IR 05000461/1986053

Insp Rept 50-461/86-53 on 860804-1010.Violation Noted: Failure of Mgt to Implement Programs to Control Maint & Mod Programs

ML20214P112
Person / Time
Site:	Clinton
Issue date:	11/26/1986
From:	Dupont S, Hasse R, Phillips M, Wohld P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20214P021	List: IR 05000461/1986053 ML20214P019
References
50-461-86-53, NUDOCS 8612040079
Download: ML20214P112 (27)

Text

U.S. NUCLEAR REGULATORY COMISSION

REGION III

Report No. 50-461/86053(DRS) .

Docket No. 50-461 License No. CPPR-137 Licensee: Illinois Power Company 500 South 27th' Street Decatur, IL 62525 Facility Name: Clinton Nuclear Power Station, Unit 1-Inspection At: Clinton Site, Clinton, Illinois

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Inspection Conducted: August 4 through October 10, 1986 Inspectors: P. R. Wohld B/24[S4 Date S. G. DuPont / k Y kr //fL/f6d Date

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R. A. Hasse 'e // 2t[gg Date

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Approved By: Monte . h111ips, Chief #h8/fs Operational Programs Section Date Inspection Summary Inspection on August 4 through October 10, 1986 (Report No. 50-461/86053(DRS))

Areas Inspected: Special, unannounced team inspection of previously identified inspection findings, followup on 10 CFR 50.55(e) items, followup on allegations, maintenance program implementation, modification program implementation, and motor-operated valve control logic. A September 19, 1986, management meeting was also included in the inspection.

Results: Of the six areas inspected, apparent violations of four criteria in 10 CFR 50, Appendix B, were identified, each with multiple examples. The attachment to this report summarizes the violations, with examples, and cross references the associated report page number PDR ADOCK 05000461 G PDR _

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DETAILS Persons Contacted-Illinois Power Company

• W. C. Gerstner, Executive Vice President, Illinois Power

1. • D. P. Hall, Vice President, Illinois Power

• J. W. Wilson, Manager, Clinton Power Station

1. • K. A. Baker, Supervisor, I&E Interface

• R. E. Campbell, Manager, QA

1. • J. A. Fertic, Director, Quality Systems and Audits

1. • R. D. Freeman, Assistant Plant Manager, Maintenance

1. • J. H. Greene, Manager, Nuclear Station Engineering

1. • F. A. Spangenberg, III, Manager, Licensing and Safety

• A. Zabel, Attorney for Illinois Power

1. J. G. Cook, Assistant Plant Manager

1. E. J. Corrigan, Director, Quality Engineering and Verification

1. H. K. Lane, Manager, Scheduling and Outage Management

1. J. S. Perry, Manager, Nuclear Program Coordination

1. J. D. Weaver, Director, Licensing

1. J. C. Wemlinger, Supervisor, Nuclear Training Department NRC-

• A. B. Davis, Deputy Regional Administrator, Region III

• C. G. Norelius, Director, Division of Reactor Projects

• C. J. Paperiello, Director, Division of Reactor Safety

• C. W. Hehl, Chief, Operations Branch

• P. L. Hiland, Resident Inspector

• R. C. Knop, Project Section Chief

1. • M. P. Phillips, Chief, Operational Programs Section

• M. A. Ring, Chief, Test Programs Section

• R. F. Warnick, Branch Chief

1. T. P. Gwynn, Senior Resident Inspector

1. C. Scheibelhut, NRC Consultant State of Illinois

• Jason, Assistant Attorney General

1. Denotes those attending the exit meeting held September 12, 1986, at the Clinton sit * Denotes those attending the management meeting held in the Region III office in Glen Ellyn on September 19, 198 Additional plant technical and administrative personnel were contacted by the inspectors during the course of the inspection.

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! ' Overview The inspection reported herein reflects increasing inspection effort in response to increased maintenance activities in preparation for fuel loading and in response to concerns generated for the adequacy of the

. conduct of maintenanc It also reflects inspection effort resulting from the:NRC Resident Inspector's concerns for the adequacy of the conduct of plant modifications. . Apparent violations were identified in both areas that included multiple examples against four criteria of 10 CFR 50, Appendix B: (1) Design Control; (2) Instructions, Procedures, and Drawings; (3) Test Control, and-(4) Corrective Action. The' violations indicated a quality breakdown in the maintenance and modification-programs, the root cause of which was'the failure of management to implement the programs controlling these activitie 'A key factor in many of the problems leading to the apparent violations was

.the lack of adequate corrective action. The inspectors found that the licensee's staff was already aware of nany of the problems identified, knew the root cause, and the necessary corrective action; however, the problems and solutions were either not raised to the management level necessary to obtain action, or,.when raised to that level, were not adequately addresse The inspectors also found that supervisors and mid-level managers failed to-understand or implement some of the basic maintenance and modification program quality requirements.- When problems were identified'for resolution, they did not fully appreciate the extent of the need nor the necessary scope of corrective action The quality breakdown in the maintenance' program was reflected by:

(1) the equipment problems identified by the licensee that were caused by improperly conducted maintenance activities; (2) improper or degraded equipment conditions identified by the inspectors, and (3) documented equipme'nt problems for which corrective actions had been inadequate. The quality breakdown in the modification program is reflected generally by poor.overall administrative control of the program and was evident.from the inspectors' review of vaulted modification packages. The inspectors found:

(1) a lack of-adequate modification testing .in a few cases; (2) test instructions,. test acceptance criteria,- test results evaluation, and documentation required by the plant procedures and accepted practices were generally lacking, and (3) inadequate documentation of safety evaluation . Action on Previous Inspection Findings Inspection in this area was for items opened in Inspection Report No. 50-461/86045(DRS)'which included motor-operated valve programs (including actions on IE Bulletin No. 85-03) and valve mechanical conditions. Two violations were identified by the inspectors that, while existing from original construction, should have been identified and corrected by valve maintenance activities conducted by the license (See Items e and f.6 below.) (Closed) Open Item-(461/86045-01): Limitorque valve operator geared limit switch lubrication controls. Mechanical Gang Box Training Procedure, GBTM-011, "Limitorque Limit Switch Gear Box Lubrication,"

was issued on July 1, 1986; documented training was held shortly

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thereafter., A precaution was added to Step No. 8.1.4.4 of Maintenance Procedure No.'. 8451.01, " Motor Operated Valves, Generic Procedure For,"

to assure that the geared limit. switches do not lose their alignment during a regreasing evolution. The above~was reviewed by the inspector and was:found.to be adequate to close.this item.

b. '(Closed) Open Item-(461/86045-02)

.-RCIC Turbine Trip and Throttle i

Valve, 1E51-C002E, safety-related strokes. A review of the electrical

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drawings indicated that the. valve operator motor thermal overloads are

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normally bypassed for both the open and close-valve strokes. The L licensee.has evaluated the valve logic and has-implemented a change to Plant ~ Technical Specification (TS), Table' No. 3.8.4.2-1,

to include this_ valve for thermal overload bypass surveillance testing. This item is considered closed.

i- c; (0 pen) Open Item (461/86045-03): Adequacy of valve differential pressure testing under IE Bulletin No. 85-03. The. licensee submitted

. a supplemental response to the bulletin, dated September _10, 1986,.

which provides additional information on this item. This item will

' remain open pending evaluation of the response by the Office of

Inspection and Enforcement.

