IR 05000456/1988028

Insp Repts 50-456/88-28 & 50-457/88-28 on 881015-1103.No Violations Noted.Major Areas Inspected:Events Surrounding Several Missed or Improperly Performed Tech Spec Surveillances

ML20206M375
Person / Time
Site:	Braidwood
Issue date:	11/17/1988
From:	Hinds J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20206M366	List: IR 05000456/1988028 ML20206M361
References
50-456-88-28, 50-457-88-28, NUDOCS 8811300551
Download: ML20206M375 (10)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Report Nos. 50-456/88028(DRP);50-457/88028(DRP)

Docket Nos. 50-456; 50-457 License Nos. NPF-72; NPF-77 Lfcensee: Contc.onwealth Edison Company Post Office Box 767 Chicago, IL 60690 Facility Name: Braidwood Station, Units 1 and 2 Inspection At: Braidwood Site, Braidwood, Illinois Inspection Conducted: October 15 through November 3,1988 Int Metors: T. M. Tongue T. E. Tay1or G. A. VanSickle Approved By: J. hM. Hinds, ., Chief Reactor Projects Section 1A h// MSS DIte Inspection Suninay Inspection from October 15 through November 3,1988 (Report No /88028(DRP); 50-457/88028(OfikTT Areas Inspected: Specfal safety inspection by the resider.t inspectors to rev E fthe events surroundin Techni;. * Specification (TS)gsurveillance several missed or improperly performed Results: Twelve examples of apparent violations of TS surveillance requirements were identified. These apoarent violations are of safety significance due to the potential inoperability of the affected systems, such as residual heat removal, containment spray, diesel gererators, axial flux difference, and power range nuclear instrumentation. When taken in aggregate, these violations demonstrate an apparent bre:kdown in management controls relative to the administration and implementation of the TS requirtJ surveillance proces s11300551 est117 gDR ADock0500g6

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DETAILS t Persons Contacted *

i r Comrnonwealth hdison Company (CECO)

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9 T. J. Maiman, Vice President, Power Operations

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K. L. Graesser, General' Manager, Power Operatiens R. E. Querio, Station Manager D. E. O'Brien, Station Services Superintendent

"X. Kofron, Production Superintendent S. C. Hunsader, Nuclear Licensing Admir:istrator *

• G. R. Masters, Assistant Superintendent - Operations  ;

G. E. Groth, Assistant Superintendent - Maintenance L. E. Davis, Assistant Superintender.t - Technical Services ,

• M. E. Lohman, Assistant Superintendent - Work Planning and Startup

• R. J. Legner, Lead Operating Engineer -

R. J. Ungeran, Operating Engineer - Unit 1  ;

R. Yungk, Operating Engineer - Unit 2 .

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8. McCue, Operating Engineer - Unit 0

+ t R. D. Kyrouac, Quality Assurance Supervisor

• P. L. Barnes, Regulatory Aswrance Supervisor R. Lemke, Technical, Staff ' prvisor J. Gosnell, Quality Conte . Supervisor R. E. Aker, Radiation / Chemistry Supervisor F. Willaford, Security Adminispator R. Byers, Site Superintendent - Projects and Construction Services Dep *L. W. Raney, Nuclear Safety W. McGee, Training Supervisor S. Hedden, Master, Instrument Maintenance R. Hoffman, Master, Mechanical Maintenance J. Smith, Master, Electrical Maintenance

• E. W. Carroll, Regulatory Assurance

• L. Bush, Regulatory Assurance t

• ?. Holland, Regulatory Assurance

• H. Pontious. Operations Staff

• K. Baer, Work Planning -

o *D. Skoza. Engineering  ;

• Denotes those attending the exit interview conducted on November 3, 1988 i and at other times throughout the inspection period. The inspector also i contacted and intervieha'i other licensee and contractor personnel during .

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the course of this in"pec? io , Purpose (93702)

s This inspection was conducted to review the cause of several missed or >

improperly perfortned Technical Specification (TS) surveillances from September 1987 to September 1988. The inspection was focused on implementation and administration of the surveillance orogra .

