IR 05000461/1997007

Insp Rept 50-461/97-07 on 970313-0522.No Violations Noted. Major Areas Inspected:Licensee Operations & Surveillance Testing

ML20217G756
Person / Time
Site:	Clinton
Issue date:	09/29/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20217G749	List: IR 05000461/1997007 ML20217G747 ML20217G752
References
50-461-97-07, 50-461-97-7, NUDOCS 9710140191
Download: ML20217G756 (17)

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U.S. NUCLEAR REGULATORY COMMISSION REGION lil

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Docket No: 50-461 License No: NPF62 Report No:

50-461/97007(DRP) .

Licensee: tilinois Power Company Facility: Cilnton Power Station

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Location: Route 54 West

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Clinton,IL 61727 Dates: March 13 May 22,1997 Inspectors: C, G. Miller, Senior Resident inspector .

Quad Cities, Team Leader F. D, Brown, Acting Senior Resident inspector K K Stoodter, Resident inspector R, A. Langstaff, Resident inspector Approved by: G. C, Wright, Chief Reactor Projects Branch 4 9710140191 970929 PDR ADOCK 05000461 0 PDR .

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EXECUTIVE SUMMARY Clinton Power Station NRC Inspection Report 50-401/97007(DRP)

This specialinspection included aspects of licensee operations and surveillance testing. The report covers a 3 week period of on site specialinspection activity with additional follow-up activities subsequent to the team visi Operations e

Poor procedure planning, poor tumer, and delays resulting from problems with spent fuel pool level, left operators to a position where an 8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> limiting condition for operation (LCO) time requirement, rartaining to motor operated valve test prep switches, of

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Section 3.5.2 of the Op',, rational Requirements Manual (ORM) would likely be exceede The inspectors found tnat shift supervisions' understanding and review of the Technical Specifications (TS) and ORM requirements for this condition, and the regulatory TS, and procedural requirements for procedurai adherence in general, was not adequat (Section 03.1.)

Inspectors found that the procedure adherence guidance contained in CPS 1005.01

" PROCEDURES AND DOCUMENTS" was inconsistent with NRC regu!ylons and TS requirements for procedure adherence and procedure changes. The inectors also determined that procedural adherence training for operators had been ineffective. One apparent violation was identified. (Section 03.1.)

The inspectors identified that CPS 3317.01 FUEL POOL COOLING AND CLEANUP (FC)," was inadequate because operators could not have reasonably performed the steps in sequence without incurring a substantialin9ow to the spent fuel pool from the upper pool and upper pool retum lines. Such inflow was considered a major concem by operators, and had resulted in a large spread of contamiration in the past. One violation was identified. (Section 03.1)

The inspectors identified weaknesses in the licensee's critique r% cess, TS/ORM LCO action statement tracking process, and procedure charene piocess. (Sections 0 and 07)

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Report Details 1. Operation

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03.1 Review of Normal Operatino and Surveillance Procedurn j Inspection Scope f71707/61726)

Procedural adequacy and adherence problems at Clinton were noted during events on September 5,1996, and January 9,1997. Changes were made in CPS 1005.01, * CPS PROCEDURES AND DOCUMENTS," Revision 36, on February 21,1997, in response to apparent viol,tions identified by the NRC at a routine exit meeting on February 14,199 '

On March 10,1997, the resident inspectors reviewed Condition Report (CR) 197 03-066, written March 9,1997, which documented the intentional failure to follow procedural steps during performance of surveillance Procedure CPS 9061.04," CONTAINMENT /DRYWELL ISOLATION AUTO ACTUATION," Revision 35. The CR stated that this violated Step 8.1.6 of CPS 1005.01. The inspectors were concemed by the implication that a willful procedure violation had occurred. On March 11,1997 NRC Region lll and Clinton management held two telephone calls to discu'is the events of March 9,1997. During the first telephone' call, Clinton management indicated that they were not aware of th? C During the second call, Clinton management Indicated that they were satisfied with the performance associated with CPS 9061,0 A special inspection was initiated on March 13,1997, to assess the March 9 performance of surveillance CPS 9061.04 as it related to the regulations and to previous performance problems at Clinto Observations and Findine g Overview of the Event The reactor was shutdown in Mode 4 with shutdown cooling being maintained via the "8" Residual Hut Removal (RHR) loop. Operators were performing surveillance Procedure  :

CPS 9061.04 which required that some normal system line-ups be temporarily changed, and that scme system functions, such as shut down cooling mode of ths RHR system, be temporarily intermpte A detailed chronology of the performance of CPS 9061.04 is attached to the end of this report. A synopsis of events is provided here, followed by discussion of the inspectors'

findings in sections labeled Conduct of Operations and Procedural Control .

