IR 05000461/1986073

Insp Rept 50-461/86-73 on 861117-870105.Violations Noted: Failure to Follow Procedures &/Or Assure Procedures Adequate,To Identify & Correct Deficiencies During Design, Testing & Mods & to Control as-built Configuration Program

ML20207P450
Person / Time
Site:	Clinton
Issue date:	01/09/1987
From:	Falevits Z, Muffett J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20207P431	List: IR 05000461/1986073 ML20207P430 ML20207P437
References
50-461-86-73, NUDOCS 8701160146
Download: ML20207P450 (12)

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U.S. NUCLEAR REGULATORY COMilSSION

REGION III

Report No. 50-461/86073(DRS)

-Docket No. 50-46 License No..NPF-55 Licensee: Illinois Power Company-500 South 27th Street Decatur, IL 62525 Fa'cility Name: Clinton Nuclear. Power Station', Unit 1 Inspection At: Clinton Site, Clinton, Illinois Inspection Condue'.ed: November 17, 1986 through January 5,1987

Inspector: Z. Falevits % ll ) 87 1)ats ' '

Approved By: James W. Muffett, Chief llc) ls q Plant.Systemr Se. tion _Date Inspection Summary:

' Inspection on November 17, 19_86 throughJanuary,_5,1987,(RepoAe No.50-461/86073(DfST)

Areas Inspected: Special, unannounced inspection to followup and review-licensee events, review of design and document control, review of as-built-configu~ ration of electrical components and systems, and training. (93702, 37702,62705)

Results: Of the areas inspected, violation of two criteria in 10 CFR 50, Appendix B, were identified: (a) failure to follow procedures and/or assure that procedures are adequate, and (b) failure .to identify and correct deficiences during design, testing and modifications and failure to control the as-built configuration program of electrical system '

- PDR ADOCK 05000461 0- PDR

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DETAILS 1. Persons Contacted Illinois Power Company

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• P. Hall, Vice President

• J. 5. Perry, Manager, Nuclear Program Coordination

• R.' E. Campbell, Manager, QA

• J. W. Wilson, Manager, CPS

• J. H. Green, Manager, NSED

• • J. W. Pruitt, Projects and Administratio'n, NSED

• W. Connell, Manager, NPS

• A. Till, Director, Nuclear Training

• J. D. Weaver, Director, Licensing

• H. R. Lane, Manager, Scheduling and Outage

• • J. Emmert, Supervisor, Electrical Engineering NSED

• J. Corrigan, Director, Quality Engineering and Verification

+*J. A. Brownell, Licensing Specialist

• • T. Warnick, Licensing Specialist

• • T.' Collings, Engineer, NSED

+P. Thomson, Engineer, NSED Sylamd/Wipco

• J. Grenwood, Manager, Power Supply NRC

+ F. Warnick, Branch Chief, Branch 1

+J. W. Muffett, Section Chief, PSS

+ N. Gardner, Clinton Project Inspector

• P. Gwvnn, Senior Resident Inspector

• Denotes those attending interview exit meeting held on November 20, 198 ** Participated in the telephone conversation on December 12, 198 + Participated in the telephone exit meeting on January 5, 1987.

2. Action on Previous Inspection Findings (Closed) Open Item (461/86071-01(DRS)): Review of concerns pertaining to (1) the incorrect presentation of the termination information depicted on schematic diagrams, and (2) the inadequacy of the configuration control programmatic policy in regards to schematic and wiring diagrams. During this review, the inspector noted several deficiencies in the design change document control program, and the posting of design changes against the affected

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. j controlled drawings. During=this inspection, additional -l deficiencies were noted. -This item is being escalated to two

. violations. (This-is further discussed in Section 4 of this i

report.)- . j (0 pen) Unresolved Item (461/86071-03(DRS)): The inspector reviewed

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-training-records of a Level II Q.C. inspector who was' qualified to j conduct inspections of-Raychem Heat Shrink splices. During this o

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inspection, the inspector further reviewed the Q.C. inspectors -

