IR 05000461/1989002

Safety Insp Rept 50-461/89-02 on 890109-0214.Violations Noted.Major Areas Inspected:Refueling Activities During First Refuel Outage,Including Review of LER 88-030 & Followup to CAL-RIII-89-05

ML20247C866
Person / Time
Site:	Clinton
Issue date:	03/17/1989
From:	Phillips M, Rescheske P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20247C859	List: IR 05000461/1989002 ML20247C854 ML20247C861
References
50-461-89-02, 50-461-89-2, CAL-RIII-89-05, CAL-RIII-89-5, NUDOCS 8903300296
Download: ML20247C866 (12)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

' Report No. 50-461/89002(DRS).

Docket No. 50-461 License No. NPF-62 Licensee: Illinois Power Company 500 South 27th Street Decatur, IL 62525 Facility Name: Clinton Power Station Inspection At: Clinton, IL 61727 Inspection Conducted: January'9 through February 14, 1989 Inspector: Peggy esche M /'

Date Approved By: Monte . Phillips, Chief Operational Programs Section LIMFf Date Inspection Summary Inspection on January 9 through February 14, 1989, (Report No. 50-461/89002(DRS))-

Areas Inspected: Routine, unannounced, safety inspection of refueling activities during the first refuel outage at the Clinton Plant (IP 60705, 60710,86700). The areas of inspection also included a review of LER No. 88030 (IP 92700).and followup to CAL-RIII-89-005 (IP 92703).

Results: The licensee encountered a number of problems during the refueling activities (Paragraph 4). Five violations were identified during the review of the significant events: (1) inappropriate procedure and activities not accomplished in accordance with instructions, (2) the one-rod-out interlock TS requirement was defeated (LER No. 89004),(3) failure to implement procedure, (4) the SRM operability TS requirement was not satisfied (LER No. 89007), and (5) three examples of training deficiencies. Further, CAL-RIII-89-005 was issued during the inspection period. The licensee actions required by the CAL have or will be responded to separate from this inspection repor Details of the CAL and NRC followup can be found in NRC Resident Report No. 89008(DRP) and subsequent resident reports. The number of events and the fact that they all dealt with refueling activities lead the NRC to believe that there may have been a lack of management attentio $h $

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. DETAILS

.. Persons Contacted

+*J. S. Perry, Assistant Vice President

+*K. A. Baker,. Supervisor, I&E' Interface

• E., R.. Bush, Director, Nuclear Programs and Scheduling

+*R. E. Campbell, Manager, QA

+*J. G. Cook, Manager, Nuclear Programs and Schedulin .

-+*R. D. Freeman, Manager, NSED

• W.' C. Gerstner, Executive Vice President

+ K. R.-Graf, Director of Ops Monitoring, QA

+*J. Greenwood, Manager, Power Supply

• J. K. Hadden, Supervisor, Scheduling and Outage Management

+ D. L. Holesinger, Assistant Plant Manager

+ M. C. Hallon, Acting Director, NPAG

+*D. L. Holtzscher,' Acting Manager, Licensing and Safety

• A. M. MacDonald, Director, NPAG- . .

• G. W. Miller, Director, Outage Maintenance

+ J. A. Miller, Manager, Scheduling and Outage Management

• J. D. Weaver, Director, Licensing

• J. W. Wilson, Plant Manager

• R. E. Wyatt,. Manager, Nuclear Training

• E. R. Balker, Project Administrator, GE

• A. J. Miller, Project Manager, GE U.S. NRC

+ R. W. Cocter, Chief, Section 3B, DRP, RIII

+ B. Drouin, Project Inspector, DRP, RIII P. L. Hiland, Senior Resident Inspector

+ M. P. Phillips, Chief, OPS, DRS, RIII

+*S. P. Ray, Resident Inspector Other persons were contacted during the course of the inspection, including members of the licensee's operations, technical, and radiation protection staff, and members of the GE refueling staf * Denotes persons attending the interim exit meeting on January 26, 1989.