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t ' (0p4n) Open Item (461/86045-04): Long term valve operability progra '.

The-licensee is preparing testing and preventative maintenance-procedures _ in this area per their revised response to IE Bulletin No. 85-03,: Action Item d, submitted by letter to Region III on-

-September 10, 1986. The scheduled date to' complete this program is i November 20, 1986, per letter to Region III, dated September 2, 1986.

l Closure of this item is pending the completion of the licensee's commitment and subsequent NRC revie (Closed) Open Item (461/86045-05): Program for valve lubrication.

! Additional walkdowns by the NRC resident inspectors since this item

! was_first identified indicated that a significant percentage of l motor-operated valve stem threads had not-been lubricated. This is contrary to Step No. 7.1 in plant Procedure No. GTP-55, " Motor i

Operated Valves," which states: " Remove stem protection cover and check that. the stem is clean and properly lubricated." Some valve l: stem threads (approximately 30) can not be checked for lubrication l by this instruction because the threads are buried within the operator

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or are lubricated through a-fitting. The procedure was used to test all motor-operated valves during the plant preoperational test phase and should have been corrected to properly address all motor operated

valves the first time it could not be used as intended in the fiel Further, maintenance Procedures No. 8451.01, 8451.02 and 8451.03,

which were written and used at the time of this inspection to verify,

test,-and maintain motor-operated valve conditions did not contain l provisions for assuring proper lubrication of the valve stem threads.

I~ The failure to lubricate motor operated valves as provided in GTP-55, failure to correct the procedure when it could not be used properly, and failure to otherwise provide an adequate procedure are considered examples of a violation of Criterion V, Instructions, Procedures, and Drawings, in 10 CFR Part 50, Appendix B (461/86053-02a).

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Immediate corrective' action by the licensee included preparing and implementing Maintenance Work Request (MWR) No. C10294 to-assure that all safety-related valve stem threads were properly lubricate The development of an adequate program for valve lubrication will be tracked by the violation. The open item is considered close f. (0 pen) Onresolved Item (461/86045-06): Motor-operated valve mechanical condition. A number of mechanical equipment degradations were identified by the inspector in the sample.of 10 valves described in Inspection Report No. 50-461/86045. A description of the degradations.and licensee actions initiated to address them are below:

(1) Inoperable handwheel operators. Handwheel operation of safety-related valves was checked by the licensee during the performance of MWR-C1029 Approximately 25 handwheel problems were identified. The licensee indicated that these will be tracked, corrected, and corrective action documented in the MWR ickag (2) Electrical conduit hole plug missing from the valve operator switch compartment. The specific conduit hole plug found missing by the inspector on June 18, 1986, was on inboard containment isolation valve No. OMC010. It provided an approximately 1 1/2 inch hole in the top of the valve operator electrical switch compartment, defeating 1its environmental qualification. -(This is further discussed as a contributor to the vimlation identified in (6) below.) .An overall external inspection of all safety-related

"alves was conducted under MWR-C10294 to address this type of condition. A number of items were identified, all of which the licensee indicated will be tracked, corrected as necessary, and documented in the MWR packag (3) Valve stems not properly lubricate This is addressed in

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Paragraph 3.e of this report.

l (4) Excessive handwheel ~ force required _to operate valves and

improperly set torque switch. The high handwheel force observation was not an item of immediate concern; however,

a spring scale measurement of handwheel operating force could i be a valuable indicator of valve condition for: (1) long term

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valve operability. trends and assessments; (2) cross checking values among identical valves to identify problems, and (3) to help identify changes in valve stem thrust requirements related to packing, packing replacement, and packing tightening.to stop leaks.

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The valve found with the improperly set torque switch,1E22-F015, was considered to be an isolated case. On further inspection by

- the licensee, a locking pin was found broken in the torque switch.

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Corrective action to replace and reset the torque switch and

perform valve operability testing was completed successfully by

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(5) Valve operator limit switch compartment corrosio The licensee indicated that the switch compartment has been cleaned, reworked, and returned to servic (6) Unqualified wire found in Valve No. 1E22-F010. The unqualified wire found is discussed in detail in Paragraph 7 of Inspection Report No. 50-461/86045(DRS). The unqualified wire was missed during two EQ walkdowns conducted by the licensee and a third check during the conduct of Maintenance Procedure No. 8451.03, Step No. 8.1.1. The missing conduit plug is another environmental qualification item, discussed in (2) above, that appears to have been missed in the EQ walkdowns on the MOVs. These constitute a failure to follow procedures and instructions and are examples of a violation of Criterion V, Instructions, Procedures, and Drawings, in 10 CFR Part 50, Appendix B (461/86053-02b).

The inspector determined that the corrective actions initiated or completed were adequate to address the problems identified and assure valve operability at this time; however, as discussed with the licensee, the activities needed to assure an acceptable mechanical condition of the valves in the long term have yet to be addresse In a letter to J. G. Keppler, dated September 2, 1986, the licensee committed to have a program in place by November 20, 1986, that will address long term valve operability. This item remains open pending satisfactory completion of this commitment and subsequent NRC revie (This item will be reviewed together with Open Item (461/86045-04) on long term valve operability testin See Item No. 3.d in this report.) (0 pen) Open Item (461/86045-07): Limitorque motor-operator wire qualification. The licensee presented information to the inspector which indicated that all of the Rockbestos Firewall III wiring insulation subgroups used in the limitorque valve operators are acceptabl The information was transferred to an environmental qualification specialist in the regional office for further revie Closure of this item is pending that review.

l Items e and f and apparent violations noted therein for inadequate lubrication and poor valve mechanical condition reflect a failure in the valve maintenance activities, conducted since construction, to assure proper valve setup for operational conditions. Itemsathroughdandg became open items primarily because of the early stage of the licensee s programs or because additional information was needed. They do not necessarily reflect a weakness in licensee performanc . Followup on 10 CFR 50.55(e) Item (0 pen) 10 CFR 50.55(e) Item (461/86004-EE): Modification of Limiter Plates on Limitorque Valve Operators. During motor-operated valve testing, using MOVATS signature analysis test equipment, the licensee performed an unauthorized modification of 36 torque switch limiter plates to allow the adjustment of the torque switch settings beyond the prescribed maximu This was done when low stem thrust values measured by the M0 VATS test

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equipment indicated a need to increase thE operator thrust output. (Thrust-target values were established by the licensee at 110% of vendor calculated

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thrust requirements for valve operation.) However, this increase in torque

! switch setting invalidated the undervoltage operability qualification for.