The surveillanen was started early on day shift, March 9,1997. In establishing the required Spent Fuel Pool Cooling and Cleanup (FC) system line up, operators allowed the spent fuel pool level to exceed the normal control rang *

Operators placed the Motor Operated Valve (MOV) Test Prep Switches (TPSs) in

" test," as directed by the surveillance procedure, at 12:27 p.m. This started an eight (8) hour time clock associated with a Limiting Condition for Operation (LCO)

under Operational Requirements Manual (ORM) Section 3. _ _ _____ -___ __ --

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The Division I containment and drywell automailc isolation signal was successfully tested. Restoration steps of Procedure CPS 9061.04 were started by the day shif +

Shift tumover was completed at about 5:30 p.m., fuel poollevel was not discussed. The on-coming swing shift became concemed by the high levelin the spent fuel pool and FC surge tank. Restetation from the surveillance was delayed as the swing shift focused on lowering the spent fuel poolleve .

The swing shift recognized that the ORM Section 3.5.2 LCO eight (8) hour time clock would expire prior to retuming the TPSs to normal"if Procedure CPS 9061.04 was performed as written. The swing shift Line Assistant Shift Supervisor (LASS) and Shift Supervisor (SS), after consultation with the Assistant Director Plant Operations (ADPO), decided to " violate" Procedure CPS 9061.04 by performing steps out of order; specifically, by retuming the TPSs to " normal."

No procedure change was prepared, but Condition Report (CR) 197 03-066 was generated by the SS to document the procedure " violation."

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The swing shift completed the Division I restoration portion of procedure CPS 9061.04. The midnight shift performed the Division 11 portion of .

CPS 9061.04, as written, on March 10,1997, without proble Conduct of Opera 11.2 rig The inspectors reviewed the performance of the Operations Department with emphasis on the decision making process and safety focu NRC Determines that Shift Supervision did not Violate Procedures The inspectors were initially concemed that the LASS, SS, and ADPO, all of whom were licensed Senior Reactor Operators (SROs), had violated a required procedure for the purpose of avoiding an unnecessary entry into ITS and ORM LCO action statement This concem was based upon the wording used in CR 197 03-066 and upon initial conversations between the Clinten resident inspectors and the LASS and ADPO on March 10 and 11,1997. The NRC expects licensees to plan and control plant activities in a manner which avoids unnecessary entry into LCOs Conversely, taking unplanned, uncontrolled actions, such as violating approved procedures, to avoid such an entry I would not be consistent with the plant's or the operators' licenses unless the criteria of 10 CFR 50.54(x) was met. Operator judgement is important to ensure that malicious compliance with incorrect or inadequate procedures does not occu During discussions with the LASS, SS, ADPO, and .%her plant staff, the inspectors were told that the decision to perform Procedure CPS 9001.04 steps out of order was based upon the belief that leaving the TPSs in " test" and entering the ITS and ORM action

. statements would require that shut down cooling be secured and that the only operable Emergency Diesel Generator (EDG) would have to be declared inoperable. These concerns were not documented in the original CR and had not been discussed with the resident inspectors. The inspectors were also informed that CPS 1005.01 Step 6.2.4, specified:

"When an activity cannot be performed as written or continuation of the activity would result in an unsafe condition, take the following actions:

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a) Stop the activity, b) Ensure the equipment is in a safe conditio c) Notify the appropriate supervisor," '

Clinton management informed the inspectors that Step 8.2.4 of CPS 1005.01 had authorized the performance of steps in CPS 9061.04 out of order, even though the involved individuals believed that they were in violation of Step 8.1.6 of CPS 1005.0 The inspectors reviewed the significance of retuming the TPSs to " normal" from "tc . Out of order with the sequence specified in CPS 9061.04. The inspectors determined that there was no safety significance associated with placing the TPSs to " normal" as long as the switches were placed in " test" when individual valves were opened or close Procedure. CPS 1401.01, " CON %ICT OF OPERATIONS" provided approved instructions for using the TPSs when operCng md closing valves, and the SS and LASS had directed that CPS 1401.01 be used during the completion of the Division I restoration steps in CPS 9061.04,