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! Description of the Events, The following is a description of the events occurring from September 1987 to September 198 !

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' At 11:45 a.m. on September 19, 1988, during a discussion of.the performance of 2Bw0S 5.0.b-2, "Emergency Core Cooling System (ECCS)

Venting and Valve Alignment Surveillance," performed on September 10, 1988, inadequate venting of the 2A and 2B residual heat removal (RHR) trains was discovered. The 2A and 2B RHR trains L were declared inoperable, partial surveillances were performed on the applicable groups and declared operable. The cause of the event was a deficiency of surveillance data sheets in that incomplete '

guidance was provided. A contributing cause of the event was failure to perform an adequate review of the surveillance procedure ,

prior to performance of the activit Permanent procedure changes i to 1/2Bw05 5.2.b-2 have been completed. A review of previously

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completed 1/2Bw0S 5.2.b-2 surveillances was conducted and revea'od i twv additional cases on Unit 1. From May 17, 1988 to June 12, 1988

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and August 15, 1988 to September 16, 1988, both trains of Unit 1 RHR

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system were inadequatly vented. Post performance reviews of the ;

Unit 1 surveillances did not identify the problem Unit I trains

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were properly vented on September 17, 1988. The circumstances <

surrounding the Unit 1 events were similar to the Unit 2 event ;

i activities. In all cases the RHR system was in a recirculating mode i

during the venting activity. The procedure provideo for not opening vent valves at all system high points if the system was in the

shutdown cooling mode with the discharge cross tie valve close The significance of this event was the improper system ventin '

The potential existed for the RHR system to not perform as desired if unidentified sufficient voids existed at s This is an apparent violation of TS 4.5.2.b (ystem high point LER 457/88023)

(456/88028-01(h)(DRP);457/89028-01(h)(DRP)).

- At 1:45 p.m. on July 2,1988, it was detemined that the 40-second t sequencing timer associated with the DG loading sequence for the !

containment spray (CS) system should have been, but was not >

addressed in the general surveillance (GSRV) program. The 40-second timer had been previously tested during pre-operational testing in 1 February 198 The 18 month timer surveillance should have had a due date of August 1987 and a mid January 1988 critical date. As a

result, TS 3.0.3 was entered and a reactor shutdown was initiated.

J At 4:48 p.m. on July 2, 1988, both trains had been satisfactorily 1 tested. At 5:02 p.m. TS 3.0.3 was exited. At 5:05 p.m. the GSEP

< alert condition was terminated. The cause of the event was an omission by the personnel involved in inputting information to the surveillance program to include provicions for testing of the 40-second sequencing timer. Contributing to this event are the two imiependent start permissives, a feature unique to the CS syste The imediate corrective actions were to generate a temporary test i procedure and to perfom a test to verify the 40-second timer

operation and demonstrate compliance on Unit 1. Corrective actions

to prevent recurrence include

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(1) A detailed review of ESF response time testing procedures to ensure all actuation circuits are included for surveillance testin (2) Procedure 18wVS 8.1.1.2 F-13, "1A Diesel Generator 24 Hour Load Test and ECCS Surveillance," was revised to include testing requirements for the 40-second time The safety significant of this event is that until the surveillance was performed, the CS system response to a containment High-3 condition was in question. Subsequent completed test data did show that the CS system was within TS requirements. This is an apparent violation of TS 4.3.2.2 (LER 456/88014) (456/88028-01(e)(DRP);

457/88028-01(e)(DRP)).

c. At 11:40 p.m. on September 28, 1987, it was discovered that the 18w0S 8.1.1.2A-1 required monthly surveillance (with a weekly requirement, prescribed by TS Table 4.8-1, due to previous test failures) for the 1A Diesel Generator (DG) had not been perfonned by 9:20 p.m. on September 28, 1987 (TS critical date). The DG was immediately declared inoperable, and the surveillance was starte At 12:40 a.m. on September 29, 1987, the surveillance was completed and the 1A DG was declared operable. The cause of the missed surveillance was a cognitive personnel error by a licensed operator who put a cover sheet for the semi-annual DG surveillance on the previous conpleted monthly surveillance. This mistake misled the operating department surveillance coordinator in that he war unable to locate the executed copy of the surveillance. Subsequently, updating of the surveillance schedule for the weekly frequency was delayed, and the operating shift personnel were not notified of the