[ - the valve operator Inadequate. evaluation of the modification and inadequate post modification testing failed to reveal this initiall After an expression of concern by' Limitorque, the licensee initiated undervoltage testing of the valves. This testing, with additional analysis,

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indicated that, under degraded plant voltage conditions, approximately 90%

of the modified valves would go to locked rotor conditions without tripping the torque' switch on valve closure. This would result in valve motor burnout. .The overall safety' significance of this was that it could have adversely'affected the operability of three emergency core cooling systems, i the shutdown service water system, and fire protection system l i

Illinois Power Company provided a preliminary report on this item in a  :

letter to J. G. Keppler, Regional Administrator, Region III, dated l

August 15, 1986. After' evaluation of the response and further discussion ,

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with the licensee, it appears that corrective action has been taken to

, assure that the valves are available to perform their design' function and i that measures have been initiated to correct.the conditions that allowed

the uncontrolled modification of the valves. Twenty-nine of the 36 valves  !

were returned to.their original design condition.- The remaining seven i valves were tested in the modified condition and found capable of closure under degraded voltage conditions.

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There are two areas of concern relating to the limiter plate modification as it was performed by Illinois Power Company: Plant Design Controls Maintenance Procedure, CPS No. 8451.02, Revision 6, Step No. 8.7.3.12, was improperly approved to direct filing down the limiter plates. The plant staff failed to recognize this as a modification when approving the procedure (Revision 6 and earlier revisions) and, 'hence, failed to follow-the provisions under Corporate Nuclear Procedure, CNP 4.08, i " Plant Modification System." This procedure specifies the appropriate design control measures, including technical review and post modification testing, that is intended to prevent the type of problem

that occurred with.the limiter plate changes. The failure to follow l CNP 4.08 is an example of a violation of Criterion III,-Design Control, in 10 CFR Part 50, Appendix B (461/86053-01a). Corrective Action

. Corrective action in response to low thrust values identified early in the valve test program was inadequate, resulting in the unnecessary i modification of some of.the limiter plate The twenty-nine valves returned to their original configuration were done so by additional i corrective maintenance or by reconsideration of how valve packing

, loads are included in the evaluation of M0 VATS test results. The j licensee has not evaluated the cause for the remaining seven valves

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failing to' meet their' design requirements without. modification. This

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leaves 1an open question'aseto whether or not there is-a problem with the seven valves as supplied by the vendors, or, if there is a factor '

that caused degradation of the-valves' capabilities peculiar to the I Clinton Power Station. Another indicator of inadequate corrective I action _is identified in Paragraph 6.b-(MWR-831175) of this report. -It

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. relates to'a limiter plate modification that resulted in the valve motor going to-locked rotor conditions at normal voltage. Subsequent maintenance corrected the_ problem. 'The final torque switch setting was at the " nominal" value with operator thrust developed well above, minimum. Documentation and evaluation of that activity was inadequate-for a determination of why the operator originally failed to meet its design. requiremen The failure to properly evaluate the cause of equipment failures is considered an example of a violation of Criterion XVI, Corrective _ Action, in 10 CFR Part 50, Appendix B (461/86053-04a).

While reviewing.this 50.55(e) item, the inspector noted that no concern was expressed by the licensee for the many valves that were not able'to perform as designed at the recommended, nominal torque switch settings (even though the' torque switches could be set high enough to achieve the design valve thrust requirements). The licensee's staff subsequently indicated that they had discussed this with a Limitorque representative who stated that the " nominal" value is the lower end of the torque switch setting range at which a valve may be expected to operate, and, that there is nothing unusual about-a required torque swit h setting anywhere between " nominal" t and " maximum." The licensee explained that all safety-related valves are M0 VATS tested to assure that the valve operator, with the "as left" torque switch settings, will operate as designed. Hence, the inspector had no further question on this at the Clinton Nuclear Power Statio This 50.55(e) item will remain open pending review of the final report (dated October 7, 1986) and resolution of the violations-identified with respect to the limiter plate modifications.

5. Followup on Allegations-

The inspector followed up on two allegations pertaining to activities

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at the Clinton site which involved the maintenance program. Results, E discussed below, indicated problems with the conduct and review of 1 maintenance activities and with the identification and implementation

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of corrective actions to adequately address problems.

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! (Closed) Allegation (RIII-86-A-0027)

i An individual contacted the NRC and stated that maintenance supervisors and management had ordered an employee to violate a procedure. The '

inspector determined from reviewing the-individual's statement that the allegation consisted of three parts: (1) that maintenance

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supervision had ordered him to accept work on testing of relief valves l with an incomplete data sheet, CPS 8120.30 0001, " Relief Valve Test *

Data Sheet," (2) that he was being discriminated against under the IP

!- Fitness for Duty Program, and (3) that there was a question on the

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adequacy of various maintenance procedures. Another item, Part (4),

was identified in information received from the Department of Labor which indicated that unnamed others were told to perform snubber testing in violation of procedural step The inspector was unable to substantiate Parts (1), (2) or (4) of the allegation but was able to substantiate Part (3). Pertaining to the third portion of the allegation, one violation was identified with two examples.

NRC Review and Conclusions (1) The inspector reviewed the procedure and recorded data sheet CPS 8120.30, " Relief Valve Test." The section of the procedure that the individual had stated as being incomplete was Step 8. which required recording the relief valve's (1G33-607A) normal operating temperature from the valve's nameplate (supplied by the manufacturer) or from other sources, such as machinery histor The individual had observed the omission of this data during the review for closure and had reported this to the maintenance supervisor who then requested him to obtain the information. The individual believed that it was not permissible to obtain the information required for Step No. 8.4.3 out of sequence because the procedure (CPS 8120.30) did not have any provision for performing steps out of sequence and, as such, the test should be re performed in sequence to obtain this data. Hence, the individual perceived the maintenance supervisor's instruction as direction to violate a procedur The inspector confirmed the facts stated above through interviews with the individual and supervision; however, through a review of the procedure, the inspector determined that recording the data out of sequence did not invalidate the test. This portion of the allegation is not substantiated and is the result of supervision not clearly communicating the requirements of the test to the individual and the individual not clearly understanding the objectives of the test being performed. Additionally, the inspector interviewed 13 other individuals at random and found no other individual who had been ordered by supervision to violate any procedural requirements.

(2) The inspector interviewed eight individuals to determine if management or supervision had discriminated against them under the IP Fitness for Duty program because of raising safety concern None of those interviewed indicated that they were discriminated against because of raising safety concerns or identifying discrepancies. In addition, the individual was interviewed and stated that the discrimination had ceased. The individual believed this was due to changes in supervision. The inspector was unable to verify that discrimination was currently being applied. Furthermore, the individual filed an employment

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discrimination complaint with'the U.S. Department of Labo By- ,

. letter,~ dated August 1, 1986, the Labor Department concluded

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. . . your allegations are unprovable . . . . . The disciplinary suspensions that have been levied . . . were for actions that were not protected. activities." This portien of the allegation could not be substantiate (3) The, individual identified that procedure CPS 8106.01, " Handling ,

of-Heavy Loads," Section 8.6.2 requires hand signals to be

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conspicuously posted and that these signs were not posted a required during heavy load handling. The. individual had raised a concern on this item and received an unsatisfactory response from the Administrative Assistant. Also, the individual's supervisor had requested a resolution on June 7, 1986; however, on August 28, 1986, the inspector found that IP was still not in compliance with the procedure in that no hand signals were poste 'The failure to correct the mir-3ing hand signal posting originally, when the procedure was first used, or to respond to the condition later in a timely manner is an example of a violation of Criterion XVI, Corrective Action, in 10 CFR Part-50, Appendix B (461/86053-04b).