After thorough review and evaluation, the NRC concluded that the shift supervision had acted in the belief that Procedure CPS 9061.04 could not be continued as written without creating an unsafe condition, that they had implemented an attemate procedure for tne control of TPS position, and inat these actions were consistent with the licensee's expectations relative to Step 8.2.4 of Procedure CPS 1005.01. Based upon this assessment, and not withstanding the issues of weak performance and inadequate upper tier procedural controls discussed below, the NRC concluded that the shift supervision

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did not violate NRC requirements when performing procedure steps in Procedure CPS g")61.04 out of orde Strenaths and Weaknesses in Performance of Shift Supervision The inspectors identified the following weaknesses in the decision making process used by the shift supervision on March g,1997:

The day shift knew that the spent fuel pool level had not increased significantly since the FC system had been secured. This information was not turned over to the swing shift. As a result, the swing shift was concemed that the poollevel was rising at an appreciable rate as a result of heat-up, and focused on poollevel control rather than restoration from the surveillanc .

Swing shift supervision did not understand that unless the criteria of 10 CFR 50.54(x)is met, the regulations require that work be performed using procedures as written, and that incorrect procedures be changed and approved prior to performance of work or resumption of wor .

Swing shift supervision was not conversant with the requirements of Procedure CPS 1005.01, the licensee's upper tier procedure for procedure adherence, in that they were not aware of Step 8.2.4 or its applicatio .

Swing shift supervision did not perform, nor did they have the Shift Engineer perform, a thorough review of the ITS or the ORM to determine the impact of exceeding the eight hour time clock associated with ORM Section 3.5.2. The LASS and the ADPO stated that they had not reviewed the ITS or the ORM but that the SS had. The SS stated that he had only scanned the ITS and ORM, All

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three stated, as discussed above, that shut down cooling would have to have been secured and the Division ll EDG would have been rendered inoperable if the eight hour clock expired. The inspectors reviewed the applicable portions of the ITS and determined that shut down cooling would p_g] have to have been secured if the eight hour clock had expired. The licensee performed a review of the ITS and reached the same conclusion as the inspactors. The inspectors reviewed the applicable portions of the ORM and ITS and outermined that the Division 11 EDG would have been inoperable, but that all applicable action statements for this condition were already met and that the EDG would have been operable again once the TPSs were retumed to the " normal" position in accordance with Procedure CPS 9061.04

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Swing shift supervision continued with performance of CPS 9061.04 after .

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performing st9ps out of sequence rather than having the procedure revised once the " safety" issue of the TPS position had been resolved. Additionally, the next shift performed the Division ll portion of the procedure without first revising the

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procedural controls for use of the TPSs. Revising CPS 9061.04 to require that TPSs be positioned using the controls of CPS 1401.01 during the Division ll portion of the procedure, as done during restoration of Division I, would have been the conservative approach because it would have minimized the amount of time the switches were in " test."

The inspectors considered the fact that a CR was written to document the procedural compliance issues associated with the TPSs and CPS 9061.04 to have been a strengt LCO Trackino issues Durino Performance of Surveillance The inspectors identified that operations personnel did not complete the procedurally required ITS LCO report when '.he "A" train of RHR was not restored to an operable status following the end of day shift on March 9. CPS 1405.03," EVALUATING AND TRACKING ITS LCO/ORM OR ACTIONS," contained a note which stated that if a ITS LCO was expected to be restored before shift tumover, then the LCO could be tracked vi4 administrative controls. However the LCO was not met and was in effect for greater than one shift which required the ITS LCO/ORM report to be initiated per CPS 1405.03, Step 8.1.7. ITS 5.4.1 requires that written procedures be implemented for activities recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978, which includes equipment control. The failure to initiate an LCO report to ensure adequate equipment control as required by Procedure CPS 1405.03 was considered of minor significance and is being treated as a non-cited violation (50-461/97007-01) consistent with Section IV of the NRC Enforcement Polic The inspectors also found that the licensee entered and exited ORM LCO requirements numerous times in relatively short periods without keeping track of the total cumulative time in a particular LCO For example, the inspector found that the short term ORM LCO requirement for placing the division 1 fuel pool cooling TPS in " test" was entered three times, for a total of about 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> in a 19-hour period due to surveillance Procedure CPS 9001.04. The ORM LCO limit is 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />. Since the operators had placed the switch to " normal" then later back to " test" on two different occasions during the test, the licensee considered the LCO clock to be reset. Although TS allowed multiple entriec into LCOs, the inspector noted thet uncontrolled entries could result in excessive equipment