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journal to determine whether he had received adequate training 1 specifically in the' inspection of Raychem. Heat Shrink splicin l

'Neither the Level II electrical inspector qualification written- 1 exam, nor the practical exam.taken by the Q.C. inspector contain any

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questions relating to Raychem Heat Shrink splices. Limited-training data pertaining to Raychem kit selection, instruction and approved cleaner for power cables was contained'in Lesson-Plan QAT-P-5350-10, Revision 0. Indication that the inspector received Raychem Splice

< training prior to his joining the Clinton project was not evident in

.his training record file.- The inspector expressed a concern that

qualification testing of the Level II electrical inspector may not have qualified him to conduct inspections on various specific

. ~ electrical activities. Also the tests did not appear to cover all of the' activities-the Q.C. inspector was certified to perform. This item remains unresolved pending further revie '

. Licensee Event Report (LER) Review and Followup (92700)

y The inspector performed an onsite followup inspection of the LERs listed

.below to determine whether the root causes of these events are related to deficiencies in electrical design and document control, or to field activities associated with these documents, and to determine ~whether the proposed corrective action appeared.to be adequate in preventing recurrence and~ meeting regulatory requirements.

i - a.- (0 pen) LER No. 86-008-00 (461/86008-LL): An Engineered Safety

Feature Actuation and Containment Isolation of the Instrument Air

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System due to Procedural Inadequacy.

! A surveillance test required lifting leads to prevent Instrument Air

, (IA) isolation valves from isolating during the test. When the test

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signal was installed after lifting'the' leads as specified in the procedure, the Containment Isolation valves automatically isolated, causing a loss of Instrument Air to the containment. The root cause for this event was attributed to procedural deficiency. The

,' surveillance procedure did not specify the correct leads to be lifte The inspector examined the licensee's methodology of preparing,

- reviewing, and approving surveillance procedures and noted that the reference drawing specified at the end of each procedure did not denote'the revision to the drawing used when the procedure was t written (this is needed to assure that latest drawings were used).

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In addition,'it was not clear.if,the test engineer writing these surveillance procedures, was required to use both the schematic-and -

. connection diagrams to assure adequacy. During the review of the surveillance procedures and their implementation the inspector noted that the: lack of adequate pretest preparation and review process, s

.. contributed to-this'and other recent licensee event ~

Due to additional concerns with this LER,'(identified by the

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. resident-inspectors), the licensee is planning to provide a

supplemental report. This matter will be reviewed further with the L supplement report, (0 pen) LER No. 86-009-00 (461/86009-LL): This event is an

. integral part of LER No. 86-008-00 and occurred at the same b time. The LER concerned Violation of Technical -

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Specification 3.3.2 due to operator error and an inadequate procedure. It appears that the member of the management reviewing '

this event in progress, was unaware that one channel was inoperable

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as part of a surveillance and determined that an instrument could be

removed from service thereby disabling both Channels of the

Automatic Depressurization System trip channels. In' addition, the P

procedure did not define the exact plant conditions as a prerequisite

for performing the-surveillance. The description of this event in i the LER report appeared to lack specific details and depth. Due

to additional. concerns raised during the review of this LER by the resident inspectors,.the licensee is planning to provide a '

l supplemental report. This matter will be reviewed in the future.

- (0 pen) LER No. 86-001-00 (461/86011-LL): Automatic initiation

of Service Water due to inadequate surveillance procedure. The surveillance procedure incorrectly required lifting wires on an i improper termination modula, causing a loss of pressure signal to-

'- the .SX' instrument loop, and resulting in an SX pump automatic star '

The inspector reviewed the following associated documents:

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(1) Suppression Pool Water Level LT-SM030(31), LT-CM013(06) Channel

! Calibration, CPS No. 9463.02, Data sheet, and Checklist, Revision

No. 22. (2) Loop schematic drawing E02-1SM013, Revision A. (3)

Connection diagram E03-1P741E, Revision M.

The review indicated that the loop schematic contained the error

, which appeared on the drawing from the time it was originally issued ,

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for construction on c?ptember 21, 1984. This error should have been detected during the original design review before the drawing was issued for construction, or during the startup and preoperational  !

