degrading and should be replace Because of the short-length of the Technical Specification limiting condition for operation action statement, the licensee decided to replace the entire card frame with one that had been tested on a bench testing rac The inspector found that the entire process was well controlled and performed in a professional manner. The decision to replace the power supply and the card frame was conservative. The prejob briefing thoroughly reviewed the maintenance activity, potential problems, and expected responses. The maintenance was conducted by knowledgeable technicians. Management oversight was present as well as quality control. Licensed operators performed the surveillance retest following Procedure OPT-4148, " Solid State Safeguards Sequencer Operability Test." Operators were knowledgeable of expected responses and exhibited careful observation for the required indications.

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l-8-M1.2 Replacement of the Unit 2 Atmo.soheric Relief Valve Pilot Valve Positioner (62707)

On February 2, the inspector observed planned maintenance to replace the pilot valve '

positioner for Steam Generator. Relief Valve 2-PV-2326. During the replacement, the technicians demonstrated good attention-to-detail when they found the current-to-pressure (I to P) converter out-of-calibration. The technicians recalibrates the converter j before continuing the replacement of the positioner. The technicians noted this in the j work order and initiated a ONE form. The inspector verified that the fire impairment was included in the work package and appropriately posted on the propped open fire door. In l addition, the impaired door was included on the fire watch tou I

The inspector concluded the work was performed in a conservative and professional manner. All work was performed in accordance with procedures and the workers were knowledgeable on their assigned task. In addition, the appropriate fire impairment l requirements were followe M1.3 Failure to Stake Motor Pinion Kev (62707)

l On January 15, during maintenance on a safety-related valve, Valve 2-8812A, the valve team found that the motor pinion key had not been staked as required by Procedure MSE-CO-8806, "Limitorque Actuator Refurbishment for Types SMB-0 Thru SMB-3/SB-0 l Thru AB-3," Revision O. Since the motor pinion key was in place, the valve was considered operable. The mechanics staked the motor pinion key and noted the condition on a ONE form. Upon review of maintenance records, the licensee found that ;

on March 24,1996, maintenance was performed on that valve that would have required l'

the motor pinion key to be stake The licensee intended to revise the procedure to include a requirement to use Locktite on motor pinion keys as an additional assurance that the motor pinion keys remain in plac ,

l The inspector found this to be conservative and appropriate. The failure to follow Procedure MSE-CO-8806 was a violation of Technical Specification 6.8.1. This nonrepetitive, licensee-identified and corrected violation is being treated as a noncited violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy (50-446/9801-03).

I M 1.4 Unit 1 Turbine-driven Auxiliarv Feedwater Pumo Surveillance I Insoection Scoce (61726)

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On January 21,1998, the inspector observed the licensee test the Unit 1 turbine driven auxiliary feedwater pump (TDAFW) using Procedure OPT-206A, "AFW [ auxiliary feedwater] System."

! Observations and Findinas

! Early in the surveillance, the reach rod for the discharge test isolation valve became i disengaged from the valve while the plant equipment operator was opening the valve.

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-9-This valve was only required to be operated during pump testing. The PROMPT was contacted, responded immediately, and reattached the reach rod to the valve. Later during the test, the engineers taking flow data noted that the acoustic flow monitor was malfunctioning. The PROMPT was again contacted and installed another acoustic flow monitor. The surveillance was reperformed satisfactoril The system engineer was present at the pump for the entire evolution, checking for excessive packing leakage, observing flash tank levels, and checking flow indication The inspector found this to be indicative of good system ownership. The engineers demonstrated good attention-to-detail by noting that pump flow rates did not appear to be correct, which lead to their discovery that the acoustic flow monitor was malfunctionin The PROMPT technicians were very responsive and used good safety techniques in reattaching the reach rod operator and the new acoustic monitor. Maintenance technicians noted the failure of the acoustic flow monitor in the work order and initiated a ONE form. The failure of the reach rod was neither noted in the work order, nor documented in a ONE form. Upon questioning by the inspector, the licensee searched ,

its database and interviewed mechanics, and found no previous failures of a reach rod connection. The licensee, concluded that this was an isolated case and not a generic concem. The inspector agreed. Given that some valves were required to be manually operated using a reach rod during accidents, the inspector found that the licensee's lack of review of the reach rod connection failure was a minor weaknes Conclusions