-On another occasion, the individual had identified that the Procedure CPS No. 8227.01, " Standby Liquid Control Pump Maintenance," required to be used by Maintenance Work Request (MWR) No. B-15099 to change lubrication in the Standby Liquid Control (SLC) pump's crankcase, was not appropriate for the tas The inspector reviewed the procedure and determined that it did not provide instructions'for adding the lubricant, the quantity, or specifications for type of lubrican This is a failure to provide procedures appropriate to the circumstances. In addition, i the inspector found that a Condition Report (1-86-02-089) had been issued on February 6,1986, identifying _ the above .

discrepancies and that the maintenance supervisor had also docuiriented the discrepancies on the MWR; however, on August 28, 1986, the inspector found that the procedure had not been revised to provide adequate instructions. The failure to promptly correct the inadequate procedure is an example of a violation of Criterion XVI, Corrective Action, in 10 CFR Part 50, Appendix B (461/86053-04c). This portion of the allegation was substantiate (4) The fourth portion of the allegation was not substantiated since, as noted in (1), personnel interviewed did not indicate any instance where they had been ordered by supervision to violate a procedur b. (Closed) Allegation (RIII-86-A-0126)

In July 1986, an individual alleged problems with the conduct of motor-operated valve testing and maintenance, and with the adequacy of corrective actions for problems identified during the conduct of these activities. The key elements of the allegation were that:

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(1) condition reports were not written for M0V problems; (2) actions taken by Illinois Power to correct M0V failures did not correct the root cause of the problems, and (3) Field Engineering Change Notice (FECN) 12329 contributed to the cause of some MOV failures.

NRC Review The inspector reviewed information provided by the individual and interviewed a number of maintenance mechanics, supervisors, and managers involved in. activities related to the allegation.

Documentation was reviewed including Maintenance Work Requests, Condition Reports, memoranda, drawings, FECN 12329, and special problem evaluations that were conducted and documented by the licensee.

Findings with respect to the specific allegation items are identified below:

(1) Condition reports not writte The inspector confirmed this allegation and found that, while some problems were addressed by Condition Reports, others were handled within the Maintenance Work Requests, sometimes inadequately. Two examples of this and an associated violation are identified in Paragraph 6.b (MWRs '

No. B31175 and 824239) of this report.

(2) Inadequate corrective action. The inspector confirmed this allegation. It is related to 5.b.(1) above, because the Condition Reports are a critical part of the corrective action proces Inadequate corrective actions for maintenance problems are violations of Criterion XVI in Appendix B of 10 CFR Part 50 and are identified in Paragraphs 4.b, 5.a, 6.a, and 6.b of this repor Inadequate corrective action was also a contributor, in some instances, to other violations identified in this report.

(3) FECN 12329 contributed to MOV motor failure This was verifie The licensee had also documented problems with the FECN and developed corrective action recommendations; however, the corrective actions were inadequat Related violations are identified in Paragraph 6.a of this report.

Conclusions Based on the findings of this inspection the inspector concluded that all of the individual's concerns were valid and that problems did exist that were not properly handled. These are specifically discussed in the referenced paragraphs. However, there were a number of actions by the licensee to address the problems, some of which the individual was not fully aware of or which had been initiated subsequent to the allegation. Most importantly, the licensee had initiated a program for post maintenance testing of all M0Vs that appeared comprehensive in scope and adequate to detect the types of problems that had been occurring. Controls were initiated to assure that each safety-related

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MOV would. receive this testing prior to declaring it operable as required by the Plant Technical Specifications. The licensee.had

' documented investigations and reports showing management's concern with the problems; however, the inspector concluded that licensee actions had not been sufficiently timely or adequate to address all

. problems identifie ' Maintenance Program Implementation Maintenance inspection activities included: (a) interviews with

. maintenance mechanics and staff'and review of maintenance problems. .. .

identified with respect to the allegation noted in Paragraph 5.b of this report; (b) a review of completed maintenance work request packages, and (c) observations of mechanical, electrical, and Control and Instrumentation (C&I) maintenance activities. The inspection findings indicated a problem with the management control of maintenance activities. Inadequate training resulted in maintenance personnel errors (evident from equipment failures);

while' inadequate provisions for the identification and correction of

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adverse conditions allowed such conditions to continue.affecting plant equipmen From discussions with QA/QC, it was apparent that some problems were being identified but there was inadequate support for their prompt and effective resolution. Also, it was evident from the mishandling of some of'

l the technical problems encountered that better engineering support of-maintenance was needed, Maintenance Interviews and Review of Identified Maintenance Problems

' Maintenance personnel were interviewed with respect to allegations-made about valve testing and modifications under maintenance work request packages. -These packages involved the use of Maintenance

' Procedures No. 8451.01, 8451.02, and 8451.03 which, together, were issued for setup, testing, and maintenance of motor-operated valve .The procedures involved the use of.MOVATS Incorporated signature analysis test equipmen Personnel interviewed identified problems that occurred early in the year,-primarily due to' inadequate training of the valve mechanics and an emphasis on plant schedules. A number of problems identified had been investigated by the licensee and corrective actions recommende Overall, the valve mechanics had a positive attitude about their current involvement in maintenance activities and their qualifications in performing valve maintenanc Further review of the identified problems indicated that the implementation of recommended corrective actions was not always adequate to-correct the problem. Also, the underlying issue of inadequate maintenance program control was not properly addressed as evident from the violations identified during the inspectio _

(1) Field Engineering Change Notice (FECN) No.12329, issued on September 28, 1985, changed the configuration of three phase power wiring to valve motors from that specified on the drawings (to obtain' proper motor rotation). New drawing copies issued did not reference the change because the FECN was not written against the drawings. This led to at least three valve motors being rewired according to the drawings such that they would experience burnout on the first valve stroke. (Motor rotation was opposite to that intended and motor damage occurred on at least one valve.) Failure to incorporate design changes into controlled design output documents is an example of a violation of Criterion III, Design Control, in 10 CFR Part 50, Appendix 8 (461/86053-01b).

The problem noted above was identified by the licensee at least by October 17, 1985, according to Condition Report No. 1-85-10-091. It was recognized as a deficiency against Corporate Nuclear Procedure, CNP 2.06, which directs plant configuration control measures. However, licensee corrective action was inadequate to prevent subsequent miswirings (again as noted above). On discussing the matter in August 1986, the licensee's staff indicated to the inspector that FECN No. 12329 was attached or referenced on valve schematic drawings to assure proper control of the wiring. However, on requesting a wiring schematic from the drawing issue room, FECN No. 12329 was not referenced on the drawing and the drawing clerk was not aware of its existenc Hence, the drawing still failed to reflect the design change, the same problem identified in October 1985. The licensee issued the appropriate Engineering Change Notices against the drawings when the problem was pointed out by the inspector. Failure to take the necessary corrective action when the problem was identified by the licensee's staff in 1985 is considered an example of a violation of Criterion XVI, Corrective Action, in 10 CFR Part 50, Appendix B (461/86053-04d).