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unavailability time. The inspector found that Operations Department procedure guidance and practice did not prohibit this practice or limit tN total amount of time equipment could remain in an LCO due to multiple entries into an LCO for the same purpos Precedural Controls The inspectors reviewed the procedulal adherence practices of operators and Operations management during performance of surveillance Procedure CPS 9061.0 Licensee Procedure Adherence Procedure was inaceouste The licensee changed procedure adherence p ilosophy significantly on February 21,

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1997, due to NRC identified apparent violationa discussed at an exit meeting on February 14,1997 (see inspection Repori 50-461/96015 for details). In discussions with the resident inspectors, licensee managers and the licensee procedure organization stated that one February 21 change to CPS 1005.01 was intended to force plant staff to follow procedure steps in the order written unless the procedure stated that the order of performance of specific steps was not safety significant. Previously, procedures had been written such that performance of steps in order was not required unless specified in the procedure. Another change made to Procedure CPS 1005.01 on February 21 was the deletion of the previous Step 8.1.9. Step 8.1.9 had allowed a " noting out" process which had been used by the licensee to change the performance of a procedure without using the Technical Specification and ORM approved process for procedure change The inspectors found, through review of the procedure and discussions with operators, that Steps 2.1.2,6.1,6.2, 8.1.1, 8.1.4, and 8.1.6 of Procedure CPS 1005.01, Revision 36, in effect on March 9,1997, directed that procedures be performed as written or changed, but that Steps 8.1.9.1,8.1.9.3, and 8.2.3.2 allowed forms of non-performance of required actions in safety related procedures.10 CFR Part 50, Appendix B, Criterion V, requires that activities affecting quality shall be prescribed in procedures and be accomplished in accordance with these procedures. TS 5.4.1 required that written procedures be established and implemented. Section 6.5.3 of the Operational Requirements Manual (ORM) required that changes, other than editorial or typographical changes, to procedures required by TS 5.4.1 be independently reviewed by an individual knowledgeable in the area affected other than the individual who prepared the procedure change. ORM 6.5.3 also required that written records of the review be prepared aad maintained. The informal procedure change methods allowed by CPS 1005.01, Steps 8.1.9.1,8.1.9.3, and 8.2.3.2 were contrary to the requirements of TS 5.4.1 as implemented by ORM 6.5.3. This was considered to be an apparent violation (50-461/97007 02) of 10 CFR Part 50, Appendix B, Criterion V, " Procedures."

The inspectors reviewed the circumstancas associated with operations personnel skipping Steps 8.1.3.7 through 8.1.3.11 in CPS 3317.01, " Fuel Pool Cooling and Cleanup (FC)," Revision 18, dated February 13,1997, when shutting down the FC system on March 9,1997. The affected stops, if performed, would have isolated component cooling water (CCW) from the FC heat exchanger. CCW flow to the heat exchanger would have been reestablished when the FC system was subsequently retumed to servic Operations personnel documented in the shift tog that the steps were skipped in anticipation of restarting the FC system in a short period of time. The conclusions from the licensee's critique (Critique OPS97-008) stated that the skipping of the steps was proper and acceptable because Step 8.2.3.2 of Procedure 1005.01, CPS PROCEDURES AND DOCUMENTS " Revision 36, with changes through February 28,

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i 1997, stated Supervision may elect to have individual sections or steps in a procedure completed without the entire procedure being performed," even though this was inconsistent with the procedural requirements of Steps 2.1.2, 6.1, 6.2, 8.1.1, 8.1 A, and 8.1.6 of CPS 1905.0 .

Although the inspectors agreed that there was no adverse safety impact due to the steps not being performed for this case, the inspectors disagreed with the critique conclusion that the skipping of steps was proper and acceptable The skipping of procedure steps was, in reality, a procedure change because actions specified by the procedure were not accomplished. The scope of change was beyond an editorial or typographical nature because there was a change in intent, since the CCW flow was not isolated. The steps skipped had not been identified within the procedure as a section which waa not required to be performe .