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l The inspector concluded that the licensee performed the surveillance in a professional manner with substantial engineering support. Unexpected problems were dealt with promptly and appropriately, with the minor exception that possible generic implications of the reach rod failure were not pursued immediately. In addition, the licensee demonstrated good attention to detail and safety technique M3 Maintenance Procedures and Documentation M3.1 Work Order Revision Requirements (92902) l i insoection Scoce i The inspector reviewed Plant incident Report ONE-PIR-97-001443, "Stop Work Order issued for All Switchgear Maintenance Activities in Response to an industrial Safety Accident that Occurred on November 17,1997"; Preventive Maintenance Work Order 3-97-336690-01; Clearance 2-97-1210; Station Administration Manual Procedures STA-606, " Control of Maintenance and Work Activities"; Procedure WCl-60 " Work Control Process"; Procedure STA-601, " Authority for Equipment Operation"; and Procedure STA-605, " Clearance and Safety Tagging."

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-10-4 Observations and Findinas During the review of ONE-PIR-97-001443, the inspector identified a potential conflict between the requirements for revising a work order, as documented in Procedures STA-606 and WCl-606, and how these requirements were being implemente Procedure STA-606 provided programmatic requirements, and administrative controls, and defined responsibilities for performing work. Paragraph 6.5.7, stated that, "lF the intent of the work instruction should be changed _QB the scope of the work changes, IBEN the WO (work order) shall be revised." The inspector found that the procedure did not define the terms " intent" or " scope." Procedure WCl-606 delineated the methods and assigned the responsibilities required to implement Procedure STA-606. Step 6.7,4.16 of Procedure WCl-606 had a similarly worded requiremen The scope of Preventive Maintenance Work Order 3-97-33690-01 stated, " clean the backs of cubicles that are inaccessible during the switchgear cleaning PM's [ preventive maintenance], due to energized feeder cables." The clearance for the work order required that the feeder cables in the back section of the switchgear be deenergize During the prejob briefing, the responsible work organization supervisor informed the m <

electricians that they would also be inspecting the auxiliary and cell switches inside the breaker cubicle, which was located in the front section of the switchgear. While this additional work was only intended to be an inspection of nonenergized switches, the

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fatally injured electrician went beyond what was allowed by this change in work scope and proceeded to clean an area at the back of the front section of the switchgear which j was behind a protective shutter and contained energized component The inspector concluded that the additional inspection conducted in the front section of the switchgear changed the scope and that Procedure STA-606 required that the work order be revised. The work order was not revised. The licensee applied  ;

Procedure STA-606 to all maintenance, including safety-related and nonsafety-related activities. In this particular case, the work order was not conducted on nor did it affect the performance of safety-related equipment and Technical Specification 6.8.1.a. which ;

requires that written procedures be implemented covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, wae not applicable. Although the failure to revise Work Order 3-97-336690-01 per Procedure STA-606 was not a violation in this case, it resulted from unclear guidance on when a change in work scope was applicable.

Procedure WCl-606, Step 6.7.4.16.A required that the responsible work organization supervisor determine when a revision is required. Step 6.7.4.16.E required the shift manager to review and authorize the revision when: (i) the impact statement information was no longer valid, (ii) the clearance boundary was affected, (iii) the Technical Specification limiting condition for operation was affected, (iv) a potential adverse condition was identified, (v) a troubleshooting work order was revised to specify r

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-11-corrective actions, or (vi) the preventive or surveillance work order was revised to perform corrective maintenance. Through discussions with the licensee, the inspector found that they were using the requirements of Step 6.7.4.16 E to determine whether a revision was necessary and not the basic requirements of Step 6.7.4.1 Conclusions The inspector found that the licensee was not literally complying with the requirements of Procedures STA-606 and WCl-606, regarding when a revision to a work order was required. The inspector concluded that the procedures needed clarification on what changes required a work order revision and on what constituted a scope or intent chang M7 Quality Assurance in Maintenance Activities M7.1 Review of Industrial Accident Insoection Scooe (92902)