(2) During M0V modification and testing approximately 17 valves were modified with improperly set limit switches. Valve closure torque switch bypass limit switches, assigned to Limitorque valve operator switch rotor No. 4 contacts 15/15c, were reassigned under maintenance work requests to rotor No. 3 contacts 9/9 Rotor No. 3 was then reset to change position towards the closed valve position to retain the original intent of the bypass contacts. In the process, rotor No. 3 was incorrectly set 90 degrees off on approximately 17 valves. This had no affect on valve operation when the valves were exercised with an associated TEST / NORMAL switch in the test position; however, in the normal position, the erroneously set bypass that is brought into the circuit on valve closure causes the valve motor to stay energized at the end of valve travel. This results in locked rotor current and in physical damage to the motor until the windings open, or short out and the valve circuit breaker opens, or the thermal overload heaters fail ope . . - The problem was inadvertently discovered by the licensee during a valve lineup on March 6, 1986, when main steam system containment isolation valves No. 1821-F067B and 1821-F067D were found closed so tightly that they could not be opened by the handwheel and would not work electrically. Prior to the time of discovery there was no QC inspection requirement for the orientation of the No. 3 rotors during or after their resetting; M0 VATS switch signatures and switch signature analyses were insensitive to the rotor orientation; post maintenance or modification testing was inadequate to discover the problem (as it was done with the TEST / NORMAL switch in the test position);

, and, operational surveillance testing, also done in the test mode,

would not detect the faulty switch settin The licensee indicated that there was no review done originally for reportability under 10 CFR 50.55(e) for the erroneously set

, valves. Only 12 valves can now be identified out of the original

17; hence, it is impossible to determine the potential safety safety significance of the original missettings. It is known that they came from a set of 23 that includes residual heat removal, high pressure core spray, reactor core isolation cooling, main steam, drywell cooling, fuel pool cooling, and fire protection systems. If the problem had gone undetected until the valves were needed, any or all of these systems could have been rendered inoperable. There appear to be 4 factors contributing to the above: (1) inadequate design change verification (specification for post modification testing); (2) failure to follow procedures and drawings that led to the missettings; (3) inadequate quality control inspection to discover the problem; and (4) inadequate post maintenance test or surveillance test specification. The failure to conduct adequate testing appears to be the most significant factor that led to allowing 17 miswiring errors prior to the first discovery. This failure is

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considered an example of a violation of-Criterion XI, Test Control, in 10 CFR Part 50, Appendix B (461/86053-03a).

The licensee had responded adequately to the switch setting problem at the. time of the inspection, including the ongoing implementation of a comprehensive post maintenance test requirement that should detect the type of problem noted above before a valve is declared operable. On October 7, 1986, the licensee issued Attachment B to 10 CFR 50.55(e) Deficiency Report No. 55-86-04. This is an addendum to the original report and addresses the cumulative problems identified during MOV testin It satisfies the reportability requirements for the 17 valve miswiring (3) Other items identified during interviews with the maintenance mechanics and supervisors included a potential problem with lubrication controls and a lack of effective shift turnover Some mechanics and one supervisor were unaware of recently

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! implemented lubricant usage control Shift crews did not-converse with the next shift to effect a smooth transition in

.the; middle of a work activity. This'was afscussed with licensee management, who indicated that improvements would be considered, as appropriat b. Maintenance Work Request (MWR) Package Review Approximately 20'recently completed MWR packages were reviewed for adequacy of maintenance performed, identification of equipment failure causes and' appropriate corrective action, and general implementation of maintenance program requirements. Problems identified during this review indicated inadequate program implementation in the areas of planning, mechanic qualification, adherence to procedures, package review, problem identification, corrective action, and engineering support.. Most significantly, improvements are needed in the licensee's own processes to identify and correct problems, both with the maintenance program and with the physical plant equipment. The following are specific findings related to the MWR package review (1) MWR No. B31175 This MWR was written to perform motor-operated valve testing,

' including the use of M0 VATS test equipment, on Vs1ve No. IE32-F002J. When.the valve failed to reach its target thrust value on April 2, 1986, the first response was to shave the torque switch limiter plate and increase the torque switch setting. This was apparently done without evaluating the problem for cause and resulted in the valve motor going to locked rotor conditions.on valve closur An April 16, 1986, entry in the MWR log reporting reinsta11ation-of the valve operator motor states "the wire coming from the motor to the heaters was made up with scotch locks. Two wires were loose and just end-capped while two more were jointed. We did not correct this because QA was not sure if . . . arrangements were already made." There is no other entry in the package to indicate that this condition was accepted as is or otherwise addressed and appears to be a failure to take corrective action for a condition adverse to qualit An April'25 entry in the log indicates that with the valve vendor representative onsite, a high handwheel torque condition necessary to operate the valve led to the discovery of " extensive rust deposits" in the stem area inside the vaive stem cove There is no indication in the package that the rust was removed or the stem lubricate A May 4 entry in the log indicates, " Repacked valve." A May 5 entry states, " Day shift supposedly had valve repaired but on further inspection the fitters had tightened packing so tight valve would not turn by hand." On May 17 the log indicates that the packing was again replaced and overtightened. A review of

E the procedure specified in the MWR for repacking instructions, CPS No. 8120.09, provided no guidance to prevent overtightening or test instructions to assure that this had not happened. Even though three sets of packing had been overtightened, one original and two replacements, no corrective action was addressed to prevent recurrence (which is particularly important if packing is reworked when a M0 VATS test is not subsequently performed).

Troubleshooting and repairs were attempted and several M0 VATS tests attempted from May 5 through May 13 without success in achieving the desired valve thrust. Finally, after the packing was replaced the second time, the yoke was repinned to the bonnet to repair looseness, and the operator was " reinstalled." The final test was successful with the torque switch settings at the minimum recommended valu The data sheets indicate more than doubling of the thrust developed for a given torque and a load reduction from stem packing friction of approximately 3,000 pounds. The root cause of the original low thrust condition was apparently corrected but never identifie The premature modification of the torque switch limiter plate, without addressing the cause of the low thrust problem, and the failure to document and evaluate the maintenance activities such that the cause could be determined are already included as a violation in Paragraph No. 4.b. In addition, other adverse conditions unrelated to the original intent of the MWR were identified including the wiring problems noted, i.e., a loose yoke, a broken declutch lever pin, and three valve packing sets excessively tightened. The maintenance supervisor and QA both signed the MWR package as complete without addressing the cause of any of the above, and, the MWR, block No. 56, "cause code" was entered as "no failure." This is in violation of Administrative Procedure, CPS No. 1029.01, which states, " Evaluate the MWR for determination of root cause and adequacy of corrective action taken. Ensure block No. 56 is correctly filled out." These additional failures to address conditions identified after the MWR was issued are examples of a violation of Criterion XVI, Corrective Action, in 10 CFR Part 50, Appendix B (461/86053-04e).