A second example of operators misapplying procedural controls because of the inconsistent guidance in Procedure CPS 1005.01 was identified by the inspectors through a review of the control room logs. The logs indicated that on March 9,1997 Steps 8,1,12.6.7(a) through (m) of Procedure CPS 3312.01, " RESIDUAL HEAT REMOVAL," steps for placing the "B" train of RHR in standby, were not performed when the preceding and subsequent steps of Procedure CPS 3312.01 were performed. When the inspectors asked the LASS about the non-performance of these steps, he stated that the steps were intended to for different plant conditions and that Step 8.2.3.2 of ('PS 1005.01 allowed supervisory pelsonnel to direct the performance of individual sections or steps within a procedure without performing the entire procedure, The operations critique of the March 9 TPS event, Critique OPS97-008, supported this conclusio Ineffective Trainina: Tne February 21,1997, change to CPS 1005.01 was implemented without effective training. The inspectors found operators, procedure writers and station management to have differing and, at times, conflicting understanding of the requirements for proceduro adherence at the station. The standards for procedure adherence contained in Procedure CPS 1005.01 had chanced numerous times since September 1996, and interviews indicated station personnel were not well briefed on the details of several the r.hanges. The inspectors reviewed the training provided for the February 21 major change in procedure adherence philosophy, and found the training to consist of merely a short tenn operations night order and an electronic mail not One example of the ineffective training associated with Procedure CPS 1005.01 dealt with Step.8.2.4. Operators interviewed were not aware of the step in some instances, and in others did not know what was specifically required by the procedure or what the procedure step was guiding them to do. The swing shift supervision and Operations Department managet involved with the procedure problem cf March 9,1997, stated that they wers not aware that Step 8.2.4 existed, but senior plant management stated that it was intended to cover the situation that occurred on their shif FC System Operatina Procedure inadeauate for Fuel Pool Level Control The inspectors reviowed the adequacy of Procedure 3317.01, "FUFL POOL COOLING AND CLEANUP (FC),' Revision 1P. dated February 13,1997, in light of the fuel pool cooling and cleanup system (FC) system level problems encountered on March 9,199 _

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As described in the detailed Chronolony of Events at the end of this report, when operations personnel shut down the FC system in accordance wi'.n CPS 3317.01, the spent fuel pool was over filled, and the FC surge tanks filled to capacity. The surge tanks and the spent fuel pool at Clinton Power Station are at a lower elevation than upper containment pools. Unless the upper pools are isolated when the FC pumps are shut'

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down, water from the upper pool retum lines and scuppers flows, by gravity, to the spent fuel pool, which overflowed to the FC surge tank The inspectors determined that Procedure 3317.01 was inadequate because the steps I for shutting down the FC system did not adequately address the inflow into the sperit fuel pool. Such an inflow had the potential to cause the spent fuel pool to overflow into potentially contaminated fuel handling building ventilation ducting if the FC surge tanks could not handle the extra inventory. This had occurred once in the past, resulting in a large spread of contamination within the fuel handling building. The need for operations personnel to respond to the problems encountered due to the inflow detracted from concurrent performance of testing activities on March 9,199 TM inspectors noted that CPS 3317.01 directed the FC containment isolation valves to be isolated several steps after the FC pumps were shutdown. However, operations personnel could not have reasonably performed the steps in sequence without incurring a substantial inflow from the upper pool and upper pool return lines, in addition, the procedure did not provide a means to reduce water levelin the FC surge tanks after the inflow had occurre CFR Part 50, Appendix B, Criterion V, instructions, Procedures, and Drawings,"

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requires that activities affecting quality be prescribed by documented instrue ions, l

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procedures, or drawings, of a type appropriate to the circumstances. The failure to have a procedure of a type appropriate to the circumstances for shutting down the FC system is considered a violation (VIO 50-461/97007-03) of 10 CFR Part 50, Appendix B, Criterion Procedure Chanae Process inadeauate to Support Plant Operations Guidance for procedures and procedure changes was contained in TS 5.4.1 and ORM Section 6.8. These requirements outlined review and approval processes for changing applicable procedures. Procedure CPS 1005.01 Sections 8.6 through 8.8 and CPS 1005.07, " TEMPORARY CHANGES TO STATION PROCEDURES AND DOCUMENTS * provided guidance on how to implement these requirement The inspectors performed a walkthrough of changing CPS 9061.04 to put the TPSs in the