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testing phases of this loop. It also appears that the test engineer 4 did not review the connection diagrams at the time the surveillance procedure was written, only the loop schematics were use (A violation relating to this event was issued in

Report No. 461/86065.)

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. (0 pen) LER No. 86-014-00 (461/86014-LL): _ Standby Gas Treatment System initiation due to a jumper installed on the wrong rela During the implementation of Preoperational Test Procedure VQ-01, a jumper was installed from termination strip RRR Point 116 to relay MQ, instead of relay L A review of the root causes of this event indicated that the responsibilities of the Te:;t Technician, Test Director, and Shift

. Supervisor were not clearly defined or understood as they relate to the prereview and execution of this test procedure. In addition, Procedure SAP-11 required an independent verification of installation after the jumpers were installed, rather than prior to their installation. Test Log Sheet PTP-VQ-01, dated October 21, 1986, contained only one independent review for installation / removal by the test engineer, and test director. Test Procedure SAP-11 requires one independent review for installation, and another one for removal. (A violation relating to this event was issued in Report No. 461/86065). (0 pen) LER No. 86-021-00 (461/86-021-LL): Automatic actuation of Engineered Safety Features due to maintenance activities whereby an electrician cut electrical wires causing an isolation of the Reactor Water Cleanup Syste The licensee has not yet formally issued this event repor This event will be reviewed when the LER is issue Concerns Generated by the LER Review The inspector informed the licensee of the following concerns

pertaining to the review of the above LERs:

• Licensee should stress the need for thoroughness in the preparation of LER * Since the root causes of these events relates to inadequate surveillance procedures; procedures may not be written to the latest E02s and E03 Also procedures may not be reviewed properl * Inadequate surveillance test preplanning, lack of attention to detail and procedural compliance by the technical and operational staf * Personnel errors were another root cause of these event This may be indicative of training deficiencie * Lack of adequate communication between individuals responsible for plant activities, specifically during shift turnove * Operators understanding of test requirements and their Technical Specification implication * Minimal management and operational personnel awareness of the events in progress for long periods of tim __ _ _ ___ __-... _

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o Licensee proposed corrective actions to these events have included:

• Training of licensee personnel.concerning the particular event * Plant Management Standing Order PMS0-30 amended to verify

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lifted leads and jumpers against E03 drawing * Stopping of work activities relating to lifted leads, jumpers, snipping leads or other activities that affect electrical circuits until an effective resolution to the problem of-

, procedural inadequacies and personnel errors affecting electrical circuit continuity is identified and correcte * Formation of a task force to review root causes and recommend corrective action * Conduct a comprehensive review of surveillance procedures and revise deficiencie . Review of Design Document Control and Posting Requirements

During the previous inspection, the inspector noted numerous errors on the design drawings and an apparent problem with posting of design change documents onto the affected drawings. During this inspection, the inspector conducted a field design and document control inspection to determine the extent of the identified problems, Document Control Review The inspector selected at random Standby Gas Treatment System Panel 0PL39JB for review. The panel's wiring is depicted on two connection diagrams, Drawing E03-0PL39JB, Sheet 1, Revision E, and Sheet 2, Revision N. Review of the controlled copies of these two drawings in the Master Drawing sets located at the Document Control Center and at the engineering office indicated that the following change documents were posted against Sheet No. 1 of the drawing:

Field Change Request (FCR)-41802, Engineering Change Notice

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(ECN's)-7492, 7517, 7502 and 7851, and Field Engineering Change

Notice (FECN's)-13983, 14188 and 14263. The following documents were posted against Sheet No. 2 of the drawing; FCR-41802 and 41883, ECN's-7492, 7502, 7517 and 7851, and FECN's-14263, 14766 and 1495 Further review of the Design Status System (DSS) list revealed that in addition to the posted documents noted above, ECN-7870 should have also been posted against both drawings to indicate pending changes affecting components inside Panel 0PL39JB; the list also indicated six Minor Modification Control Packages (MMCP) affecting each drawing.