(2) MWR No. B24239 This MWR was issued for testing valve No. 2SX076B which has a rotating stem. Page 6 of the MWR log indicates, " Stem wobble noted throughout entire stroke," then, on Page 18, an entry indicated "0K" in reference to the noted wobble. There is no indication that the wobble noted was ever evaluated, corrected, or accepted as is. On questioning from the inspector, the licensee indicated that the "0K" referred to an evaluation passed on verbally by the maintenance mechanic. Because the mechanic was not qualified to make that determination, and because of uncertainty of the nature of the wobble, the licensee reperformed a valve stroke for evaluation. They reported that the valve operated acceptably but that the stem was bent approximately 1/8

inch off center. Engineering had not evaluated the acceptability of the bend at the time of the inspection (in terms of the affect on packing, strength of the stem, etc.). The failure to properly address the wobble is another example of failure to take adequate corrective action and is an example of a violation of Criterion XVI, Corrective Action, in 10 CFR Part 50, Appendix B (461/86053-04f).

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(3) MWR No. C15673 Documentation indicated as " attached" (a Nonconforming Material Report) was not attached. The missing documentation was located and added to the package during the inspection.

(4) MWRs No. C05813, C18057, C06655, and C22713 During the review of these maintenance packages, the inspector noted that not all of the supporting documentation was attached, and as such, did not provide for an adequate assessment of the maintenance actually performed. In MWR No. C22713, torque values were not provided for bolting replaced after a relief valve gasket replacement. MWRs No. C05813 and C18057 required specific torque values to be applied; however, the documented work description stated only that the components had been torqued and that the quality control inspector had accepted the maintenanc This did not provide assurance that the correct torque values were applied or that the approval review of the maintenance activity could verify the adequacy of the maintenance performe MWR No. C06655 required replacement of two missing washers and bolts on a diesel generator repair activity. However, the revicw of the material receipts attached to the MWR documented that 101 bolts and 10 washers had been received for installation per MWR No. C06655 and that 98 bolts and 10 washers had been returned after completion of maintenance activities per MWR No. C0665 The conclusion from the receipt documents would be that three bolts and no washers had been installed. However, the work description per MWR No. C06655 documented that two washers and bolts had been installed. This problem was actually attributed to the accounting method used by Clinton's purchasing where the actual counting of material was done upon return to purchasing and not when issuing the material for use. This could lead to the loss of accountability of safety-related or non safety-related material resulting in an extensive search to determine the effect on the quality of the Clinton Power Statio Both of these examples, failure to document the actual torque values applied and the lack of material accountability are examples of violations of 10 CFR Part 50, Appendix B, Criterion V (461/86053-02c) in that Administrative Procedure CPS No. 1029.01,

" Preparation and Routing of Maintenance Work Requests,"

Section 8.2.19, requires that all materials and parts be listed and that all supporting data and documentation, such as receipts and torque values, be attached to the MW . - . -

.- Observation of Maintenance Inspection in this area was limited to a small number of activities; however, it was enough to indicate a need for better control of mechanical maintenance. No problems were identified in the electrical or C&I area In an attempt to observe mechanical maintenance, the inspector selected a second shift, valve repair activity that continued from work started on the previous shift. No maintenance was accomplished or observed because a lack of turnover between shifts caused confusion for the second shift mechanics about the status of previous electrical wor As it turned out, a QC inspector had failed to sign off for this work prior to ending the first shift, and QA, on reviewing the lack of QC sign-off, found that QC was using an inspection sheet written to Revision 6 of the maintenance procedure while work was actually being performed to Revision 7. On arriving to observe the next available activity, the inspector found the work stopped because the mechanic did not have the drawing he needed and did not seem to understand where to start (in the middle of work already begun by others). When the supervisor went to the job location to assist the mechanic, the supervisor discovered that the material already in place for the job was not as specified by the drawings. Hence, this work was stopped pending resolution of the material problems. The next activity observed involved the adjustment of fire and secondary containment door closure mechanisms. No problem was identified with the maintenance work activity; however, the inspector noted that a problem report had been written involving difficulties encountered when the doors were closing against a small, confined space. It did not appear that closure mechanism adjustment was going to resolve the problem because of the air pressure resistance at the end of door closur These maintenance problems observed were noted to licensee management for consideration. No violations were identified since the licensee identified the problems noted and acted appropriately to take corrective action. However, the problems noted are definitely not indicative of a well controlled process and indicate the need for improvement of the licensee's control of maintenance activitie ! 7. Motor-0perated Valve Control Logic The motor-operated valve control logic adopted by Illinois Power appears unnecessarily complex and has contributed to valve problems identified in this repor The design appears to be the result of combining the following: (1) common practice in the use of small motor, motor overload relays; (2) Illinois Power's, General Electric's, and Sargent and Lundy's

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philosophy for application of Limitorque geared limit switches and torque

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switches; and (3) NRC concerns suggesting bypassing motor overload relays per Regulatory Guide 1.106. The resulting design failed to consider

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potential problems with unnecessary complications in the final design.

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j The circuit design (also discussed in Inspection Report No. 50-461/86045(DRS), Paragraph 3.a) incorporates motor overload relays and_ bypass' switches.in the main control room which not only bypass the overloads but also change the torque switch bypass logic. Per Surveillance Procedure CPS No. 9381.01, Revision 20, MOV Thermal Overload Bypass Device Verification,: there are 111 bypass switches for 312 valves. Wires are N ' disconnected and then relanded in the energized condition in order t verify,that each valves associated bypass contacts open. (The bypass

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function itself is not fully verified by this test.) The inspector stated-that the goals of safe and reliable valve operation might be better served .

by a simplified design that could eliminate this requirement. This could also simplify programmatic evolutions in the areas of setup, maintenance, testing,: operating, and surveillance. The licensee noted the inspector's <

a-i comments on this item and' agreed that some simple changes in the circuit design appeared beneficia . M'odification Program Implementation ScoNetofInspection Compl'ebdmodificationpackageswereinspectedtodeterminethe 5 adequacy of the modification program implementation. This included

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a review of safety evaluations;and post modification test procedures, criteria, results, and ac_ceptance. The inspection indicated.that

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program implementation was generally inadequate. Violations were Y

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s' identified in the areas of safety evaluations, post modification

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testing, procedure adherence, test control, and corrective actio ~h Because of problems identified, the licensee proposed immediate measures to complete necessary testing and;to assure that desig ,

modifications and applicable testing were adequate. The packages were reviewed to assure thaO none of the completed preoperational test

, results were, invalidated. This was done to assure plant readiness for othe low power license.. During the' period of September 22-29, 1986, the inspectors-reviewed a random sample of the. licensee's rework on-the packages and foundsthe documentation to be adequate to support the acceptability of!the licensee's activities and that there was no '

reason <to restrain plant; licensing because of this issu '

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^ Modification Packages Revi'ewed

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a The inspectors reviewed the following modification packages:

• HP-06, Added a pipe support to.the High Pressure-Core Spray

1. (HPCS) mini ~ mum flow line as corrective action for

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vibration discrepancies identified during transient ,

testing.

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AZ-10, Incorporated powar supply separation to meet the

- requirements of'10 CFR Part 50, Appendix .;

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• IA-10, Incorporated filtration for secondary instrument air to s

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the Main Steam Isolation Valves (MSIV) and Safety

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Relief Valves (SRV).