'equirement in a timely manner. The corrective actions were to perform the missed surveillance and to discuss with operating personnel the importance of verifying that the correct surveillance coversheet is used. The safety significance of this event is that, due to the previous surveillance test failures, the operable status of the DG was questionable. This is an apparent violation of TS 4.8.1.1.2 (LER 456/87047) (456/88028-01(a)(DRP); 457/88028-01(a)(DRP)).

d. On four separate occasions (October 7, 21, 27, and 29, 1987) the required daily calorimetric was not performed within the TS critical time period. On October 7, 1987, documentation of the completed surveillance was lost. A subsequent surveillance war completed at 1:38 p.m. The TS critical time was 7:30 a.m. Therefore, there was no documentation to verify the surveillance had been completed within the specified time limit. This item was reviewed with the individuals involved, stressing the importance of utilizing operating provisions to complete surveillances. This occurrence was discovered during the operating staff review of the surveillance on October 22, 198 ;

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On October 21, 1987, the calorimetric calculations were performed

, outside the time allowed by TS (6:00 a.m. on October 21,1987).

Due to thermal power fluctuations, which were caused by clogged condensate strainers which resulted from a licensee initiated power increase, prerequisi'es for the surveillance could not be me Corrective actions included additional operator guidance and -

administrative controls to ensure timely completion of surveillance requirement On October 27,1987 ct 7:00 a.m. (TS critical time), a calorimetric surveillance was required. Due to the same types of evolutions as on October 21, 1987, the calorimetric was not completed on tim The surveillance was completed at 1:07 p.m. on October 17, 198 On Octooer 29, 1987, the calorimetric calculation was performed outside the time allowed by TS (9:00 a.m. on October 29,1987)asa result of an improper turnover by the midnight crew Shift Control Room Engineer (SCRE) with the day crew shift SCR The requirement to perform the calorimetric was listed on the turnover sheet; however, the critical time for performing the surveillance was not identified. The surveillance was completed at 12:04 p.m. on October 29, 1987. The individuals involved were counselled, stressing the importance of conducting a thorough turnover and maintaining cognizance of surveillance tracking. This occurrence was identified during the operating staff review of the surveillance

. on October 31, 1987. The safety significance of these events is that until the daily calorimetric is satisfactorily completed, the i potential for a non-conservative indication of reactor power existed. The late completed test showed that the power range nuclear instrumentation never exceeded the 2% difference between

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calculated and indicated values allowed by the TS. This is an apparent violation of TS 4.3.1.1 (LER 456/87054)

(456/88028-01(b)(DRP);457/88028-01(b)(DRP)).

e. On November 7,1987, during the review of the September 5,1987 Unit 1 "Shif tly and Daily Operating Surveillance Package," 18w05 0.1-1,2,3, it was discovered that Data Sheet 11, Unit 1 Mode 1, 2, 3. "TS Data Sheet Primary Plant and Accumulator Operability," was missing. The missing data included the status of safety injection (SI) accumulator alarms, accumulator water volume, accumulator nitrogen pressure, accumulator isolation valve status, and pressurizer pressure. The surveillance package had been disassembled for ease in collecting data. The package was later reassembled and reviewed by shift per.tonnel. When the package was reviewed by the operating staff, Data Sheet 11 was no longer part of the package. An extensive search was conducted to locate the missing sheet, but the search was unsuccessful. The cause of the event was the methodology used at the time of the surveillance. The imediate corrective action was to conduct a search for the missing sheet. Action to prevent recurrence was to restructure the surveillance so that disassembly of data sheets is no longer necessa ry. The safety signif!cance of this event is that until the sequence of events recorder and shift oaily logs were reviewed,

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subsequent to identifying the problem, the potential for an undetected inoperable SI accumulator existed. This is an apparent violation of TS 4.5.1.1 and 4.2.5 (LER 456/87059)

(456/88028-01(c)(DRP);457/88028-01(c)(ORP)).