" normal" position, and to control subsequent TPS use with the existing procedural controls of CPS 1014.01. The inspectors found that this type of change could have taken from 1 to 3 shifts to complete under the temporary procedure change process in place on March 9,1997. This was an inordinate amount of time for a change to allow an action which shift supervision and Operations Department management felt to be simple, safe, and conservative, and which operators took even though they believed that it violated their procedures. The inspectors found that the requirements of 1005.07 were more restrictive than the regulations and plant's license required. and were inconsistent with other licensees' practices and procedures. Although not a regulatory concem, the inability to processes procedure changes in a timely manner contributed to the ongoing procedure adherence policy problem ' ___

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c. Conclusions Poor procedure planning, poor tumover, and delays resulting from problems with spent fuel pool level, left operators in a position such that an 8-hour LCO time requirement, ped.aining to motor operated valve test prep switches, of Section 3.5.2 of the ORM would likely be exceeded. The inspectors found that shift supervisions' understanding and review of the TS and ORM requirements for t'Js condition, and the regulatory, TS, and procedural requirements for procedure? adherence in general, was not adequat Inspec4 ors found that the procedure adherence guidance contained in CPS 1005.01 w inconsistent and not in compliance with NRC regulations and TS requirements for procedure adherence and procedure changes. An apparent violation was identified. The inspectors also determined that procedural adherence training for operators had been ineffectiv .

The inspectors noted that CPS 3317.01 was inadequate because operators could not have reasonably performed the steps in sequence without incurring a substantialinflow to the spent fuel pool from the ugr pool and upper pool retum linen. Such inflow was considered a major concem by s perators, and had resulted in a large spread of contamination in the past. One violation was identified.

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The inspectors noted weaknesses in the licensne's critique process, TS/ORM LCO action statement tracking process, and procedure change proces O7 Quality Assurance in Operations Operations Critiaue l

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On March 12,1997, the licensee conducted a critique of the March 9 surveillance

! procedure violation. The inspectors attended the brMf and reviewed the critique report (OPS97-008) which was issued several days late Although a Condition Report (CR 17-03-066) was generated shortly after the event on March 9, the CR was not marked as "significant" or"potentially significant"; but rather was marked as "other " The station did not treat the event as significant until several days later when NRC management notified station management of the problem. The critique was initiated after the management call. A number of crew members involved with setting up the surveillance procedure were not invited to the critique. The critique report concluded that using a procedure change method which was supposed to have been prohibited by a procedure change on February 21,1997, was justified. The critique process failed to identify the wide disparity in understanding of management requirements for procedure adherence. The critique failed to give tracking numbers and dates to follow-up actions in the critique report. Since the CR was marked "other," no action dates were assigned to the CR for corrective action due to the licensee's low level handling of CRs classified as "other "

The licensee uncovered severalimportant facts in the critique process and generated follow-up action plans which had the potential to solve a number of the individual problems noted in the event. The critique time line was also considered a strengt _-

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.08 Miscellaneous

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_ _ 08.1 Related Enforcement Actions inspection Report 50-46196015 contained a number of examples of failure to follow procedures which the NRC has concluded were related to inadequate procedure

.. guidance in CPS 1005.01, Apparent violations 50-461/96015-01h, I, j, m and n and 50 461/96015-03a and b are considered further examples of the apparent violation of 10 CFR Part 50, Appendix B, Criterion V, " Procedures" described eariier in this repor Apparent violation 50-461/96015 01p will be tracked as a violation (50-441/97007 04),

and is cited in the Notice of Violation forwarded with this repor .2 Office of Investinations Activities The Office of Investigations (01) performed additional interviews of plant staff personnel involved with the procedure violation of March 9,1997. No additional actions outside of those associated with this report were deemed necessary as a result of those interview X1 Exit Meeting Summary

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The inspectors presented the preliminary inspection results to members of licensee management on March 21,1997, and at the close of the inspection period on May 22, .