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• PR-11, Incorporated authorization to use larger pump motors for fixed and portable Containment Atmosphere Monitoring-(CAM) unit * -

_ AP-12,_ . Incorporated revised relay and breaker settings to provide coordination of Division 1:and 2 Motor-Control Centers (MCC) to meet'the requirements of

~10 CFR~Part 50,. Appendix .

• MS-13, Incorporated the use of butt welds instead of socket welds on the air supply-lines to.the SRV .* SX-12, _ Replaced ~three foot pound motors on operators.for valves No. ISX063A and ISX063B with five foot pound

. motors. These valves are the discharge valves from the safe. shutdown cooling system to the DG heat-exchanger * SX-15, Incorporated a multi-hole orifice in the Fuel Pool Cooling (FPC) Heat Exchanger piping to reduce unsatisfactory system vibrations identified during testin *~ HP-17, Incorporated authorization to fabricate Limitorque motor. pinion keys and corrective action ~for an identified condition on Limitorque motor-operator models No. SMB-3, 4, and * _ RH-17, Incorporated design change of Valve No. 1E12-F023 motor-operator (Residual Heat Removal (RHR) system test return line) as corrective actions for a previous failure of the motor-operator and to support M0 VATS testin '* DG-24, Incorporated changes-to the start system logi:: in the Division III emergency diesel generator (dedicated to the HPCS system).

• DG-35, Incorporated de-energizing the Division III Air Start Air Compressor (ASAC) and the generator space heater during a Loss Of Coolant Accident (LOCA) since these devices are not qualified or isolated from the safety-related bus as required by Illinois Power FSAR commitments.

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• DG-36, Incorporated recalculation of the HPCS MCC loads due to various changes in overload heater size, breaker size, and trip' setting * DG-39, Incorporated installation of heavier springs in the existing Divisions '. and 2 emergency diesel generator air start solenoids. The actual installation was S completed under Temporary Modification No. 86-05 ,

These:14 plant modifications were a random selection from those for

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which applicable preoperational testing had been completed,. reviewed, and approved by the Test Result Review Group (TRRG) and the Joint-Test

. Group (JTG). Inspection Results (1) Safety Evaluations Since.the licensee had not yet obtained an NRC operating license, the provisions of 10 CFR 50.59 did not directly apply to the modifications reviewed. However, since the FSAR had been

" frozen," the licensee had implemented the provisions of 10 CFR 50.59 through rocedure CPS No. 1005.06. " Conduct of.-

10 CFR 50.59 Reviews,p' as a means of assuring that the plant configuration remained consistent with the plant safety analysi Two of the safety evaluations reviewed were found to be deficien (a) . Modification No. DG-24 The Division III Diesel Generator (DG) is dedicated to the HPCS system. The start circuitry for this DG contains a seal-in. feature for the start signa Prior to this modification,. a start signal would seal-in iffthe DG were in

the " emergency stop" mode or " operate" mode ~. Further, if start signal were received while the DG was in the " emergency stop" mode, or if the emergency stop were used to terminate a DG start from a spurious start signal, the DG would start if subsequently placed in the " maintenance" or " operate" modes due to the sealed-in signal. Modification No.'DG-24 modified the circuit for the Division III DG by de-energizing the seal-in relay when the DG was in the " emergency stop" mod This cleared any previously sealed-in start signal and prevented any new start signal from sealing-in when placed in the " emergency stop" mode. -The reason stated for performing the modification was that Technical Specification No. 4.8.1.1.2.e.14 requires that the " maintenance" mode

prevent the DG from starting.

Procedure CPS No. 1005.06, " Conduct of 10 CFR 50.59 Reviews,"

requires that the basis for concluding that no unreviewed i safety question exists be documente The documented safety

! evaluation did not address the function of the start' signal

seal-in or what impact the modification had on the previous safety evaluation. Therefore, there was no documented basis for concluding that modifying the seal-in feature presented n no unreviewed safety question.

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m (b) Modification No. SX-12 The safety evaluation performed for Modification No. SX-12 in accordance with CPS No. 1005.06 also failed to provide a basis for concluding that no unreviewed safety question existed. This included a failure to assess the potential impact of added power requirements for the larger motors on the emergency power source These examples of the failure to document the bases for concluding that no unreviewed safety question existed as required by CPS No. 1005.06 are examples of a violation of 10 CFR Part 50, Appendix B, Criterion V, (461/86053-02d).

(2) Post Modification Testing Seven of the modifications reviewed contained inadequate post modification testing. This resulted largely from the lack of adequate acceptance criteria on which to base a tes .(a) Modification No. HP-06 Modification Package No. HP-06 contained no test acceptance criteri (b) Modification No. PR-11 tance criteria prescribed Modification No. PR-11stated, on form No. 1011.01F001 test accep'after pump / motor installation, functionally test (the) pump operation." This is not acceptance criteria as defined by CPS Station Operating Manual Administrative Procedure CPS No. 1005.01,

" Preparation, Review, Approval, and Implementation of Station Procedures and Documents" which requires the specification of design or operation limits "against which the test results shall be judged for approval / disapproval."

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(c) Modification No. AP-12 Modification No. AP-12 prescribed, on Form CPS No. 1011.01F001, a surveillance test and drawing " CPS No. 8504.01 and E02-1AP04" as acceptance criteria. Design and operating limits were not clearly stated; hence, judgement could not be clearly made for approval / disapproval or evaluation of the adequacy of the design modificatio (d) Modification No. SX-12 Modification No. SX-12 contained no acceptance criteria to verify the adequacy of using larger, modified valve motors.

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(e) Modification No. SX-15 Modification No. SX-15 did not provide acceptance criteria for evaluating the vibration data other than "per NSED Detailed Impact Assessment, required testing has already been performed under_ Temporary Modification No.86-164."

The " testing already performed" contained no design or operating limits for acceptance, only data that was collected, reviewed and approved by NSE (f) Modifications No. R-17, DG-35, and DG-39 Modifications No. RH-17, DG-35, and DG-39 prescribed either a specific surveillance test or just " functionally test" as acceptance criteria which do not meet the requirements for criteri (g) Modification No. DG-24 Modification No. DG-24 provided no acceptance criteria nor was any post modification test performe In general, test evaluations and documented test acceptances for the design and installation adequacy of the above modifications were inadequate in that appropriate test acceptance criteria were not identified. Criterion III, Design Control, in 10 CFR Part 50, Appendix B, requires verifying the adequacy of design by suitable testing and that design changes be subject to the same control measures as those applied to the original design. CPS Procedure No. 1005.01, Appendix A, implements this, in part, by requiring post modification testing and that " specific acceptance criteria, against which the test results shall be judged for approval / disapproval, shall be clearly stated." The failures to specify post modification test criteria are examples of a violation of 10 CFR Part 50, Appendix B, Criterion III (461/86053-01c).