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b. Design Control and As-Built' Inspection (1) The. inspector conducted a field inspection of Panel 0PL39JB to determine the adequacy of the installations as compared to the drawings and design change document requirement The inspector could not determine'the as-built configuration of this panel due to the fact that for every device or termination point to be checked on this panel it is necessary to review all-design changes posted against the drawing simultaneously with the configuration depicted on the drawing required. The existing system makes modification and testing of the design in the panel extremely difficult and could possibly lead to errors and unnecessary licensee events. Durit.g the panel inspection, the inspector noted that several electrical components have been

! installed and wired in the panel to modify the logic of several circuit; documentation of these changes could not be found on the latest drawings or on any of the existing change documents posted against these drawings. The inspector expressed the concern that during modificatior:s or testing activities

! associated with this panel the engineer will not be able to determine the as-built configuration of the panel using the existing system. This might lead to placing jumpers at the wrong points or lifting the wrong wires and therefore disturbing electrical circuit continuit Additional review of this issue indicated that FECN-13095 had been superseded by FECN-15413 which was approved but not authorized for field incorporatio The superseded FECN was removed from the drawing posting before the new FECN could be posted. CPS Procedure 2.51, Revision 1, Paragraph 5.3.3 states that " Approved but unauthorized design changes . . . shall not be posted against controlled copies of affected document Upon authorization these changes shall be distributed and posted." This inadequacy in the procedure allowed a situation in which a superseded document whose design change requirements have been incorporated in the field was removed from the system while a new change document could not be posted until it was-authorize Nuclear Station Engineering Department (NSED) Procedure D.20, Revision 5, " Processing Plant Modifications" required in Paragraph 3.6 that when a modification is cancelled or superseded by another modification, the Director of Design Engineering forward the cancellation notice from NPC to the cognizant engineer via the Supervisor; the cognizant engineer confirms by walkdown and/or document review that the system and components are in the pre-modification configuration, at this time he is to coordinate with the Drafting Supervisor to ensure that all Control Room drawings are marked to show as-built conditio Documented evidence of the completion of these activities with respect to superseded modification FECN 13095 was not available for review during this inspection (one month after it was superseded).

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Conceptual Change Incorporation-Standard,-Table 2, " CPS

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- Document Updating Frequency" requires that in the plants'

operational phase, Sub-tier "B'f drawings.:be updated when more

$ than three outstanding modifications have been completed are iposted against the drawings;:the time: limit allowed before

,1 -these drawings are required-to be revised was noted as.four '

y weeks. The subject drawings review E03-0PL39JB,: Sheet-1-contained ten design change documents of which six have been

fully implemented in the-field. Sheet 2 of. Drawing E03-0PL39JB

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contained ~12 design change documents of which eight have been sfully implemented in the field. -(Note that Panel 0PL39JB is

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identical to OPL39JB; therefore,:this panel could contai identical deficiencies as noted in Panel 0PL39JB.)

During No. 461 /86071) that FECN-1439 was not posted against controlledthe C

. Drawing No. E03-1P741E-002, Revision N, as. required by procedur :Also, FECN-14036 was still posted against a superseded drawin Based on the findings outlined above, the inspector informed

the_ licensee that failure to follow procedures and/or failure

.to assure.that procedures are adequate for their intended function are considered examples of a violation of Criterion V,

Instructions, Procedures, and Drawings in 10 CFR.50, Appendix B

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(461/86073-01(DRS)).

B - (2) The inspector conducted a design review of the control circuit logic of Residual Heat Removal Valves 1E12-F008, F009, F023 and F040, as depicted on schematic diagrams E02-1RH99-504, 516, 519 and E02-INB99, 225, 226 and 22 Regulatory Guide 1.106-1977, " Thermal Overload Protection for Electric Motors on Motor Operated Valves"' states in Section C

that in order to insure that safety-related motor-operated

valves whose motors are equipped with thermal overload t

protection devices-integral with the motor starter will perform

their function, one of the-following two alternatives should be ~ ,

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implemented: (a) the thermal' overload protection devise should be continuously bypassed and temporarily placed in force ,

only when the valve motors are undergoing periodic or

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maintenance testing or (b) those thermal overload protection-i devices that are normally in force during plant operations