+ Denotes persons attending the exit meeting held on February 14, 1989, via teleconferenc . Background Information The Clinton Power Station (CPS) is a BWR-6 plant with a Mark III containment, a unique design when compared with typical BWR plants (BWR-2 throLgh BWR-5). Movement of fuel at Clinton is more comparable to that of r. PWR, in that, the Spent Fuel Pool (SFP) and Reactor cavity are in separate buildings. Further, fuel is moved between the SFP and containment via a fuel transfer system. At Clinton, this transfer system is inclined due to the difference in elevation of the SFP and containment f

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poo A design ~ of interlocks and valves. provides for the movement of fuel-(and other items) on a carriage assembly through the transfer tub The inspector. observed that because of the design, routine refueling activities are apparently more complex and time-consuming as compared with typical BWR. Further, equipment problems are more frequent, particularly involving the Inclined Fuel Transfer System (IFTS).

In January 1989, subsequent to the initial operating cycle at .the Clinto plant, the licensee, Illinois Power Company (IP), commenced refueling activities. General Electric Company (GE) was contracted to perform this first refuelin On January 6, the plant entered Made 5 (Refueling)'and i the licensee proceeded to disassemble the reactor. In addition, control '

-rod drive mechanism (CRDM) work was commenced on January New fuel movement from the SFP to the upper containment pool was started on January 10. Refueling the reactor was performed in stages: new fuel moved to the containment pool, a lengthy radiation survey with the first spent fuel bundles removed from the core, removal or shuffling of irradiated fuel.in the core, and loading new fuel, completing each

. quadrant of the core. Activities also included removal and storage of the.five startup' neutron sources used in the initial cor A number of significant events occurred during the course of the refueling activities and are described in Paragraph 4. On February 21, 1989, the licensee completed refueling the reacto . Inspection Activities The inspector performed a review of the. procedures used by the licensee in preparation for the refuel outage and during the refuel activitie The procedures included administrative controls and the requirements of Technical Specification (TS) Section 3/4.9, " Refueling Operations." The inspector directly observed portions of the refueling operations during regular hours, shift turnovers, and back shifts, in the control room, and on the refuel floor (828' elevation in containment) and the SFP floor (755' elevation in the fuel handling building). The types of activities monitored included: fuel movement and documentation, updating the fuel status boards, communications between the refueling stations, periodic surveillance testing, equipment maintenance, housekeeping and material accountability, and radiation protection practice In addition, a number of licensee meetings were attended, such as, critiques, outage and management meetings, and Facility Review Group (FRG) meeting A sampling of the below listed procedures, and completed surveillance and equipment operability checklists, was reviewed during the course of the inspection. Other documents related to the refueling activities, such as condition reports (CRs), Maintenance Work Requests (MWRs), Quality Assurance (QA) Department audits and surveillance, refueling personnel qualifications, and Control Room and Shift Supervisor Logs were also reviewed as a matter of routin CPS No. 1001.05, " Authorities and Responsibilities of Reactor Operators for Safety Operation and Shutdown"

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CPS No.101'3.02,i" Fuel- Handling General Responsibilities

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CPS No.1019.04, " Tool and Material. Control for the Refuel Floo und: Fuel Handling Floor During Refueling Outages" CPS No. 1401.01, " Conduct of Operations"

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CPS No. 1898.00, "Special Nuclear Materials Program" CPS No.1898.00C001, "SNM Transfer Checklist" CPS No. 3702.01, " Inclined Fuel Transfer System (IFTS)"

CPS No. 3703.01, " Core Alterations" CPS _No. 3870.01, " Fuel Handling Platform Test" CPS No. 3870.02, " Refueling Bridge Test"

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CPS No. 8106.02, " Qualification of Crane Operator" CPS No. 8106.03F003, " Daily Crane Inspection Checklist"

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CPS No. 8106.03F005, " Crane Operators Log"-

L CPS No. 8109.01C001, " Inclined Fuel Transfer System Blank Flange Removal Checklist" CPS No. 8117.01, "Drywell Head Removal" CPS No. 8117.02, " Reactor Vessel Head Piping and Insulation Removal" CPS No. 8117.03, " Reactor Vessel Head Removal"'