f. At 2:00 p.m. on June 9, 1988, the Station Chemist was informed that l four release tank samples required for both n.onthly and quarterly composite samples for TS 4.11.1 compliance were missing; therefore, the analysis could not be performed. The root cause of this event B a program management deficiency in that there were no specific provisions for the proper disposition of composite samples once they had been analyzed for gamma activity. Samples are now kept in a locked storage caoinet in the chemistry area. No isotopic samples from the release tanks will be disposed of until chemistry management verifies that composite samplot are properly stored. Composite samples will be disposed of following chemistry managen.ent verification that required analyses have been completed. This event was reviewed with appropriate chemistry department personnel, stressing the necessity to appropriately obtain, control, and analyze all samples required for compliance with TS. This event is an apparent violation of TS 4.11.1 (LER 456/88013).

At 12:00 p.m. on July 21, 1988, during a routine review of TS requirements for Table 4.11.1, it was discovered that two of the sampling requirements had not been incorporated into the surveillance program; therefore, they had never been performe These were the condensate polisher sump discharge monthly grab and composite samples and the waste water treatment discharge quarterly composite samples. The cause of this event was a misinterpretation of the amended TS requirements by a nonlicensed chemist. The correct interpretation of the TS table was verified by the Radiation Chemistry Department. The monthly and quarterly composite samples were obtained. Actions to prevent recurrence included enhancing the checklist used to document review and compliance with TS changes tu ensure proper interpretation of the changes are addressed. The General Surveillance Program procedure was reviewed to ensure the proper review of and concurrence with items being added and/or changed. A review of the TS was performed to identify any similsr types of tables and to ensure that the surveillance requirements are being properly fulfilled; none were identified. The significance of this event is that with the missed samples a complete documentation of liquid discharges was not available. Also, during a release with elevated levels, the licensee would have been relying on an automatic function to preclude a release above acceptsd limits without complete documentation on what is being released. This is an apparent violation of TS 4.11.1 (LER 456/88017)

(456/88028-01(d)(DRP); 457/88028-0(1)d(DRP)).

g. At 8:00 a.m. on May 31, 1988, it was discovered that documentation for the performance of surveillance 2Bw05 8.2.1.1-1, "Unit 2 DC Bus Train Operability Weekly Surveillance," could not be located. A l

thorough search of the Shif t Engineer's office and Control Room was

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immediately conducted. However, the only evidence that could be found that indicated that the surveillance was completed was the GSRV program entry, which is not an adequate assurance that the surveillance was completed satisfactorily. The surveillance was performed at 8:50 p.m. on May 31, 1988, with satisfactory result The critical date was May 29, 1988. This event was reviewed with the operating staff. The event was attributed to personnel error associated with losing the surveillance documentation. The safety significance of this event was the potential undetected inoperability of the Unit 2 DC bus. A review of operator rounds packages indicates this equipment was functional curing this even This event is an apparent violation of TS 4.8.2.1.1 (LER 457/88010)

(456/88028-01(f)(DRP);457/88028-01(i)(DRP)). On September 25 and 27, 1988, the licensee identified that the Axial Flux Distribution (AFD) surveillance per, TS 4.2.1.4, for Units 1 and 2 had not been performe The cause of the event was a personnel error in the administration of the surveillances. The hand-written records erroneously showed that the surveillances had been performed. This resulted in the critical date for the surveillance being exceeded on both units. The Unit 1 interval was exceeded by 17 effective full power days (EFPD) and the Unit 2 interval was exceeded by 18.5 EFPD. The licensee's corrective actions were to reduce power on Unit 1 to less than 90% and to perform the surveillances on both units. The AFD data showed that both units were within acceptable limits. Additional corrective actions include entering the surveillance into the GSRV program, assigning specific responsibilities for core burnup to a designated individual, and reviewing the event for Byron and Zion. The licensee will review all TS surveillances that are designated "0" (Other), i.e., those that are not on a time frequency. The significance of this event was a potential for being outside the Oc1ta I target band without proper indication cf penalty minutes accumulated and requirad power reduction. This is an apparent violation of TS 4.2.1.4 (456/88028-01(g)(DRP); 457/88028-01(g)(DRP)).