[. should be bypassed under accident condition During the followup review, the inspector noted that an apparent deficiency might exist in the closing circuitry of the

, safety related valves whose full' closure is imperative i during a design basis accident. The typical valve cic,ing

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circuitry for such valves is depicted on Drawing E02 un99-504, Revision G. Assuming the valve is in the-fully open position and an ESF signal to close the valve is received coil MC (close) will energize through 5-6 of relay 95RH1A, 9-9c of l'

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-valve limit switch and the ESF relay contact. This. circuit

'will: stay. sealed in through MS/a, TSC and 74-E12F8 relay contact. or through MC/a, 7-7c and 9-9c limit. switches of the valve and'5-6 contact of relay 95RH1A. Assuming that while the valve _is traveling towards-its closed postion we get an overload at the same time as the 7-7c and 9-9c contacts open (approximately 95% closed); at'which point the 74 relay will drop, dropping the seal in through the TSC contact and stopping the valve at 95% closed. This will not allow the valve to travel to the full closed positio During the' field inspection, the inspector examined the " seal in" circuit of the RHR. valves noted above, several concerns were raised. The inspector attempted to review the logic diagrams to determine the correct logic applicable to these valves but was informed by a Sargent & Lundy engineer that the logic-diagrams are outdated and could not be'used._ The inspector requested that the licensee contact the General Electric site representative g- to discuss and resolve this issue. On December 1, 1986, the licensee informed the inspector that a review is being conducted to resolve the inspector concerns noted abov This item is considered unresolved pending licensee action and NRC review (461/86073-02(DRS)). Design Change Document Review-The inspector selected the design change documents posted against

' SGT panel 0PL39JB for review of technical adequacy, methodology of review, approval and final field implementation, adherence to procedures, applicable regulations, FSAR requirements, the control of design interfaces and coordination among participating design group CPS Management had made a decision at the beginning of 1986 that certain design change documents not be incorporated into the drawings, but continue to be posted against the drawings. This policy existed until the later part of the year and apparently L contributed to the fact that.a large number of design change

? . documents are posted against panel OPL39JB.

The following observations were made during this review:

(a) FECN-13095 was issued on April 30, 1986 to implement design changes required by Field Problem Report FPR-6403 and 661 The required modifications were incorporated into the panel b in the field. Subsequently, FECN-15413 dated October 25, 1986

was approved and issued to supersede the changes added ie per FECN-13095. Since FECN-15413 had not been authorized for

? incorporation it was not denoted as a modification which

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required changes to the applicable drawings. Posting of FECN-13095 had been removed from both panel drawings on

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October 21, 1986. This resulted in a condition in which the

! equipment and wiring required by FECN-13095 was already i installed in the field but this modification was not reflected l on the applicable design drawing or design change documents.

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Thisi ledito a condition:in which inadequate design control.

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. existed due to.the lack of;as-built configuration control. In addition,'testfengineersandthedesignengineeringgroupusing

.these drawings to modify'or test'the circuitry did not have the c

, _true as-built configuration of:the' installed components and

, electrical circuits; a situation _which if not corrected may- ,

. lead to a' breakdown in-the design and configuration control m . syste (b) The inspector noted that approximately half of the' design changes written against Panel 0PL39JB were written to correct errors and omissions made to previous design changes.-

, -(c) FECN-5525 dated July 31, 1985 was improperly translated onto

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. Revision N of-connection diagram E03-0PL39JB, Sheet 2 in that the red-black conductor of external cable IVG06C was shown terminated to termination point 118 rather than to 119 as-required by the ECN. Currently, field installaticn conforms to the ECN, but, does not conform to the drawing. This deficiency C

reflects'an instance of inadequate design review of this drawing conducted by the engineers before it was issue '

, ~In addition, the test group should have identified during the ,

post testing that the' Schematics (E02 series drawings) and I wirings (E03 series drawings) do not conform with each othe (d) The NRC' inspector could not. find a requirement to assure that

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all outstanding design documents posted against a particular

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' drawing are reviewed prior.to conducting a design chang ,

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(e) Lack of design control coordination between the field engineering group and the Sargent & Lundy engineering office

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in Chicago. For example, FECN-14953 was issued on June 6, 1986 to address concerns noted in FPR-100533 pertaining to ECN-552 ,

! ECN-5525 contained inaccuracies which required revision.