l The inspector reviewed the licensee's investigation findings surrounding an industrial accident which caused a fatality on November 17,1997. Included in the review were Plant incident Report ONE-PIR-97-001443; Preventive Maintenance Work Order 3-97-336690-01; and Clearance 2-97-121 Observations and Findinos On November 17,1997, a contract journeyman electrician contacted an energized, nonsafety-related,6.9 kV bus high voltage primary connection. The electrician was fatally injured. Following the accident, the licensee issued a stop work order on all electrical switchgear maintenance activities. The stop work order was lifted incrementally as each electrician and supervisor attended detailed retraining on electrical safety and on switchgear operatio The electrician was one of four electricians working on Bus 2A1, Cubicle 9, using Work Order 3-97-33690-01. This work order was one of several activities to be performed while 345/6.9 KV Station Service Transformer 2ST was deenergized for maintenanc Although Transformer 2ST was deenergized, Bus XA1 was still energized from Transformer 1ST through Cubicle 9. Therefore, the primary connections to Bus XA1, located behind the safety shutter, were energize Plant incident Report ONE-PIR-97-001443 documented several reasons why the

electricians should have known that the bus was energized. Specifically, the supervisor wamed the electricians that the bus was energized during the prejob briefing, the t

clearance associated with the work order contained special instructions warning that the ,

XA1 bus was energized, the status lights on the front of the switchgear provided !

indication that the bus was energized, the safety shutter had a warning label which j l

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l cautioned against exposing energized bus connections, and training held five days earher described this type of switchgear and its dual feed power source The inspector also noted that other indicators were available to the electricians that I would have provided a warning that the primary connections were still energized. With the work order clearance still hanging, the lights and meters on adjacent cubicles (same switchgear) indicated that they were energized. Since the breaker in Cubicle 9 was removed, these lights indicated that power was being supplied to the bus through a different source. A warning tag attached to the safety shutter did caution that opening the shutter may expose energized connections. A statement from the supervisor documented that the electricians were warned that the bus was energized. However, the wording contained in the clearance special instructions did not clearly indicate that the bus was energize Conclusions The inspector concluded that the electricians had several indicators available to inform I them that the bus was energized. While the licensee did not determine why the electrician opened the shutter doors, the plant incident investigation was thoroug M8 Miscellaneous Maintenance issues (90712) l M8.1 LClosed) Licensee Event Reoort 50-446/97-003-00: core alterations performed before l completing prerequisites. This issue was discussed in Inspection Report 50-45/97-20, i

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50-446/97-20. No new issues were revealed by the repor lli. Enaineerina E2 Engineering Support of Facilities and Equipment E Quick Technical Evaluation Missed Load Sheddina Feature of Nonsafety Insoection Scooe (37551)

The inspector reviewed the licensee's quick technical evaluation on the operability of both units' Train B diesel generators. The inspector compared the licensee's conclusions to Technical Specification 3.8.1.1, the Final Safety Analysis Report, and the Safety Evaluation Report to verify that the conclusions were appropriat Observations and Findinas l On February 13, a licensed senior reactor operator performing Generic Letter 96-01,

" Testing of Safety-Related Logic Circuits," reviews identified that the load shedding capabihty of Motor Control Center XEB4-3 was not included in the applicab!e surveillance procedures. At 1:30 p.m. (CST), the licensee determined that the Train B diesel L__-__________

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-13-generators for both units were inoperable until the load shedding of the motor control center was verified. The motor control center can be powered by either unit's Train B 6.9 kV safety bus. Because the Unit 1, Train A diesel generator had been declared inoperable earlier that day for planned maintenance, both diesel generators for Unit 1 were inoperabl With two diesel generators inoperable, Technical Specification Action Statement 3.8.1. requires, in part, that one of the diesel generators be restored to operable status within 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. Two diesel generators are required to be operable within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> following the loss of the first generator. The Unit 1, Train B diesel generator was declared inoperable at 1:30 p.m. Maintenance was complete on the Train A diesel generator and the generator declared operable at 1:49 p.m. The Train A diesel generator had been originally declared inoperable for maintenance at 4:00 a.m. that moming. The joint engineering team completed a quick technical evaluation on the operability of the Train B diesels and the licensee concluded that both diesels were operable at 3:08 p.m. The licensee met the allowed outage time for both unit Technical Specification 4.8.1.1.2.f.4 requires that each diesel generator be demonstrated operable at least once per 18 months, during shutdown, by simulating a loss-of-offsite power and venfying load shedding from the emergency busses. The loads on XEB4-3 were required to be shed to ensure that the voltage and frequency dips of the safety-related busses were acceptable. The initial load on the Train B diesel generator 6.9 kV bus upon breaker closure was approximately 1100 kW. The failure to load shed Motor  ;

Control Center XEB4-3 would, in the worst case, add an additional load of approximately l 152 kW through a 6.9 kV to 480 V transformer. The licensee concluded that the additional load on the 480 V side of the transformer would have little effect on the voltage and frequency dip of the diesel generators and concluded that the diesel generators were operabl The inspector found that the licensee's quick technical evaluation was reasonable, based on sound engineering principles, provided the required engineering support to the operation of both facilities, and that the diesel generators were technically operable. The inspector found that the licensee continued to conduct a thorough review of the testing of safety-related circuits. The inspector will review the impact of concluding that the diesels were operable without testing this load shed feature in a future report (50-445/9801-04; 50-446/9801-04).