CPS No. 8117.04, " Reactor Vessel Stud Removal and Installation" CPS No. 8117.05, Steam Dryer / Separator and Shroud Head Removal" CPS No. 8117.11C001, " Upper Containment and Fuel Building Pool Gate Installation and Removal Checklist" CPS No. 9000.010001, " Control Room Operator Surveillance Log -

Mode 1, 2, 3 Data Sheet" CPS No. 9000.01D002, " Control Room Operator Surveillance Log -

Mode 4, 5 Data Sheet" CPS No. 9000.02D001, " Unit Attendant Surveillance Log Data Sheet" CPS No. 9000.03D001, " Core Alterations Surveillance Log" CPS No. 9031.13, " Source Range Monitor Channel Functional"

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. CPS No. 9090.01, " Refueling Interlocks Operability Test /0ne Rod Out' Interlock Operability" CPS No. 9091.02, " Refueling Bridge' Crane / Hoist Operability" CPS No. 9092.01, " Inclined Fuel Transfer System Interlocks Functional" r (Closed) LER 461/88030, " Inadequate Work Practice for Controlling Empty-Slings Results in Fuel Boxes Toppling and Damage to Fuel in Excess of Two Thousand Dollars." This event occurred on October 24, 1988, during new fuel receipt activities in the Fuel Building. Of the six fuel bundles in the three affected boxes, five bundles sustained damage. The licensee provided to the inspector a package documenting the event which included the condition report, evaluation and consequences of the event, draft results of the vendor inspection of damage, the completed immediate and short term corrective actions, and the proposed long term actions to be taken. This event was not considered safety significant since the fuel bundles were new, not irradiated, and the radiological conditions remained unchanged following the event. The inspector noted that a similar event had occurred at another facility with the fuel bundles sustaining similar damage, as documented in LER 416/87014. Therefore, the amount and type of damage to the fuel bundles was not considered unreasonable during the event at the Clinton Plant. Based on the documentation' reviewed, the inspector had no further concerns or questions regarding this item, and the LER is close . Description of Significant Events On January 6, 1989, the Clinton Plant entered Mode 5 (Refueling) and the licensee commenced the initial refueling outage. The first notable event cccurred during the removal of the steam dryer and separator, when tFe licensee encountered an unexpected radiation interlock which prohibited normal movement of the containment polar crane. The interlock was improperly bypassed on two occasions and the event was not communicated to the appropriate IP management. During the subsequent three weeks of onsite inspection (January 9 through 26,1989), the following significant events occurred: (1) the one-rod-out interlock Technical Specification (TS) requirement was defeated during CRDM maintenance (LER No. 89004),

(2) tool and material control on the refueling floor in containment was not maintained as required by plant procedures (NRC identified), and (3) during core alterations, the source range monitor (SRM) operability TS requirements were not satisfied (LER No'. 89007). An interim exit meeting was held with the licensee on January 26, 1989, discussing the above stated four potential violation Following the onsite inspection, twe coOtional events occurred: (1) an incorrect irradiated fuel bundle was removed from the core, and (2) a startup neutron source was dropped coto the core. Based on these last two events and the other problems encountered by the licensee during the refueling operations, Region III NRC issued Confirmatory Action Letter CAL-RIII-89-005, dated February 1, 1989, in which the licensee agreed that refueling operations would not resume until concurrence of the Regional Administrator was obtaine _ _ ______--__ _--__- _ - _ - _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ - _ . __ _ _ _ _ _ - -

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The inspector was present when the dropped' source.was retrieved on February 3, 1989. The licensee encountered one notable problem'during L the operation: an unexpected interlock prohibited refueling bridge movement over the core with the mode switch in Shutdown. The personnel involved in the source retrieval were not aware of the existence of this interlock;- operations were temporarily suspended until the problem was resolve On February 19, 1989, a management meeting was~ held in Region III with the licensee-to discuss their response to the CAL. A detailed discussion of the CAL and' subsequent licensee actions can be found in NRC Inspection Report No.- 461/89008. The licensee obtained concurrence of the Regional Administrator on. February 15, 1989, to resume refueling activitie During the completion of refueling, no further significant problems were encountered by the license .The following is a discussion of the' events which occurred during the refueli,ng operation. ' The information was based on review of licensee documentation (e.g., critique reports), direct observation by the