(LER456/88021)

, The licensee failed to perform proper quarterly vibration tests on i

the IB, 2A, and 2B RHR pump On February 18, 1988, during an investigation of the upper motor bearing vibration readings taken on the IB CS pump on February 8,1988, it was discovered that the  :

'.ower motor bearing vibration readings were improperly performed for the 18, 2A, and 2B RHR pumps due to incorrect placement of

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transducers for vibration tests. The pumps were declared inoperable, satisfactorily tested, and declared operable by 2:24 p.m. on Februa ry 29, 1988. The cause of the event was an improper inter-pretation of ASME Section XI concerning pump vibration data

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acquisition points. This resulted in incorrect identification of mandated vibrational requirements for pumps forming integral units with their drivers and the generation of inadequate procedures and training requirements.

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I The affected procedures have been revised to clearly specify the location for the vibration readings and to provide appropriate acceptance criteria. The significance of this event is that the performance of safety-related pumps could have been deteriorating and gone undetected. This is an apparent violation of TS 4. '(oursuant to testing requirer 456/88028-01(1)(DRP); ~ts of ASME Section XI (LER 456/88007)

457/Luu28-01(i)(DRP)).

J. At 12:50 p.m. on December 24,1987, it was 11scovered that the

"Fower Operated Relief Valve (PORV) and PORV Block Valve Stroke Test Surveillance," BwVS 0.5-2RY.1, required every 92 days, had not been completed. The critical date for completion was December 17, 198 PORV 1RY456 was inoperable due to excessive seat leakage, and its dssociated block valve Was closed. At 1:05 p.m. both PORV block valves and the remaining operable PORY (this is an ASME Class B valve),1RY455A, were declared inoperable due to the incomplete surveillance which had been initiated on December 11, 1987. The surveillance was satisfactorily performed on both PORV block valves and 1RY455A, thus the valves were declared operable at 1:16 p.m on Decenber 24, 1987. The cause of the overdue surveillanca was confusion relative to a procedural requirement which mandated that both PORVs and associated block valves be operable to perform the surveillance in Modes 1, 2, and 3. The corrective action taken was to revise the procedure to enter a Limiting Condition for Operation Action Requirement (LC0AR) and perform the surveillance should one of the PORVs be inoperable. The significance of this event is that an unidentified potential for the PORVs and block valves to be

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inoperable existed. The potential also existed for pressurizer safety valves to operate unnecessarily if the PORVs were inoperabl This is an apparent violation of TS 4.4.4.2 and 4.0.5 (LER 456/87061)

(456/88028-01(j)(DRP); 457/880?8-01(j)(DRP)).

k. On July 22, 1988, it was discovered that the licensee had failed to *

perform the required surveillance on two essential service water valves. At 8:12 p.m. on March 1,1988, an Out-0f-Service (005) was placed for work activities on the IB containment chiller, which included SX isolation valves ISX1128 and 1SX1148 to isolate the chiller. On April 10, 1988, BwVS 0.5-2.SX.1, "ASME Surveillance Requirement for Essential Service Water Valves," was partially performed due to the 1SX1128 and 1SX114B valves being 00S for <

containment chiller wor May 2,1988, was the critical date for completion of BwVS 0.5-2.SX.1. At 11:35 a.m. on May 21, 1988, the 005 on the containment chiller was cleared, and the chiller was returned to service. The surveillance requirement for ISX112B and 1SX1148 was not completed. At 12:57 p.m. on July 22, 1988, upon discovery of this deficiency, the valves were satisfactorily tested and declared operable. The root cause of this event was that no guidance was provided for actions to be taken when a surveillance procedure cannot be completed because portions of the items addressed in the procedure are 00s. Actions to prevent recurrence are to revise the equioment 005 procedure to require that a copy of the Surveillance Data Package Cover Sheet be attached, in addition, the "R/S Sury Required" "Yes" box of Section 5 of the 005 form is to 8 '

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i be checked when attaching a copy of the Surveillance Data Package Cover Sheet for any surveillance that cannot be completed due to an existing OOS. The significance of this event was the potential inoperability of the two SX valve This is an apparent violation of TS 4.0.5 pursuant to ASME Pressure Vessel Code Section XI (LER 456/88018) (456/88028-01(k)(DRP); 457/88028-01(k)(DRP)).