IV. Plant Support R1 Radiological Protection and Chemistry Controls Insoection Scoce (71750)

The inspectors observed radiological protection activities during routine tours and I observations of maintenance activities, walked down selected doors that were required f

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-14-to be locked for radiation protection purposes, and reviewed primary and secondary water chemistry result Observations and Findinas The inspectors found that radiation protection technicians were present during maintenance activities in radiation areas. All of the selected doors that were required to be locked for radiation protection purposes were verified locked by the inspectors. The licensee closely monitored primary and secondary chemistry results, and the inspectors found that the results were within the prescribed limit R4 Staff Knowledge and Performance Insoection Scooe (71707. 71750)

During tours in the radiological controlled areas, the inspectors questioned licensee personnel on their knowledge of the radiation work permit requirement Observations and Findings The inspectors found that the radiation workers were generally knowledgeable of the radiation work permit requirements.

l F2 Status of Fire Protection Facilities and Equipment Insoection Scope (71750)

During periodic tours, the inspectcrs reviewed the licensee's control of transient combustibles and fire impairments. When transient combustible materials or fire impairments were noted, the inspectors verified that permits had been issued in accordance with procedure Observations and Findinas The inspectors found that the licensee formally controlled both impairments and combustibles. Plant personnel demonstrated knowledge of the requirements without exception. The inspector observed security personnel adequately monitor and document the status of impairments.

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V. Management Meetinas t X1 Exit Meeting Summary The inspectors presented the results of the inspection to members of licensee management on February 17,1998. The licensee acknowledged the findings presented. No proprietary information was identifie _ _ _ ._

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i4 I ATTACHMENT SUPPLEMENTAL INFORMATION

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PARTIAL LIST OF PERSONS CONTACTED

- Licensee R.D. Bird, Jr., Plant Support Manager

~ M.R. Blevins, Vice President, Nuclear Operations D.E. Buschbaum, Technical Compliance Manager W.G. Guidemond, Shift Operations Manager R.D. Walker, Regulatory Affairs Manager INSPECTION PROCEDURES USED IP 37551:. Onsite Engineering IP 61726: Surveillance Observations IP 62707: Maintenance Observations -

IP 71707: Plant Operations IP 71750: Plant Support Activities IP 90712: Inoffice Review of Written Reports of Nonroutine Events at Power Reactor Facilities ITEMS OPENED AND CLOSED Opened 50-446/9801-01 VIO Failure to document the heat related degradation on an operations notification and e.aluation form on the Unit 2, Train B, solid state safeguards sequencer was a violation of Technical Specification 6.8.1 (Section 01.2).

50-446/9801-02 NCV Failure to perform Technical Specification surveillance of daily calibration check on power range neutron flux high, overtemperature nitrogen-16, and overpower nitrogen-16 setpoints (Section O4.1).

50-446/9801-03 NCV Failure to stake residual heat removal pump suction valve motor operator pinion key (Section M1.3).

50-445/9801-04; IFl Followup on the regulatory compliance with diesel generator 50-446/9801-04 load shed surveillance requirements (Section E2.1).

GQied 50-446/9801-02 NCV Failure to perform Technical Specification surveillance of daily calibration check on power range neutron flux high, overtemperature nitrogen-16, and overpower nitrogen-16

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Closed 50-445/97-010-00 LER Technical Specification required shutdown due to an inoperable solid state safeguards sequencer (Section 08.1).

50-446/97-002-00 LER Manual reactor trip due to failure of rod control system (Section 08.2).

50-445/96-007-00 LER Automatic reactor trip caused by lightning strike (Section 08.3).

50-446/98-001-00 LER Missed Technical Specification for reactor trip system instrumentation due to pere,onnel error (Section 08.4).

50-446/9801-03 NCV Failure to stake residual heat removal pump suction valve motor operator pinion key (Section M1.3).

50-446/97-003-00 LER Core alterations performed before completing prerequisites (Section M8.1).

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