' inspector, and discussions with the licensee, a'. On January 7,1989, GE personnel were removing the steam dryer per CPS No. 8117.05. A radiation protection (RP) person was the only IP person present in containment during the activity. The GE refuel supervisor had the capability to communicate with the control roo As the dryer was. lifted from the reactor vessel with the polar

, crane, expected area radiation monitor (ARM) alarms occurre However, a 10 millirem per hour (mrem /hr) radiation alarm unexpectedly activated an interlock which stopped crane movemen The crane operator determined that by pressing a reset button, crane power was restored. A second person was necessary to hold the reset while the crane operator completed the lift and moved the dryer to the storage pool. The dryer was suspended for approximately ten minute The control room and the appropriate IP management were not notified of the problem encountered or that the crane interlock was overridde The procedure being used had not addressed the interlock or the actions to be taken in the event of the alar Further, training had not addressed the interlock or its functio Plant Manager Standing Order PMS0-041, " Override of Interlocks,"

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provides the established controls for defeating or overriding an interlock (e.g., management notification and concurrence).

This instruction was not followed during the dryer mov On January 8, 1989, during preparations for the moisture separator removal, the decision was made by the GE supervisor and IP RP persons to utilize the reset button throughout the separator mov The appropriate management was not informed and was not involved in the decision. The separator removal and storage was subsequently complete IP representatives eventually became aware of the events; however, they also did not recognize that a significant problem existed or that PM50-041 was not followe On January 12, 1989, IP management

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. was finally briefed on the incidents and immediate actions were taken (e.g., a condition report was written). During an engineering

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review of the crane operation and design, the licensee discovered that the apparent loss of power to the crane was due to the crane operator's foot being removed from the dead man switch. The interlock prohibited normal crane movement, however, power was available for lowering a loa In accordance with 10 CFR 50, Appendix B, Criterion V, activities affecting quality shall be prescribed by documented instructions or procedures, of the type appropriate to the circumstances, and be accomp S.hed in accordance with these instructions and procedure Contrary to this, CPS No. 8117.05 was not appropriate, in that, it

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the actions to be taken in the event of the alarm. Further, the dryer and separator moves were performed by overriding the interlock. Neither activity was accomplished in accordance with PMS0-041. This is considered to be a violation (461/89002-01(DRS)).

In accordance with 10 CFR 50, Appendix B, Criterion II, the licensee is required to provide for indoctrination and training of personnel performing activities affecting quality as necessary to assure suitable proficiency was achieved or maintained. Contrary to this, IP and GE personnel involved in overriding the ARM interlock during movement of the dryer and separator, were unaware of PMS0-04 Contractor personnel had not been trained on PMS0-041. This is considered to be an example of a violation (461/89002-05a(DRS)).

b. On Janusry 6, 1989, with the mode switch in Refuel, the licensee was preparing to commence work on the CRDMs (removal and repair). It was determined that the channel 2 position indication probe (PIP)

on control rod 36-09 was not working properly, resulting in a " rod block." On January 7, 1989, with the rod fully inserted, a shorting plug was installed on channel 2 in accordance with CPS procedures, to simulate the " rod-full-in" signal. An "all-rods-in" condition was necessary to perform the "one-rod-out" surveillance, CPS No. 9090.01. Subsequently, rod 36-09 was fully withdrawn. In order to uncouple'the rod from its mechanism, it was necessary to withdraw the rod to the over-travel positio Licensee personnel determined )

that a shorting plug would have to be installed in place of the channel 1 PIP to overcome a " rod block" expected during the maintenance wor Between 1327 and 1809 hours0.0209 days <br />0.503 hours <br />0.00299 weeks <br />6.883245e-4 months <br /> on January 7, the shorting plug was installed and a " rod-full-in" signal was simulated on the channel 1 PIP. At approximately 0025 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> on January 8, during shift turnover, the licensee recognized that the "one-rod-out" interlock had been defeated by simulating the full-in signal on both PIP channels for rod 36-09. Although no additional control rods were withdrawn, the condition existed whereby another rod could have been I withdrawn. This condition was in violation of TS Sections 3.9.1 and 3.9.1. The reactor mode switch was immediately placed and locked in the Shutdown position (TS Action Statement 3.9.1.b).