4. Evaluation of the Event Based on the inspector's analysis of these and previous similar events, it appears that a lack of effective management controls exist relative to the administration of the surveillance program. Prior to this special inspection, the resident inspectors had identified concerns about the surveillance program to the licensee through Notice of Violations (NOVs)

rnd management meeting NRC Inspection Report 456/87014; 457/87014, from April to June 1987, expressed a concern that the review process of the surveillance packages by the operating staff was not adequately controlled and could result in lost surveillance packages. Inspection Report 456/87023; 457/87022, from June 21 to August 1,1987, contained an NOV with three examples of missed surveillances which had exceeded their critical dates (due date plus 25%)

due to administrative scheduling errors. Inspection Report 456/87035; 457/07033, from September 13 through October 24, 1988, contains an NOV for failure of short term corrective actions relative to five separate occasions of a missed 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> hourly AFD serveillance. The cause was a TS misinterpretation by the operators on shift. This report also documents an October 5,1987 management meeting with the licensee. The NRC staff identified that licensee management attention was needed relative to the administration of the surveillance program. Inspection Report 456/88019; 457/88019, from May 29 through July 9, 1988, identified an inspector concern relative to the frequent performance of surveillances on or shortly before their critical dates. Additionally, it was stated that scheduled due dates for surveillances were frequently missed resulting in challenging the critical date. Also, it was stated that this indicates a lack of management emohasis on performance of surveillance activities in accordance with published schedule The events detailed in Section 3 of this report are similar in origin when compared to the events and concerns documented in previous NRC inspection reports. A major similar origin or root cause noted was personnel errors leading to lost surveillances TS misinterpretations, procedural inadequacies, and scheduling error Also, the inspector found that a conmon contributor to exceeding the TS critical time and dates, for many of the examples detailed in Section 3 of this report, was that the review process was completed after the critical date. In addition, several of the surveillances were performed very close to the critical dates, which ;id not allow time to review and possibly reperform the surveillances ' aore their critical dates were exceeded. All of the events describ J in aggregate demonstrate a lack of

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overall management con' ols for the management of personnel involved in identification, complecion, and documentation of surveillance activitie This lack of control resulted in missed or incomplete surveillances, which verify that operation of the plant is in accordance with the TS . Corrective Actions Initiated by the Licensee Subsequent to the events in Section 3 and 4 of this report, the following types of corrective actions were implemented:

For the NOVs describe 6 in Section 4, which were prior to the events detailed in Section 3, the corrective actions consisted of changes to procedures or operator aids to address the specific events. A broad scope corrective action plan was not used. Also for the majority of events described in Section 3 the corrective actions were for the specific events. Most of the corrective actions consisted of procedure changes, counseling of personnel, and administrative changes to address the specific event. Some of the corrective actions, such as for the missed SX valve surveillance, were adequate and did cover a large area. The corrective actions in general were too event specific and as evidenced by the continued missed surveillances were not broad enough in scop ; Conclusion The conclusion of '.he NRC staff is that a stronger management control of the Braidwood surveillance program is needed. When each item in Section 3 is reviewed separately the specific event was adequately managed, but in aggregate, with the NRC concerns and NOVs identified in Section 4 of this report, it appears that the licensee has failed to exercise adequate management controls to ecsure that the TS related surveillance program is administered in a manner that ensures proper identification, completion, and documentation of the required surveillances. This failure to adequately perform TS surveillances is an apparent violation with multiple examples (456/88028-01(DRP); 457/88028-01(DRP)). Exit Intervie'., (30703)

The inspectors met with the licensee representatives denoted in paragraph I during the inspection period and at the conclusion of the inspection on November 3, 1988. The inspectors sunnarized the scope and results of the inspection and discussed the likely content of this inspection report. The licensee acknowledged the information and did not indicate that any of the information disclosed during the inspection could be considered proprietary in natur