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i- i 1997, An additional exit was conducted via telephone on August 11,1997, to discuss apparent violations, corrective actions, and the need for a predecisional enforcement conference. Mr. John G. Cook, Senior Vice President, Illinois Power Company, stated a predecisional enforcement conference was not necessary, The licensee acknowledged the findings presented, i

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Chron* 7 of Events. March 9.1997 0741 Day shift main control room personnel signed on to CPS 9061.04 and continued performing steps to complete the procedure prerequisite Operations secured the fuel pool cooling and cleanup (FC) system per Section 8.1.3 of CPS 3317.01 as required by CPS 9061.04. Operator logs indicated Steps 8.1. through 8.1.3.11 of CPS 3317.01 were not performed since component cooling water to t,he FC heat exchanger was to remain in service. Upon securing the FC system, spent fuel pool and FC surge tank level increased to ~28 feet due to drain back from the upper pool. Surge tank levelindication remained on scale through the remainder of day shif Details:

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The strip chart for FC surge tank levels showed that indicated level was approximately 18 feet prior to the FC pump being secured. The indicated 18 foot level was within the 16.5 foot to 19 foot band specified by Procedure 3317.01. Actual level was 5 to 10 inches higher (as determined by informallicensee calculations) because of flow velocity past the tap for the level transmitter in the suction line for the FC pumps. The licensee had not previously evaluated the effect of flow on the level instrumentatio Operations personnelisolated the FC filter domineralizers in accordance with ( Steps 8.1.3.3 and 8.1.3.4 of Procedure 3317.01. As a result, the normal water makeup and rejection f'ow paths for the FC system were isolate Operations personnel shut down the FC pump in service in accordance with Step 8.1.3.6 of Procedure 3317.01. Indicated FC surge tank levels increased due to pressure sensed by level transmitter becoming a static head (consistent with the transmitter's calibration).

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Operations personnel spent 5 to 10 minutes discussing how to address performance of Steps 8.1.3.7 through 8.1.3.13 of Procedure 3317.01. As discussed previously, the operations personnel chose not to perform these step Inflow from the upper poets and upper pool retum lines raised indicated level in the fuel pool and surge tank to 28 feet (top of the scale for the FC surge tank level instrumentation). Operations personnel were monitoring the surge tank levels during the evolution of shutting down the FC system and recognized that the levels were high. However, Step 8.1.1.1 of Procedure 3317.01 only permitted start-up of the FC system when indicated surge tank levels were 24 to 27 fee Consequently, operations personnel were prohibited from starting up the FC system which would lower surge tank level Operations personnelisolated the FC containment isolation valves which stopped the inflow from the upper pool retum line __ .. . . .

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Gradual expansion from heat up of the spent fuel pool, from approximately 86*F to 90'F, caused a slight poollevelincrease. Operations personnel on the day shift concluded that the tank and pool level would not reach the height of the ventilation duct, so no action was considered necessary to remove water from the syste The MOV TPSs for the following Division i subsystems were placed in test as directed by 9061.04:

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Containment isolation

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Shutdown Service Water .

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Drywell Cooling and Chilled Water

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Component Cooling Water

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Fuel Pool Cooling and Cleanup

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Fire Protection

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Combustible Gas Control

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Instrument Air

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Suppression Pool Cleanup

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t Containment Building /Drywell Purge HVAC

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Cycled Condensate

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Makeup Condensate The MOV TPSs were usually in the " normal" position which bypassed the thermal overloads on the respective MOVs, ensuring that the MOVs will close under accident conditions. During the performance of surveillances, the thermal overloads were placed back into the MOV circuitry such that the MOV would trip when thermal overload set points were reached rather than causing valve damage. Placing the MOV TPSs in " test" necessitated an entry into ORM action 3.5.2 which required that the TPSs be placed back in the normal position within 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> or enter the appropriate technical specification action statement The MOV TPSs for RHR train "A" was placed in " test."