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The licensee documented this event in LER No. 89004. The cause of L .the event was' attributed to personnel error, in that,:the personnel

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performing the work had not.had a detailed understanding of the Rod:

L Control.and Information. System (RC&IS) one-rod-out interlock logi L Licensee: evaluation of the event concluded that other options (other L .than installing the second jumper) were'available which would have allowed the interlock-to . remain in effect during maintenanc TS Section 3.9.10.1 allows one control' rod and/or drive mechanism-to.be removed frore the core when the mode switch is in Refue TS 3.9.1.a requires that when a control rod is withdrawn, the one-rod-out interlock must^be operable. Contrary to this,-the-licensee defeated the interlock which violated the TS requirement The TS Action Statement 3.9.1.b was satisfied upon identification of the condition by the licensee. This event is considered to be a violation (461/89002-02(DRS)). ,

c '. CPS No. 1019.04 provided the instructions for control of tools,

. equipment, and material on the refuel floor (828' elevation in containment) during.the refueling outage. Inventory.was required to

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be contro11ec and documented in the material logs for areas inside the railings;around the flooded pools in containment. . Security persons were assigned as material controllers responsible fo maintaining the logs and ensuring compliance with CPS No. 1019.0 l The Material Control director had ultimate responsibility for

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ensuring material control and designating material controllers'.

Prior to the outage, GE supervisors were informally notified by IP of their responsibility for material contro' On January 19, 1989, the licensee was preparing to begin a lengthy radiation survey of the first spent fuel bundles removed from

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i the core. The refuel floor in containment was to be evacuated with the exception of fuel handling personnel. At approximately 0751 hours0.00869 days <br />0.209 hours <br />0.00124 weeks <br />2.857555e-4 months <br />, the IP RP person directed the Security material l controller to leave his post and exit containment. At this time, i the GE supervisor supposedly had material control responsibilit The last material le;; cr,try was at approximately 1000 hours0.0116 days <br />0.278 hours <br />0.00165 weeks <br />3.805e-4 months <br />. On January 20 at approximately 0500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br />, access to containment was ;

restore On January 20, 1989, at approximately 0830 hours0.00961 days <br />0.231 hours <br />0.00137 weeks <br />3.15815e-4 months <br />, during routine monitoring of refueling cctivities, the inspector entered containr. an Review of the material logs and discussions with i the GE supervisor resulted in the following inspector concerns:

items had been taken into the exclusion area and were not logged, ,

the material control post had not been re-established when access i to containment was restored, and the GE supervisor did not understand >

his responsibility with regard to material control. Subsequently, a )

Security material controller was posted, an initial material survey t was performed in the exclusion area, and a condition report was written. The apparent cause of the problem was that only informal direction on material control responsibilities was given to GE, and a

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formal transfer of responsibility was not defined (during the period )

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of restricted containment access). Later on January 20, another survey of the refuel floor was conducted by the licensee. A' number I of items were identified which had not been logged (e.g., bale handle cleaning tool and underwater camera equipment). Further surveys were conducted.by GE personnel and IP Quality Assurance persons, resulting in additional discrepancies in maintaining material contro 'In accordance with TS 6.8.1, written procedures are required to be. implemented covering activities such as refueling operation Contrary to this, cps No. 1019.04 was not implemented on the-refuet floor in containment. This is. considered'to be a violation (461/89002-03(DP.S)).