[ (f) FECN-14766, 14953 and ECN-7517 indicate changes to E03 drawings a and no references were made to the applicable E02 drawings.

!- -(g) The Wire number was missing from numerous termination points on

~ Drawing 0PL39JB, Sheet 2, Revision N. Also, wire designations

~ on termination Points 42, 48, and 120 are different even though,

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electrically they reflect the same polarity point; Schematic i Diagram E02-0VG99-017 indicates that "VG398Y1" should be the  :

only wire designation. These types of discrepancies may lead

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to confusion in reading the drawings and possible errors in l

' testing. activitie (h) On August 12, 1986 ECN-7492 was issued to allow the temporary i

! inctallation of VE 400 series temperature switches to meet the -

(- requirements of ANSI N50 One day later on August 13, 1986,

[ ENC-7502 was issued to make the temporary installation of ECN-7492 permanen s

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(i)~ FECN-13903.was issued on February 1, 1986 to ensure that-E02:(Schematics) and LO3s (wiring) drawings agree with the as-built configuration. Review of this FECN_ indicated that-lalthough the terminations of conditioning devices were c rearranged the end' result does not reflect the as-built configuration. The FECN indicates that termination one through

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m twelve exist in the field; however, these numbers do not appear- '

on-the field devices. Furthermore, Device OPDY-VG023 (shown on Page 8 of FECN-13903) was:not revised as were all the other identical devices on this FEC *

i The inspectors concerns is that some of the design change documents

[^ are unnecessary and technically inconclusive. The inspector noted 1 that-the design change document review process requires final review- .i

[ and concurrence by the licensee's NSED engineers, it_ appears that i the review conducted is a documentation review rather than a

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technical review.

! During the previous inspection (see Report (461/86071(DRS)) the inspector identified the following deficiencies on Schematic Drawing No. E02-1LD99-007:

• Cable designated'as VG99-087 should be VG99-027.

• Cable designated as VG99-013 should be VG99-01 '

• Cable designated as VG99-013 should be VG99-00 e- DTF's were not written to revise Panel Module Wire Tests

Associated with Modifications on Drawing E02-1LD99-07 Based on the findings _ outlined in Section C above the inspector.

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informed the licensee that failure to identify and correct

- deficiencies during design testing, and modifications, and fa:1ure to control the as-built configuration design program

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of electrical systems.and components are examples of a violation of. 10 CFR Part 50, Appendix B, Criterion III (461/86073-03).

. On December 3, 1986, in a telephone conversation with the licensee the licensee's engineer stated that currently 31 potential cases similar to the one identified in Panel 0PL3JB have been selected by the licensee for review. The inspector will follow up on this issue during a future inspection.

' Open Items

4: Open items are matters which have been discussed with the licensee, which will be reviewed further by the inspector, and which involves i some action on the part of the NRC or licensee or both. Open items '

disclosed during this inspection are discussed in Paragraphs through '

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. Unresolved Items-An unresolved item is a matter about which more information is required in. order to ascertain'whether it is an acceptable' item, an open item, a deviation, or a violation. An unresolved item

. disclosed during this inspection-is discussed in Paragraph . Exit Intervie :The Region III inspector met with licensee representatives (denoted under. Paragraph 1) at the conclusion of the inspection on November 20 and in a telephone conference on December 4, 1986 and a final exit during a telephone conference on January 5, 1987. The in~spector summarized the purpose and findings of the-inspection. The licensee acknowledged this information. The inspector also discussed-the-likely informational content of the inspection report with regard to documents or processes reviewed by the inspector during the inspectio The licensee did not identify any such documents / processes as proprietar