1358 MOV TPSs for the following systems were placed in " test."

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RHR B

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Shutdown Service Water Train B

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Division 11 Containment Isolation During this time, shutdown cooling (SDC) via RHR "B" was secured in accordance with CPS 3312.01, Section 8.1.1.2.6, in preparation for CPS 9061.04. However, the control room logs indicated that Steps 8.1.12.6.7a - 7m for placing RHR in standby were not performe Once RHR "B" was secured, the plant was in a condition with no trains of SDC running, which required an entry into TS action statement 3.4.10.B. The licensee was allowed to l

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secure both trains of SDC for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> within an 8-hour period for the purpose of performing surveillances, in addition, a 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> time clock was started to ensure that a train of RHR was retumed to service prior to exceeding the allowed TS time for performing surveillance initiated the Division I containment and reactor vessel isolation control system logic. Due to this initiation, train "A" of the standby gas treatment system started and three ventilation systems (fuel building HVAC and containment building /drywell HVAC (VR/VQ))

shutdown as expecte The "B" train of RHR was filled and vented and returned to service in SDC. This ended the two hour time clock referred to in the 135B entr Shift tumover occurred. Day shift did not tum-over that the spent fuel pool level had remained essentially constant since the FC system was secure Swing shift operations personnel noted that the FC surge tank level was greater than 28 feet and the plant computer was displaying white data (white data is used to show that the indication was not accurate). It was also verified locally that about 5 inches of room

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existed until the spent fuel pool began flooding the fuel building HVAC scuppers. The shift supervisor authorized draining water from the surge tank by opening drain valve 1FC106 per PMSO-43, " VERBAL INSTRUCTIONS TO CONDUCT OPERATIONS."

Operations personnel started removing water from the FC system by routing a hose from a 3/4 inch FC system vent line to a floor drain in the fuel handling building. Although procedural steps did not exist for removing water in this manner, the inspectors considered the creation of an altemate method for removing water within the shift supervisors authority. The normal methods of removing water from the FC system were not available because the FC demineralizers had been isolated and the RHR systtim was out of service for testing under CPS 9061,04. The initial removal of water from the FC system resulted in a rainor spillin the fuel handling building. Water was originally routed from a FC system vent to a nearby floor drain. However, operations personnel did not recognize that the floor drain initially used was not piped directly to the floor drain syste Instead, flow from the floor drain was routed in a short section of pipe to the building level below the FC system floor drain, to a tygon hose connected to the short section of pipe by tape, and then via the tygon hose to the actual floor drain system. Water initially drained from the FC system overwhelmed the taped connection between the short section of pipe and the tygon hose and a minor spill occurred. When radiation protection personnel identified the spill, operations personnel temporarily secured flow until a hose could be routed directly to the floor drain system. Radiation protection personnel then performed surveys of the area and determined that no contamination had occurred. However, tape connection of a tygon hose to the pipe from what appeared to be a floor drain created the potential for a spread of contamination to occu i

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1830 FC surge tank level was still high and efforts to partially drain the tank continue .

1945 The SS noted that Step 8.2.12 of CPS 9061,04, which restored the position of the MOV TPSs, would not be performed pdor to the expiration of the 8-hour ORM action time clock entered at 1227. The SS then contacted the ADPO to inform him of the current status of CPS 9061.04. Although the SS and the ADPO were aware that performing steps out of sequence was a violation of procedures, the SS proposed and the ADPO concurred that Step 8.2.12 could be performed out of sequence in order to maintain the operability of certain plant equipment. Following the discussions with the ADPO, the SS directed the operating crew to perform Step 8.2.12 of CPS 9061.04 out of sequence. A condition report was initiated regarding the procedure " violation."

2015 Operators continued restoration of the valves to complete the Division 1 portion of the surveillanc ,

2226 Drain valve 1FC106 was shut and draining of the FC surge tank was stoppe (3-10-97)

Operators moved the TPSs for division 2 valves to the test position as part of continuation of the surveillance test. Procedure changes were not made prior to proceedin .

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INSPECTION PROCEDURES USED IP 61726: Surveillance Observations IP 71707: Plant Operations

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ITEMS OPENED 50-461-97007-01 NCV Failure to initiate LCO record 50-461-97007-02 EEI Inadequate procedure adherence procedure 50-461 97007-03 VIO Inadequate FC system procedure 50-461-97007-04 VIO Failure to provide adequate HPCS surveillance procedur ITEMS CLOSED 50-461-97007-01 NCV Failure to initiate LCO record 50-461/96015-01p eel Failure to provide adequate HPCS surveillance procedure, t

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i PERSONS CONTACTED '

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Licensee

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' J. Cook, Senior Vice President 4

..W. Connell, Vice Ptssident

' P. Yocum, Manager - Clinton Power Station

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R. Phares, Manager - Nuclear Assessment ~

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