In'accordance with 10 CFR 50, Appendix B, Criterion II, the. licensee is required to provide for indoctrination and training of personnel-

. performing activities affecting quality as necessary to assure suitable proficiency was achieved or maintained. Contrary to this, contractor personnel.did not adequately understand their responsibilities for material contro Training and direction were ineffective in assuring material control was maintained on the refuel' floor in containment. This is considered to be an example of a violation (461/89002-05b(DRS)). On January 21, 1989, core alterations were in progress in quadrant A of the core. SRM channel D was declared inoperable due to its failing surveillance test CPS No. 9431.13, Section 8.5, " Discriminator Threshold Voltage Adjustment." The SRM was retracted from the core, and a MWR was generated to troubleshoot and repair. l The high voltage power supply cable was disconnected and danger %gged in preparation for the maintenance.. The indicated reading for channel D was approximately 300 counts per second (cps), while the other three SRMs (A, B, and C) were closer to 10 cps. TS Section 3.9. requires that during core alterations, at least two SRM channels arc operable, one of which is located in the quadrant where core alterations are being performed and the other detector located in an adjacent quadrant. When.this condition does not exist, core alterations must be immediately suspended (TS Action Statement).

SRM channels B and D were in the two adjacent quadrants when fuel was moved in quadrant At approximately 1550 hours0.0179 days <br />0.431 hours <br />0.00256 weeks <br />5.89775e-4 months <br />, SRM channel B dropped below the TS requirement of 3 cps, and core alterations were suspended in accordance with TS 3 9.2.b. The reading was restored to above 3 cps per CPS No. 9431.13, and at approximately 2125 hours0.0246 days <br />0.59 hours <br />0.00351 weeks <br />8.085625e-4 months <br />, channel B was declared operable and fuel movement resume On January 22, 1989, at approximately 0055 hours6.365741e-4 days <br />0.0153 hours <br />9.093915e-5 weeks <br />2.09275e-5 months <br />, SRM channel B again dropped below 3 cps and core alterations were stoppe The Control Room Shift Supervisor (SS) investigated SRM channel D operability and incorrectly concluded t's ; the work on the MWR had not started. The SS declared SRMD operable and at approximately 0140 hours0.00162 days <br />0.0389 hours <br />2.314815e-4 weeks <br />5.327e-5 months <br /> directed that core alterations be resumed. Further investigations by the Control and Instrumentation (C&I) personnel determined that SRM channel D was not operable. At approximately

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0545 hours0.00631 days <br />0.151 hours <br />9.011243e-4 weeks <br />2.073725e-4 months <br />, the SS declared SRM0 inoperable and core alternations were suspende Since both SRM channels B and D were inoperable from 0140 to'0545 hours0.00631 days <br />0.151 hours <br />9.011243e-4 weeks <br />2.073725e-4 months <br />, no adjacent SRMs to quadrant A (where fuel movement was in progress) were operable, thereby violating T This is considered to be a violation (461/89002-04(DRS)).

The licensee documented this event in LER No. 89007. Evaluation by the licensee determined:that the cause of the event was failure of the SS to review all .available' information and consult with his staff assistant prior to declaring SRM channel D operable. . Further, the SS was not fully aware of the status of SRMD due to an inadequate shift turnover and/or lack. of detail . in the log entrie As part of the refueling activities, irradiated fuel was removed from the core and transferred.to the SFP. Prior to picking up a fuel bundle from the core, the coordinates and location of the bundle was verified by a GE spotter and an IP Refueling'SR Irradiated bundle serial numbers could not easily be read with binoculars; therefore, verification by core location rather than serial number was performed prior to removing the bundle from the core.. The refuel bridge mast was positioned over the core location by using grid markings on the pool wall 'and trolley, and the digital position readouts on the bridge. The bundle was then grappled, removed from the core, and transferred to the IFTS upender. The licensee was verifying the bundle serial number in the upender with an underwater camer On January 28, 1989, an incorrect fuel bundle (diagonal to the