(3) Test Documentation Clinton Power Station administrative Procedure No. CPS 1003.01,

" Design Control and Modification" which implements the requirements of Corporate Nuclear Procedures No. 4.05," Plant Modification Control Procedure" and 4.08, " Plant Modification System" requires in Section 8.1.13 for major modifications and 8.2.11 for minor modifications that all testing documentation shall be attached to the Plant Modification Package by the Plant Technical System Engineer. However, the inspectors found that seven modification packages (PR-11, AP-12, SX-12, HP-17, RH-17, DG-24 and DG-39) did not contain test data or test procedure The inspector did find that the data may be included in maintenance work request or surveillance test documentation but would not be included in the modification package for review or approval. The failure to follow Procedure No. CPS 1003.01 is an example of a violation of 10 CFR Part 50, Appendix B, Criterion V (461/86053-02e).

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During the reviews of modification packages for HP-06 and SX-15, the inspectors noted that the post-modification testing directions were not prepared in accordance with CPS 1011.01 in that precautions, responsibilities, prerequisites, limitations, test equipment, acceptance criteria, system restoration, etc., were not properly addressed. Procedure No. CPS 1011.01 implements the requirements of 10 CFR Part 50, Appendix B, Criterion XI, Test Control. The two examples noted above, in failing to properly control testing, are examples of a violation of Criterion XI (461/86053-03b).

(4) Corrective Actions During the review of the PR-11 modification package, the inspector found that the iPodification of increasing the size of the air pump motors and modifying the installation mounting of the compressor assemblies on the Containment Atmosphere Monitoring (CAM) units were, in part, corrective actions for Condition Report No. 1-86-06-001. The condition report was originated on May 29, 1986, because Stone and Webster Engineering Corporation (Contractor)_ maintenance personnel had replaced a 1/3 horse power (H.P.) motor with a 1/2 H.P. motor from the same manufacturer (Thomas Industries) without initiating a modificatio As a result of a Facility Review Group (FRG) meeting on June 27, 1986, a Clinton Power Station Comment Control Form was initiated on July 1,1986, requiring NSED to " address the potential hole (or breakdown) in configuration management in that a different size motor was bought, approved by NSED and (IP) Quality, and installed without a plant modification review." The FRG comment also identified a safety concern because of the " lack of configuration control." The NSED's response for corrective actions was that " Plant Modification No. PR-11 has been issued to cover installation of the replacement compressor assemblies" and that "NSED is revising some internal procedures and conducting training to better define configuration control on vendor designed and supplied equipment." The inspecter found these corrective actions to be inadequate in that they did not provide measures to prevent maintenance contractors, such as SWEC, from repeating unauthorized modifications, since revising procedures and conducting training on configuration control is internal to NSE The failure to identify and correct the root cause of a condition adverse to quality is an example of a violation of 10 CFR Part 50, Appendix B, Criterion XVI, (461/86053-04g). Similar violations are documented in Inspection Report No. 50-461/66052 and others where Illinois Power has failed to take corrective actions to preclude repetition of identified conditions adverse to qualit Another example of an unauthorized modification is given in Paragraph 3.a of this repor Conclusions During the review of the modification packages, various problems were identified. In general, the inspectors found that the requirements of the licensee's program were not properly implemented at any level, including Nuclear Station Engineering Department (NSED), Plant Staff-Technical and the responsible supervision and management of these organizations. The inspectors concluded that this condition existed because the engineers, supervisors and the Director-Plant Technical were not fully aware of the requirements of the Corporate Program, procedures (Corporate and Station), and their responsibilities under-these programs and procedure . Management Meeting Exit-Interview on September 12, 1986 The inspector met with licensee representatives (denoted in Paragraph 1) on September 12, 1986, to discuss the scope and findings of the inspection. The licensee acknowledged the statements made by the inspector with respect to items discussed in the report. The inspector also discussed the likely informational content of the inspection report with regard to documents-or processes reviewed by the inspector during the inspection. The licensee did not identify any such documents / processes as proprietar Management Meeting on September 19, 1986 During the inspection, it was apparent that there were significant problems with management control of the plant maintenance and modification programs. Problem areas within these programs are related to the quality assurance criteria in Appendix B of 10 CFR 5 They include Design Control - Criterion III; Instructions, Procedures and Drawings - Criterion V; Test Control - Criterion XI; and Corrective Action - Criterion XVI. Together, the problems identified represent a programmatic breakdown in the maintenance and madifications areas, due to inadequate management control, and represent a failure to comply with Criterion II, Quality Assurance Program, which requires the suitable control of activities affecting qualit During a management meeting in the Region III office on September 19, 1986, the licensee presented their understanding of the cause of the problems identified and a program of corrective action. A proposal was made and agreement was reached with the Region III staff on items to be satisfactorily completed prior to low power licensin The proposals for long term corrective action appeared adequate and responsive to all the issues identifie Attachment:

Cross Reference: Violation Examples to Report Details t

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Clinton

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Report No. 50-461/86053-CROSS REFERENCE: VI0'LATION EXAMPLES TO REPORT DETAILS

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Trackin Appendix B

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Number- Number Paragraph Criterion - Violation Failure to lubricate valves

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~ 02a 4 V per GTP-55, failure to correct

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procedure, and failure to provide an adequate procedur '02b 6 3. Failure to identify unqualified conditions during implementation of 8451.0 Ola 7 III Improper handling of a modification regarding the-

filing down of torque switch limiter plate I 04a- 8 - XVI Failure to properly evaluate the cause of equipment failure during torque. switch

adjustment '

. 04b .10 5.a.(3) XVI- Failure to implement

corrective actions regarding procedural ~ violations of 8106.01.

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04c 10 ~5.a.(3) XVI Failure to implement

!: corrective actions regarding

inadequate procedure 8227.0 Olb -13 6.a.(1) III Failure to incorporate design-l changes into controlled design

output documents.

{ - 04d 13 6.a.(1) XVI Failure to take corrective ,

, action regarding Condition Report No. 1-85-10-09 >

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03a 14 6.a.(2) XI Failure to conduct adequate testing which allowed

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miswiring of 17 torque switch bypass limit switches.1

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n Le O4 16- 6.b.(1)~ XVI Failure to evaluate root

, cause and take corrective actions regarding problems identified in MWR No. B3117 : 04f- 17 6.b.(2) XVI, Failure to evaluate root cause.and take corrective action regarding wobble of-valve in MWR No. B2423 c 17 6.b.'(4) V Failure to. document torque-values for MWRS No.~C22713, C05813, and C18057; and lack of material accountabilit fo: MWR No. C0665 d 22 2 8.c.(1)(a) V' Failure to-document bases for 8.c.(1)(b) concluding no unreviewed safety question existed per Procedure CPS No. 1005.06 Olc 23 8.c.(2)(a) III Failure to specify post 8.c.(2)(b) modification test criteri .c.(2)(c)-

8.c.(2)(d)

8.c.(2)(e)

8.c.(2)(f)

8.c.(2)(g)

.02e 23- 8.c.(3) V- Failure to include test data or test procedure with vaulted modification packages as specified in Procedure No. CPS 1003.0 b 24 8.c.(3) XI Failure to properly control testing for modifications No. HP-06 and SX-1 g- 24 8.c.(4) XVI Failure to identify and correct the root cause of unauthorized plant modification by SWE Although identified against Criterion XI, this violation also involved failure to follow procedures (Criterion V) and inadequate design change verification (Criterion III).

2Although identified against Criterion XVI, this violation also involved failure to follow procedures (Criterion V).

i