^ correct peripheral bundle) was removed from the core and transferred to the upender. This violated the approved fuel move sheets CPS No. 1898.00C001. The error was identified during verification of the serial nember with the underwater camer Refueling operations were suspended while the licensee evaluated the error. The cause was determined to be personnel error due to poor judgement and inattention to the details of the operation. The licensee took immediate corrective action which included: personnel briefings, changes to the underwater lighting to reduce shadows near the periphery-of the core, and use of an additional floating viewing aid. The inspector noted that, following completion of the refueling operations, the licensee was required to perform a full core verification with the underwater camera. Any discrepancies in fuel location would potentially be identified during this independent verification, On January 31, 1989, the last of the five startup neutron sources was being removed from the core with the bridge crane auxiliary hoist. A bridge operator inadvertently bumped the auxiliary hoist grapple disengage button, causing the grapple to disengage and allowing the source rod to fal The source came to rest with the bottom end on the top bundle support plate and the upper end against '

the side of the reactor. The immediate action taken was to perform sections from the dropped fuel bundle procedure. These actions were considered appropriate for the circumstances. Radiation surveys

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resulted in no noticeable increase in radiation level Initial assessment of damage'to the source and vessel components that may

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.have been impacted by the dropped source, indicated no apparent p damag ~

The inspector returned to the site on February 1,1989, to followup on this event. Discussions with'the. licensee indicated that the cause of the event was not due to a lack of care or attention on the part of the operators,.but rather an error in,not recognizing the hazard of unprotected control buttons. The licensee's evaluation L of the event resulted in promptly installing protective covers over the control buttons. The. inspector noted that an' unauthorized guard had been installed on the refueling mast grapple disengage button prior to this event. An approved cover was' installed subsequent to the even The licensee developed a plan to recover the source and assess any damage incurre CPS No.-2800.26, " Dropped Neutron Source Recovery,"

was written and approved for use. The scurce was recovered on February 3, 1989. The method of retrieving the source was to first upright the source rod using an air pliers attached to 'the refueling bridge monorail hoist. The-instrument handling tool was then'used, as with'ncrmal source removal, to transfer the source to the appropriate storage location. The underwater camera was necessary during the operation to verify proper engagement of the tools and to conduct a visual examination of the source rod. No indication of damage.to the source was observed. According to the licensee, .

additional examinations would be performed in the area of the vessel

@ ere the source droppe Prior to the operation, the. inspector attended the FRG meeting and personnel briefings on the procedure. As part of the training provided to.the refueling personnel, a dry and a wet run of the source recovery was conducted in the SFP are Using a simulated source (mock-up of similar size and weight), the ability of the air pliers was demonstrated. A loss of instrument air test was also performed, and resulted in the air pliers remaining closed on the mock-up. The inspector observed the demonstration and the subsequent source retrieval operatio During the source retrieval, the inspector noted the following:

after the completion of the prerequisites to the procedure (CPS No. 2800.26), the licensee attempted to move the refueling bridge over the core. An unexpected interlock was encountered which prohibited bridge movement over the core when the reactor mode switch was in Shutdown. The refueling personnel (IP and GE)

were not aware of the existence of this interlock, and another

.. attempt at moving the bridge failed. The operation was temporarily suspended to identify and resolve the problem. Although TS allows core alterations to be performed in either the Shutdown or Refuel mode, it was evident from the design documents that bridge movement into the core area was prohibited in the Shutdown mode. It was necessary to suspend operations for approximately two hours to

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complete the one-rod-out . interlock. surveillance . required to place :

-the mode switch in the Refuel position. The licensee documented -

the problem in a. condition repor In accordance with 10 CFR 50, Appendix B, Criterion II, the licensee is required to provide for'. indoctrination and training of personnel performing activities affecting quality as necessary to .

assure suitable proficiency was achieved or maintained. ; Contrary to this, the persons-involved in the~ source retrieval operation were not aware of an interlock (or its function) which prohibited refueling bridge movement over the core when the mode switch was in Shutdown. This is considered to be an example of a violatio ,

(461/89002-05c(DRS)). : Based on the information avail.able at the i end of the inspection period, it was evident that no training had '

been provided regarding this interlock. Further, the function o the interlock was apparently unknow . Exit Meeting On January 26, 1989, the inspector held an interim exit meeting onsite with licensee representatives. On February 14, 1989, an exit meeting was held via teleconference with Region III NRC and licensee representative Persons attending the meetings are denoted in Paragraph 1. The inspector summarized the scope and findings of the inspection. The licensee acknowledged the statements made by the inspector with respect to the violations (Paragraph 4). 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 proprietary.

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